Today, I drove home from work post-call, crying. I had a busy, largely sleepless night, with the lovely addition of the onset of a head cold. I made it through the call shift, made it through my work shift in the morning, then headed to a feedback session with one of my course directors. The course was "Empathy" and involved interns listening to comments made by patients on tape, then delivering empathic responses back.
Most of us had a hard time with this.
One intern said she felt like she couldn't respond to the happy patient because she only sees suffering or she assumes the patient is manic or borderline--she didn't know how to treat someone who was just happy. My responses felt to me like I was still using them as questions to extract more information, instead of just interjections to let the patient know I was listening and perceiving what they said.
My course director said I had done a good job, and that I had "a practical, pragmatic approach" that she felt would become less self-conscious and improve over time. I started to say something in response and instead tears welled up (I've cried in front of her before, so I doubt she was shocked).
I told her I felt like I used to be better at empathy, at understanding where patients come from and what they're going through, and trying to connect, and that I've lost something this year. That I used to enjoy trying to connect with patients, and now I find it difficult (I didn't tell her that often, I don't bother trying).
As I drove home, I started to cry again. At first, I couldn't tell what was bothering me. I assumed it was tiredness + being sick. It felt too bad to be that simple, though. When I get really upset, I feel a squeezing pressure in my chest that seems to wring tears from me (yes, I'm aware this is psychosomatic). I tried to think, what was bothering me? Then I realized I was still crying over what I'd lost this year. But why am I so burned out, empty? What have I lost?
I think a combination of forces has dried up my empathy well (maybe it wasn't very deep to begin with?). Call it soul, or humanity, or empathy, or sympathy, or "being with"--whatever--I feel like mine has shriveled a little (or a lot) under the blaze of a ferocious burn out.
(A note about burn out: when high school seniors, or college seniors moan about being "so burned out on school right now", that is not the same. This kind of burn out leaves you feeling hollow and empty. It invades your personal life, your marriage, your quiet time, and your dreams, even when not at work.)
I'll point a finger at chronic sleep deprivation. I've been working around 60-65 hours per week (which is not that much, really, by medicine standards; please, surgeons, don't hit me) and taking 5-6 calls per month for the past 6 months. I don't feel recharged between calls, and I think over time my reserves have gotten lower. I've taken some vacation time and tried to catch up, but it seems to only take one call to flatten me out again (I like my sleep, so sue me).
That's not the whole story, though. Part of it is the patient population I treat. On call, the most memorable patients are the substance-using (usually cocaine or alcohol) homeless narcissists (or antisocials) who are in it to get a free bed. I used to fight this, but I've given in to the system where I work. This system pulls these patients in and suckles them for a while. Aww, did you relapse for the 40th time? Was that placement not nice enough for you? You didn't make any of your follow up appointments (often, despite having benefits, bus passes, or special transportation) and couldn't be bothered to take your meds (given out for free), but that's okay, come here baby, I have a bed and a tray for you. I strongly feel that this system thereby encourages these patients to continue this behavior. There's no need to make choices or take responsibility when there's always a cushy safety net. Just say the magic words ("I'm thinking about hurting myself", but don't have a real plan) and you're in. I don't mean to suggest that all my patients are like this, but enough of them are (and they all seem to come in crisis at 3 am, because they know an intern is on, rather than during the day when the attending will send them to outpatient rehab) to be grating. I said in a previous post that there are few true psych emergencies at 3 am, and I still hold that to be true. There are some, and I'm happy to treat those, but most 3 am consults to the ER are for someone who's crashed off cocaine, feeling suicidal, and completely oblivious to the idea that cocaine could make them feel this bad. They want me to fix their sadness, but don't want to give up the high.
Some few of these patients can be verbally abusive, which makes it oh-so-exciting when I get to call the police or security to escort them out.
I hate the stigma against the mentally ill, even though I recognize some of it within myself. I recently treated a patient with delirium tremens who had a CIWA of 21 on my exam. The reason for consult was "rule out other psychiatric issues". My note politely stated that I would reassess other psych issues after pt was more alert and oriented (not A&O x none like on my exam) and that the primary team should consider increasing the lorazepam drip. Agitated patients who cannot give a clear history of alcohol or benzo use are often shuttled to psych while having withdrawal. I've seen patients not receive appropriate treatment of surgical or medical conditions with no other explanation than "due to psych diagnosis". (I also hate inappropriate medicine consults by psych because someone forgot how to look up the dose on a blood pressure med, so I'm perfectly aware that this is a two-way street).
Of course, when I went to the dentist last week and saw that my chart said (in Magic Marker on the front cover) "depression, nervousness, psych problems", I nearly cried in the dentist's office. I mentioned having a history of depression and anxiety during my intake, but I had no idea it would be proclaimed on the front cover of my chart like that, for all the office staff to see. So I understood my patient last night who told me she had lied to her psychiatrist about her previous suicide attempts because she was too ashamed, so she said she'd never done anything.
I believe a lot of my burn out is related to having been an intern for nearly a full year. Internship and residency are tough (yes, even in psych). I also believe that I would be pretty burned out no matter which specialty I'd chosen.
But a part of this burn out is psych itself. It's the overuse of meds, the overuse of diagnoses, the stigma against psych patients and psych doctors (but man, are you glad to see us when you need us!), the massive pharma scandals (Seroquel, Zyprexa, and Abilify all come to mind), the overmedication of children who need appropriate discipline (and the recent revelation that the data supporting stimulant use was oversold to us), and the overwhelming feeling that I'm not cut out for this like I thought I was. I'm not as good at psych as I thought I could be, which is tough for me, as I'm usually good at clinical work (for pete's sake, I won an award for best clinician of my med school class when I graduated!). I doubt I'd be a terribly skilled therapist, and I believe that therapists should be skilled. I have some sensitivity to what people are feeling and am able to read between their words, but I'm finding that doesn't seem to be enough. In other words, I'd probably be a competent psychiatrist, but not an excellent one, and that's not good enough for me.
So for all these reasons, and one other big one (and maybe a few I forgot), I'm switching residencies to internal medicine. The other big one, obviously, is that I like medicine and miss it. I think I'd be pretty burned out right now if I'd just finished a year of medicine internship, so I'm trying to think pretty realistically (although sometimes I'm so desperate to escape my burn out that I get "grass is greener" syndrome and wish for medicine to fix my problem). I wasn't a fan of medicine as a med student, largely due to a certain attending who tore me a new one and then said I should go into medicine (which is a dumb reason to avoid a whole field, really). I clicked with medicine as an intern, though. I was good at it. I was my usual gets-too-flustered-when-paged, OCPD-I-might-have-missed-something self on medicine just like on psych, but I was better there. I was better able to see the big picture on medicine than I remembered, and less able to see the big picture in psych than I thought.
So there, that's my big announcement. Will switching residencies solve everything, or anything at all? Maybe not. It's not that I hate psych, because I don't, despite all the mean things I just said about her. After all, you have to care about something to get angry about it. There's nothing magical about doing internal medicine now (and many of the same problems exist there as well); I still don't know exactly what my career will look like from here (which makes me nervous), but I realized at some point in the fall that I could no longer see myself as a psychiatrist, and in November I realized I could see myself as an inpatient medicine attending, or supervising residents in a clinic, giving lectures to med students--in short, similar plans to what I had for psych, only now in medicine. I'm doing psych consults this month, which is giving me some closure (which I needed). I'll miss psych, especially during the sweet 3rd and 4th years of psych residency when they work 8-5 M-F and I'll be a ward upper level on medicine. I'll miss the intern class I came in with--they're wonderful people, and it has been a pleasure to watch them learn how to be doctors. The psych department is full of people who are special to me and I will miss them.
Fortunately, I'm staying within the same medical college, so the switch is relatively painless. I'll be a PGY-1.5 for 6 months, then start PGY-2 in January. This will put me 6 months behind for medicine, but 6 months ahead for psych. I still plan on doing a fellowship, so I'll be a trainee for a long time ahead.
I've thought about combining medicine and psych, and I think that's a definite possibility. I could run a primary care clinic for psych patients, for example. My psych program has offered to let me come back in the future if I want to do so; I haven't ruled this out (although I do NOT want to be a trainee for the rest of my life).
So now, on to different things. As of next Wednesday, I will no longer be a Tiny Shrink. As I've already changed the handle on this blog a couple of times, I think I'm going to close the blog out and maybe start a new one. If I do that, I'll post a link. As I struggle to find my identity as a doctor, I'm not sure it's fair to make my blog struggle with me. It's kind of like CSI picking a new lead actor when Gil Grissom's character left (or maybe not). So I think this is goodbye for now. I really appreciate anyone who has read this blog or left a comment (or indeed, made it to the bottom of this circumstantial, rambling mess of a post), and I thank you.
Tuesday, June 23, 2009
Today, I drove home from work post-call, crying. I had a busy, largely sleepless night, with the lovely addition of the onset of a head cold. I made it through the call shift, made it through my work shift in the morning, then headed to a feedback session with one of my course directors. The course was "Empathy" and involved interns listening to comments made by patients on tape, then delivering empathic responses back.
Tuesday, June 16, 2009
In brief, 3 of the nasally-applied Zicam products (which are sold as supplements, and therefore not regulated by the FDA) may be causing people to lose their sense of smell. The FDA has urged patients to stop taking the products, and has notified the manufacturer that they will not be allowed to market these products without FDA approval.
My favorite part of this article:
On its Web site, however, Matrixx says the allegations are "unfounded and misleading."
The company contends that "there is no known causal link between the use of Zicam Cold Remedy nasal gel and impairment of smell. No well-controlled scientific study has demonstrated a potential cause-and-effect relationship between the use of Zicam and diminished smell function. No court cases have revealed any reliable evidence of any causal relationship."
Well, whaddaya know! They know how to play ball! They may not have to do "well-controlled scientific [studies]" to prove that their homeopathic product works, but they want the FDA to produce one to prove it hurts people!
Does Zicam cause anosmia? I have no idea. Matrixx is correct that there is no current proof of a causal relationship. However, if we regulated these supplementary products, at least for safety if not for efficacy, then we'd likely know the answer to this question. Not that it matters, as I've never used the stuff, but as I like to be able to stop and smell the roses (or at least my gardenias), then I will probably avoid Zicam--just to be safe. One fewer day of cold symptoms or a lifetime of not being able to enjoy eating as much... not much of a choice, in my book.
Thursday, May 14, 2009
Sunday, May 10, 2009
Analyzed by Tiny Shrink at 8:24 PM
Sunday, May 03, 2009
I've decided that the one of the best ways to be mentally healthy is to garden. By this I mean I'm tired, cranky, burned out, and counting down my remaining calls, but when I drive home, I get out of my car, go into my yard, and just smile. I keep buying more and more plants to plant because it just makes me happy to putz around in the dirt. Yes, my ancestors were farmers, but I've never felt like I was particularly good at growing things until recently. My flowers are blooming, my trees are finally upright and that lovely dark green, and my herbs are tasty (I bought this the other day and it is AWESOME).I'll be making an announcement at some point on here, but I haven't decided how I'm going to do it yet. No, I'm not pregnant, nor did I get pregnant and sneak off to give birth, nor did I adopt a Malawian baby. For now, I'm just going to put up some pictures of my plants:
Sunday, April 12, 2009
Analyzed by Tiny Shrink at 4:04 PM
Wednesday, April 08, 2009
Tuesday, March 10, 2009
This whole "spring forward" thing just plain sucks. Chronic sleep deprivation + post call + losing an hour of sleep had me very unhappy this weekend.
Fortunately, the weather has been lovely, so we planted a tree and some azaleas this weekend. Now, I have new flowers, 2 new trees, a few herbs, and re-organized landscaping. There is something healing about planting something.
I'm not a great example of how to keep yourself healthy during internship, but I do my best. I'm averaging 1 workout per week, which isn't great, but it's better than 0 workouts per week (baby steps, people, baby steps). I'm really trying to eat better, making overall healthy choices and not drinking sodas unless I'm on call. I planted some green things in the ground. We're hanging out with our neighbors more often. I actually sat down with a huge stack of NEJM's, JAMA's, and Green Journals a couple of weeks ago and skimmed/read them all (which also got them off my coffee table). We bought a Roomba, which is helping keep the cat hair at bay.
If we could only invent a pill that instantly gave you all the sleep you were missing (without taking away the time to get all that sleep), I'd be set.
Monday, February 23, 2009
In psychiatry, even more than in internal medicine, we treat a lot of patients who are currently or have been homeless. From work I used to do at a clinic for homeless patients, I'm aware that there are different "levels" if you will of homelessness. There are people who stay with family or friends, people who live in motels, people who sleep in their cars, people who live in shelters, and people who sleep on the street. Sometimes whole families are homeless, but most of my patients are single. There are people who are transiently homeless, and people who are chronically without a permanent place to stay. Many are "mentally ill", but this covers a very wide range of possible diagnoses. I've met some patients with chronic psychotic disorders, often untreated, who have no family to look out for them and were homeless. Many of my patients, though, have personality disorders (usually narcissistic, borderline, or antisocial) and/or are chronic drug and/or alcohol abusers.
In psych, we refer to some of the last group as "having poor coping skills." In other words, they don't know how to be "grown-ups" as our culture and society mandates. Especially when substances are involved, their only method of coping with stressful situations may be to pop a pill or drink a bottle. They may come to psychiatric attention because of a suicide attempt or accidental overdose; sometimes they come to the emergency room voluntarily because they "feel suicidal" or "think I'm going to hurt someone". Patients in the latter group sometimes aren't admitted to the hospital, and are discharged back to the streets.
I've noticed that I have a bias against this latter group. Even though psychiatrists (and other physicians) treat substance abuse, many of us seem to think of these disorders as non-psychiatric and non-medical for some reason. It's easier sometimes to make allowances for someone with bipolar or schizophrenia than for someone who's "just drunk" or "just high" or "just a borderline". I think part of it is because there is such a large volitional component to drug use, ie, no one MADE them do the drugs (we assume), whereas no one chooses schizophrenia (although schizophrenics may choose not to take their meds, or may choose to do drugs). It's true that there is a heritable component to addiction, and also true that many patients start using substances as young teenagers (13-14 years old) before they're able to fully appreciate the consequences of their actions.
So why the bias? Why do I feel like I have a hard time treating these patients? (For that matter, I think many doctors have a hard time treating such patients). Part of it is the volition thing. Part of it is that there's a narcissism involved with substance abuse--people who are addicted care mostly about their addiction, and often (at least the ones who come to the psych ER) can be less than friendly. Some become outright abusive. Part of it is what some of these patients do to feed their habit--I've had some say they prostitute themselves, some who beg, and some who steal, and these are just the ones who talk about it. Some are on disability, which is frustrating to someone who works hard; why should they get their $3000 check per month and get to spend it all on crack?
It would also be different if these patients were asking for help with their addiction when I see them. Instead, many of them seem to be saying "the right words" to get admitted to the psych hospital because it's cold outside, or raining, and have no intention of quitting their drug of choice. This irritates me. It's a hospital, not a free hotel. If I admit all of these patients, then there's no room for the acutely psychotic patients wandering off from home or the manic who hijacked a bus.
One of my patients said something profound to me the other day. This person had been homeless in the past, and was facing discharge to the streets. The quote: "I've been homeless before, man, I've slept on the streets before. Man, when you're out there, it's like you're not a person anymore, it's like you're not a human being."
So how to balance humanity with doing the right thing, which often means denying these patients admission? I'll be honest, this is hard for me. I find this emotional balance to be very tiring. I guess just like the paging etiquette thing, I just have to keep trying. I don't have an actual solution, at least not yet.
Wednesday, February 18, 2009
Analyzed by Tiny Shrink at 11:35 PM
Tuesday, February 17, 2009
[Homeless patient receiving disability payments from the government, angry with me for not admitting him to the hospital to protect him from homelessness]: "I pay your salary, did you know that?"
[Sleepy, cranky me on call]: "...?"
[Well-rested co-intern the next day, upon hearing the story]: "Actually, my tax dollars pay for your health care AND my salary."
More Truisms from Psych Call:
1. The "urgency" of the patient in the emergency room is indirectly correlated with how late it is.
2. If you get angry and yell at me for being "racist" because I won't admit you to the hospital, it isn't going to make me relent--it's going to make me call security to escort you from the ER.
3. The potential dangerousness of the patient is indirectly correlated to the likelihood that the nurses will actually have changed him/her out of their street clothes, put them in a gown, and removed their belongings from the room. We've seen bottles of alcohol and sometimes weapons.
4. If you come to the ER with a wussy overdose attempt, like, taking a couple extra antipsychotic or antidepressant pills (barely over the therapeutic limit, and not a drug like lithium or a tricyclic), it is entirely possible that the ER doc will have the nurse place an NG tube and do a gastric lavage. No, I will not pull it out of your nose for you. Actions --> consequences.
5. The "urgency" of the patient in the emergency room is indirectly correlated to the likelihood they caught an ambulance to come to the ER. This holds true in most areas of medicine, not just psych.
6. The corollary to #5: the urgency of the patient is entirely unrelated to whether the police brought them in. Sometimes the police bring in the really outraged, psychotic, agitated patients who were swinging an axe at traffic; sometimes the police bring in the chronically suicidal "I called 911 and said I wanted to kill myself and no it has nothing to do with how much wine I drank tonight".
7. The lateness of the ER consult is directly correlated to my level of crankiness and indirectly correlated to my level of "give-a-shit"ness.
Sorry for the rant, but psych call is mentally stressful and involves dealing with a lot of manipulative people trying to angle their way into the hospital. I hope that venting like this will help me not burn out and be able to keep showing up for call. /crankiness
Sunday, February 08, 2009
Rules for Paging Properly:
1) If you are going to be allowed to page me incessantly, then you should be required to wear a pager so I can return the favor.
2) If you page me, please wait 5-10 minutes for a response before paging back. Heaven forbid I be answering another page, seeing to an emergency, walking in a hallway without a phone, or sitting on the john. I am very conscientious about returning pages and really try hard not to make you wait, but sometimes it's unavoidable.
3) Please attempt to coordinate your pages. Having 2 different nurses page me about the same patient within 30 seconds of each other (indeed, I received page #2 while I was on the phone with nurse #1) is a little annoying. Especially when said patient isn't actually dying of a heart attack or writhing in severe pain, but "just wanted to talk to the doctor."
4) I know mistakes happen, but please attempt to look through the medications before paging me to say Ms. so-and-so needs a sleeping pill. If I stop what I'm doing and pull up the chart only to find Ambien in their list of meds, it's a little irritating.
5) Blood pressure of 135/anything does not excite me and I do not need to be paged for this, unless it was 220/190 5 minutes ago (in which case, why are they on a psych floor?).
6) The primary team arrives around 8 am M-F. I do not need to be paged at 7:20 (while I'm trying to check out and leave) for 2-day long sore throats or potassium of 3.2 drawn 4 days ago. I appreciate your incentive and that you are trying to help care for your patient, but it can wait.
7) When possible, please page me to an extension you'll be easily reached at. If you page me and I call you right back, only to reach someone who puts me on hold "while I find out who paged you", I get a little irritated, especially when this happens frequently.
8) Perhaps most importantly, when I call you back, please introduce yourself and state the patient's name clearly (perhaps even spell it) before rushing into the story of how the patient has an urgent foot rash. I have some hearing problems--not your fault--and I will have to interrupt your story to ask you to repeat the name, spell it, and wait while I access that patient's chart in the computer before you get going again. Also, if you have a non-American accent, it is going to be difficult for me to understand you over the phone, especially if you speak rapidly.
9) On my end, I promise to keep trying to answer pages promptly, identifying myself clearly when I call back, being really nice (or at least non-snarky) when I answer, and trying to educate the people paging me about appropriate paging. (Hey, I said "trying", didn't I? Stop looking at me, swan!) I know I fail at this frequently, but I really do try, I swear. I don't like paging people only to get yelled at, so I don't want to be the person yelling.
Monday, January 26, 2009
I'm taking psych call this month at a large hospital. Call duties include consults from the ER, consults from the med/surg floors (rare, since they're after hours or on weekends), "behavioral emergencies" throughout the hospital, and covering the inpatient psych unit, which houses 40-50 patients. I would just like to throw in there that my psych calls are nearly as stressful as my medicine float shifts--psych call is not easy.
A couple of weeks ago, my urology elective experience suddenly and unexpectedly came in handy.
(If you're squeamish, stop here.)
I had just returned a page from the nurse in the emergency room and was hearing about a patient I had to see (the usual "super urgent" med refill type) when I received 2 pages in about 1 minute from the floor. GODDAMN, dude, I'm on the phone with the emergency room! I'm sorry, but people need to learn some pager etiquette!
I returned the page with a slightly snarky "Did someone page Dr. TS TWICE? Can I help you?"
A slightly panicked male nurse answered "Yes, doctor, patient so-and-so has gotten his, ah, his penis caught in his zipper."
"Uh, is it, uh, is it still stuck? Is it bleeding?" (I was stuttering and nearly speechless)
He assured me that it was not bleeding, but was still stuck. Holy Christ! I called the ER and told them I had a medical emergency to deal with on the floor (at which point I was "reminded" that there's a policy to see ER patients within 20 minutes of arrival--Eff You, guidelines! The nurse actually asked me why the floor nurses couldn't just "deal with it" themselves. Um, it's not YOUR junk caught in a zipper, but if it were I doubt you could wait an hour while I deal with Ms. "I didn't know how to operate the automatic refill telephone number"). I raced upstairs.
The patient was lying on his bed so calmly I didn't realize it was the right man, until I saw his fly hanging open. It seemed to be an accidental injury (although I'm sure weirder things have happened). I donned gloves and did a quick inspection--whoo-ee, that skin was really wrapped in the zipper. (I warned you about the squeamish thing!) I left the room and paged urology.
"Um, hi, this is the psych intern. I have a patient with his penis caught in his zipper. What do I do?"
Uro: "You pull."
WTF??? ARE YOU KIDDING ME???
He wasn't kidding. I went in and attempted to pull on the zipper, but the patient freaked out (naturally) and wasn't going to tolerate it. I paged urology back and explained the situation.
Uro: "I can come up there if you want, but I'm just going to pull harder."
The nurse on duty wouldn't let me take the patient down to the emergency room, since "this is a hospital up here, there's no reason a patient can't get treatment up here just like anywhere else." I had no choice. I asked for a bottle of lidocaine, a syringe, and some wound dressing materials. We got the patient into the treatment room, I did a little local anesthesia, gave him a Vicodin, donned my gloves again, and PULLED.
It didn't budge (but at least this time the patient didn't feel a thing).
We found a suture removal kit with a pair of forceps, which I used to try to get a grip on the zipper. This time when I pulled, it moved a teensy bit. I had the male nurse try to pull, I tried to pull, but we made almost no headway. I carry trauma shears in my pocket (you never know when these bad boys will come in handy) so we tried cutting the zipper off the pants and then cutting the zipper in half. Now, we were left with even worse leverage. I was beginning to freak out, thinking OMG WTF I JUST RUINED THIS MAN'S PENIS!
The patient started talking to us at that point. He said he'd had this problem before (WTF???) and had seen a doctor with similar complaints before. He then reached down, grabbed hold of the zipper, PULLED, and the zipper broke in half; he PULLED again and it came off his skin. I nearly fell over with shock, amazement, relief, and nausea; the male nurse had turned around and was unable to watch.
True, he had several lacerations that I cleaned with iodine and dressed with ointment. I put him on some antibiotics (his hygiene wasn't so great, and god only knows what was on that zipper), and we found him some sweatpants and some briefs. I also lectured the patient on a) wearing underwear and b) tucking it back while zipping up his pants. Honest to god, this was a grown man. I actually told him "Dude, you only have one of these, TAKE BETTER CARE OF IT."
One of the highlights of the evening: I wrote an order in the chart to this effect: "Patient to wear briefs and non-zippered pants while injury heals."
Not exactly what I had in mind when I signed up for this (but certainly a great story!)
Saturday, January 24, 2009
If you have a few minutes and want to read about the history of nationalized medicine in England, France, and Switzerland, as well as the history of how the American health care system came to be, and even the American telephone system(?!), go read this article by Atul Gawande in The New Yorker. Go, now.
I found the link at Kevin, MD. Congrats on Best Medical Blog of the Year!
Friday, January 23, 2009
I've long admired the attendings who really know EBM. I have aspirations to be one someday: have an office filled with articles to print out for residents, know which trial said what, who conducted the important trials, be able to read articles critically and pick up on subtle clues that the research was or wasn't great.
I initially said "always" instead of "long" in that first sentence, but I changed it. My first experiences with EBM were pretty pointless. In our first year of med school, we took a mini-class in statistics, where we had to memorize the "ABCD" tables and what sensitivity/specificity meant. It didn't make much sense to any of us, and everyone groused through the course. That summer, I had to do a project for my preceptorship that involved "PICO" questions. They're ridiculously easy to write, so I couldn't figure out why I had to do so many. I was told that I needed to learn how to search Pubmed properly, so I had to have a good question. Later, I had more lectures on how to search Pubmed well. Seriously, people, most med students now are pretty familiar with Google or other search engines and know how to conduct a quick internet-based search to get what they want. Sitting through stifling lectures about "boolean operators" and learning the difference between searching with AND and with OR... Shoot me.
I think med students may get turned off by the statistics and the uselessness of learning how to search the internet and lose sight of why EBM overall actually matters. It has very little to do with PICO questions, after all.
The way I see it, EBM has several points. First, doctors should know how to critically appraise an article, so when the drug rep hands you the article about linezolid vs vancomycin you aren't blindsided by the pretty graphics. Second, doctors should know how to search the literature to find answers to clinical questions--this is where PICO comes in, but it isn't always necessary to go through that whole process. Still, if you want to read the actual study that UpToDate based their guidelines on, you should have an idea of where to find it. Third, all of this critical appraisal *should* lead to evidence-based guidelines for treatment. I know many doctors get upset at the idea of "cookbook medicine", but I'm all for some standardization (with final discretion always with the doctor and the patient, of course). If the literature said Drug X is very good in diabetes, but not Drug Y, then I think a doctor who wants to prescribe Drug Y to a diabetic should have a really good reason for doing so.
So what are the downsides to EBM? Why isn't everyone doing it? I think there are several potential problems:
First, while the randomized controlled trial is the gold standard for testing therapies (new drugs, new imaging, new surgical techniques & devices, etc), not everything can feasibly have an RCT. Pregnant women and children are often overlooked for studies, because who wants to have their fetus or small child experimented upon? The elderly are often excluded from studies, as are the really ill patients. Thus, RCT's often ignore whole populations that may need a treatment, so then we have to try to extrapolate the results to an untested population (or, if you're a purist, just say "there's no evidence for X in pregnant women" and don't treat). Diseases with very small numbers of patients may be studied in fantastic trials that can't reach statistical significance due to lack of power. And sometimes, you just can't randomize people to have a certain condition--see the satirical "Parachute use to prevent death and major trauma related to gravitational challenge: systematic review of randomised controlled trials" from the BMJ.
Second, there's often a disconnect between study data and clinical practice guidelines. You don't usually base guidelines on the results of one study, but sometimes that happens--see the WHI hoopla. A treatment may become standard of care based on one study (like using steroids for spinal cord injury) and then even when later studies debunk it you can't change the standard of care (defensive medicine, anyone?). Other times, it takes years and multiple studies to "prove" something works or doesn't work, meaning at any given time the guideliness available are many years behind the evidence. Also, guidelines are written by "panels of experts", so sometimes it's difficult to tell what's truly EBM and what's "expert opinion".
Which brings me to my third problem: we in medicine haven't done a good job of selling the public on EBM. Patients don't really know about sensitivity and specificity, false positives and false negatives, statistical likelihood of disease, number needed to treat, etc. How many people would take Lipitor if they knew that between 100-250 people have to take it to prevent one MI? How many people would clamor for increased HIV testing in the ER if they were the patient with the false positive who had to go through the extra testing and fear of having HIV? Even worse, one may still be sued successfully for following EBM practices when it results in a poor outcome.
Fourth, there's a wide disparity of practices between patients with money and good insurance and patients who do not, or even between geographic areas. In a rural area, if you have stable angina, you're likely to get nitro; in an urban area, you're likely to get a cath. Do people in urban areas live longer? (I don't know, but I haven't seen the evidence). I feel like one goal of EBM *should* be to reduce some of these types of disparities, but it hasn't really happened. The growth of medical technology outpaces the body of literature.
Finally, what do we do when there is no evidence? Many of us are not comfortable doing nothing, and many patients are not comfortable doing nothing. For example, when a patient has viral bronchitis, we know the evidence says DO NOT GIVE ANTIBIOTICS. Yet, patients still come to the doctor with cough and runny nose. There's no evidence for giving cough syrup or inhalers, yet I think many of us do so, simply for the sake of doing something (and to get the patient off our backs about the freaking antibiotics, the answer was NO).
So why do I heart EBM? I feel that it's the best system out there for keeping abreast of the unbelievable amount of medical knowledge available. Sure, it's got flaws, and perhaps in the future a new system will come along and wipe EBM off the map, but until then we should use what we have.
You can wake up now, I'm done.
Monday, January 19, 2009
Monday, January 12, 2009
This dude gave a quote for a smoking-related article on CNN that I think is a) dumb and b) illustrates a point about paying for healthcare.
So, $139 is too much to pay to quit smoking (when apparently everything else this guy has tried has failed)--fine. But to imply that "they" would rather pay for lung cancer... when the treatment would involve some combination of surgery, radiation, and/or chemotherapy, along with hospital stays, and medication, and would cost THOUSANDS of dollars, that makes $139 seem more like a bargain. Essentially, this guy is saying that $139 out of his pocket is intolerable, so he'd rather make his insurance/Medicare/Medicaid (or whatever health coverage he has) pay for lung cancer instead--because clearly, if $139 is too much for this guy, then thousands is beyond his reach.
Retired radio broadcaster and iReporter Gerald Dimmitt, 65, has smoked since he was 14."I've always smoked a pipe," he said. "I have successfully quit about 40 times." But, he says, he always restarted, because "it calms me down."
Dimmitt has even more incentive to quit now, since developing lesions and irritation in his mouth. After speaking to his doctor, he received a prescription for Chantix, a pill to aid with smoking cessation. But when he went to pick up his prescription at the pharmacy, he was charged $139 (because it's not generic) for two weeks worth. Outraged, he left the Chantix behind.
"If smoking is so dangerous ... why then do they want to charge $139 to make me stop? There is something very wrong with that. I guess they would rather pay to take care of lung cancer," he said.
I'm largely a supporter of some form of universal health care (although not single-payer), but I'm still torn on some issues, and this is one of them. This guy is going to deliberately forego a treatment that could help him stop smoking and save himself and his health insurance (or Medicare/Medicaid, I don't know what he has) thousands of dollars because he doesn't want to pay out of pocket. Essentially, his insurer is now going to pay for his poor judgment that he's acknowledging publicly on CNN.com.
Now, is the answer to subsidize anti-smoking therapy? Maybe that's not a bad idea, if we're going to suggest banning smoking on federal property and such--use penalties on one side and rewards on the other, give a little extra incentive. Is the answer to penalize such people who are deliberately NOT trying treatment which may be effective in quitting who are deliberately placing an extra burden on the health care system? Maybe--in the private insurance world, these people may already pay a higher deductible, and I'm okay with that. I think that even with a universal health plan, people should be required to pay for part of their health care. ER visits should cost money. Prescriptions should cost money, especially brand-new brand-name meds like Chantix (although I'll admit, $139 for 2 weeks does seem steep).
I just hope his insurer read his little "comment". I guess it's less "dumb" than I initially thought, because if his insurer will pay for his lung cancer why should he pay to quit smoking? Oh, I don't know, unless he'd like to LIVE without CANCER. Because lung cancer kills you. People (myself included) need to take some freaking responsibility with their own health.
Now I'm all riled up to start my Monday. Grrr.
Friday, January 09, 2009
I'm learning the ropes in psychiatry, and one issue that comes up is "commitment". Why is it that you can "commit" a patient to the hospital for their schizophrenia, but not for their myocardial infarction? What is the difference? How are the procedures different for each? What if the patient wants to leave AMA? I think there's a lot of fear and misinformation surrounding this topic, so I'd like to delve briefly into how a medical hospital stay is similar to and different from a psychiatric hospital stay.
If Mr. X walks into the emergency room with chief complaint of "chest pain", he gets triaged to the medical ER. Likely within a few minutes he'll have an EKG and cardiac enzymes done. If the EKG shows massive ST elevation and the troponin is elevated, the doctor will say "Mr. X, you are having a heart attack. You need to come stay in the hospital to have treatment."
Mr. X has two options at that point: say "sure doc" or "no way". If he says yes, he signs the consent form and is off to the cath lab. If he says "no way", it's a little more complicated. Is he delirious? Is he drunk? In other words, is he in his right mind and able to make this decision? Is he unconscious without family around--if so, you treat emergently and let the consent work itself out later. If he is not delirious, you assess him for capacity to refuse treatment: does he know what a heart attack is, does he know what the treatment is, does he know he could die without treatment, does he know he could live with the treatment? If he meets capacity and says "doc, I know I could die if I leave, but I do not want treatment" then he signs a paper stating that he is leaving Against Medical Advice (AMA) and walks out the door. The procedure is the same if he's already on the floor and decides to leave.
What if Mr. X is delirious? What if his brain is deoxygenated and he's agitated and trying to leave, but only yesterday he told his wife "absolutely treat me if I have a heart attack?" In this situation, you can obtain consent from his wife (or next of kin) for treatment and pursue treatment. If you document that the patient does not have the capacity to refuse, and you feel that the benefits of treatment likely outweigh the risks, and that they are "not themselves" (disoriented, delirious, etc), then you now have the ability to use restraints against this patient if you need to do so. Ever see the patients tied down in the ICU so they won't pull out the vent tube? A patient who is septic, hypotensive, and delirious may try to pull out a tube--they're uncomfortable--and clearly doesn't know that what they're doing can kill them. That patient is at that moment being held and treated against their will, so this is not something you take lightly. Restraints usually have to be assessed every few hours by a doctor, and patients may need to be sedated so they don't a) have discomfort that led them to try to pull the tube out in the first place and b) fight against the restraints so hard they have rhabdomyolysis.
Therefore, not everyone in the medical hospital is there with their consent. An adult with capacity may consent to or refuse treatment and this should be honored. An adult without capacity to consent to or refuse life-saving treatment may be restrained in certain situations. The family may provide consent for treatment if the patient is incapacitated (which is how we end up with so many demented patients in the ICU--another issue altogether).
So how is it different in psychiatry?
If Mr. Y walks into the same emergency room with chief complaint of "I want to kill myself", he gets triaged to the psychiatric ER. Shortly thereafter a doctor or "mental health professional" (maybe social worker or PA) will assess the patient and perform a mental status exam. If the patient is very depressed, still says he will kill himself, and states that he keeps a loaded gun at home just for this purpose, the doctor will say "Mr. Y, I'm concerned for your safety. You need to come stay in the hospital to have treatment."
Mr. Y has two options at that point: say "sure doc" or "no way". If he says "sure doc" then he signs a consent for mental health treatment and is admitted to the psych unit (after some basic labs to be sure there's nothing major medically wrong at that moment). If he says "no way", then it gets tougher. If his risk of committing suicide seems very high, as in he is an elderly Caucasian male, feels hopeless, has no family, lives alone, has a firm plan for death, is in dire financial straits, and it's the anniversary of his wife's death, then you may make the argument that he is in imminent danger of harming himself and should be admitted to the hospital. (If his risk is low, he's a "frequent flyer" in the ER who uses this line to get a warm bed because the shelter was full and his check is spent, etc, then "Sayonara!") You may also argue that the patient's severe depression is preventing him from making rational decisions or having full capacity to refuse treatment.
For psychiatry, instead of having the family sign the patient in when they refuse but lack capacity, you file paperwork with the court--legal "commitment". This varies from state to state, but usually involves some manner of stating that the patient is in imminent danger of harming himself or others, lacks capacity to refuse due to mental illness, and will acutely decompensate and/or likely kill himself if allowed to leave without treatment. The patient will be brought to a locked psych unit and will remain until treatment is completed. Patients who are on "involuntary" status don't necessarily stay longer than "voluntary" patients; it simply means that they must stay until a physician releases them or the court determines that they may be released.
Now, if Mr. Y signs himself in voluntarily, but 4 hours later decides he wants to leave, what do you do? On the medical floor, the patient asks to sign out AMA. In the psych unit, they ask for essentially the same thing. Different states have a different procedure for doing this, but the patient must ask for a document stating that they want to leave (essentially AMA). A doctor must come examine them within a certain period of time to determine whether the patient has capacity to leave. Mr. Y in our example above told us 4 hours ago he wanted to kill himself and has a gun. If the doctor examines him and he says "doc, I want to leave so I can go kill myself", then the doctor is going to have to file paperwork to commit him to the hospital--after he's already there. If the patient is stable, and doesn't meet criteria for legal commitment, then you must let them leave AMA after they request it.
We often err on the side of having patients sign in voluntarily so that the patient isn't forced to be committed legally, but sometimes that leads to a double standard (in my opinion)--we're saying the patient has capacity to accept treatment (which we want), but not to refuse (which we don't want). I think one reason we do this is because we want to use the commitment process as infrequently as possible. Once a patient has been committed, this becomes a matter of public record with the court, where if they sign in voluntarily this is covered by HIPAA.
Legally, it's all very complicated. Due to some abuse of commitment in the past (in this country and others) a very complicated set of rules must be followed. The patient must meet criteria for admission (usually reserved for acutely suicidal, acutely psychotic, acutely manic, etc) and be either about to commit suicide, about to hurt someone, or be completely unable to take care of themselves (the manic patient wearing their undies in the snow to preach the gospel in the middle of the street, for example) to the point that they cannot practice basic safety. Once you file paperwork with the court stating that you've examined them and they should be committed, they'll be assigned a court date. After around 72 hours, a second exam must continue to document that patient still requires involuntary hospitalization. The case will go before a judge at some point who will either confirm the commitment until a doctor says they may be released or will deny the commitment and order the release of the patient.
You can also order emergency medication. After his heart attack, Mr. X became hypotensive and was acutely bleeding, and was unconscious so he couldn't sign the consent for blood products; he will still be transfused. After his admission, Mr. Y became acutely psychotic and agitated, tried to throw tables at the staff, tried to punch through a glass window, and refused to take his meds; if he refused to take an oral med, he would likely get a shot of something sedating (usually haldol 5 mg + Ativan 2 mg) to calm him down. If Mr. Y continues to refuse to take his meds, continues to be agitated and dangerous, you can petition the court to order medication.
Some people would argue that the two aren't the same at all. After all, the patient with the MI who is bleeding is going to die; as my med student put it yesterday "well, psych stuff isn't life-threatening." It depends. Even patients in locked psych units can commit suicide if they're determined enough; they can commit homicide, they can attack other patients or staff. A condition called "agitated delirium" or "excited delirium" can actually cause a patient who is so overstimulated by their psychosis (and often by drugs) to suddenly drop dead. Maybe it's not as clear cut as the MI situation, but psychiatric patients can die from their disorders or related complications. Speaking for myself and the people I work with, we wouldn't put someone in the hospital against their will and medicate them against their will if it didn't seem vitally important to that patient's ability to survive.
Legal commitment remains controversial; just look at the wikipedia page. Obviously, there is some overlap with this and medical treatment, but some striking differences as well. I think we should continue to work very hard only to use involuntary hospitalization and forced medication when absolutely necessary. Judicial oversight helps keep the process honest, but I'm sure mistakes are made. It does help to compare it to what happens in the regular hospital; if you're out of your right mind and lack capacity you're not leaving, whether it's post-MI or the aliens infiltrating the TV set. If you need emergency IV fluids or emergency sedation, it's an emergency, period. This is a rather awesome power doctors wield, and I'm kinda glad there's a judge looking over this process.
Sunday, January 04, 2009
And it's a lame one. I've been busy, blah blah blah, vacation/work/learning psych call. All the same old excuses, and largely the same ones I use when I don't go to the gym. Hmm, methinks I need some new excuses! (Or I need to get my fat butt to the gym--I gained at least 5lb on that cruise, but at least the food was amazing!)
Happy New Year to you and yours!
And for the love of god, if it's not too late, try not to take your first disability check of the year and go celebrate by snorting/shooting up/smoking >$100 of cocaine. Try to pace yourself, or you're going to end up in a psych ER seeing and hearing Satan telling you to kill yourself, and that's just not pleasant.