02 May 2011

Relevance, irreverence

Were I not taking a year off from med school, I could be a doctor soon.

This sounds obvious. Yes, in the practical sense, in 12 months I would be an MD.
Instead, I’m doing three months of fourth year before taking off for an MFA. The fourth year schedule (for later) is so flexible that I could actually spend an entire quarter not here, doing a third semester of my MFA in an entirely different city. And graduate with an MD.
Soon, I could be an MD.
I won’t be.

To take a leave of absence, you have to formally withdraw from school. The form asked what I’m doing - simple. Then it asked what the relevance is. Relevance. (the career advisor/head of ob/gyn department asked me the same question. Relevant. How is poetry relevant. I’m not going into ob/gyn, anymore*) .

*for many reasons, but the above was probably influential on some level

Sometimes, in progress notes, admit notes, presentations, we put this more delicately. Call it “pertinent.” What is the pertinent past medical history, pertinent family history, pertinent social history. “Go do a focused history and physical.” Then, present, giving the pertinent positive* and negative* findings.

* “Positive” is something in the history or physical that would support a particular diagnosis; “negative” is something not present that could have supported the diagnosis/could refute it by not being there. Or, in the case of some things things, including a diagnosis as generally benign as strep throat, not having a cough makes the case more likely that it’s strep. Pertinent negative.

Is his appendectomy 25 years ago relevant? No. (unless there was excessive bleeding or some other unusual reaction) .

Is her mother’s breast cancer at age 84 relevant? No, not to her health risks. (but did her mother die recently? Was she taking care of her mother? Did she live with her mother?)
What about my patient’s son’s other mother’s history of joint problems – was that relevant to his twisted ankle (broken or not?) after jumping down from the bed? No, the other mother (the mom sitting with me – her wife, she called her) wasn’t his biological mother, though it was her brother who was the sperm donor. (But in asking that one question of family history – lax joints/bone problems/connective tissue disease? I learned about the family structure, the genetics, the relationships in this child – my patient’s – life) .

Is the patient’s chest pain relevant? Well, we’ve effectively ruled out a heart attack, but there are a few other physical conditions it could be. (But, has he had any life changes? New stressors? Anxiety attack?)

The patient with insomnia doesn’t just get ambien – he gets asked why. And you should screen for physical conditions that could be contributing. And you should ask about depression. Relevant.

Doctors redirect because patients don’t know what is relevant and what is not. There’s something learned over time – the right questions to ask, and how to ask them. And in presenting, what's necessary to say. 
There are patients who ramble.
There are patients with whom I dread doing a review of systems.

Technically, there are 12 points to go through. (How often are all really covered?)
Any changes in your health?
There are the favorites. We ask in one breath – as if a patient can remember them all, or anyone who doesn’t anticipate the list can answer them in order. These can be abbreviated by one letter each, usually, written with slashes in-between, after a +/- or denies*/endorses**.

*As if the patient might be lying
**As if the patient is selling a particular product: her body? how her body functions?

Fever, chills, weight loss? (No, you don’t have cancer) .
Changes in appetite/Nausea/vomiting/etc? (then I won’t worry about that system)
Any changes in your skin? (What kind of changes? Too many to enumerate, so it gets short-handed. Changes. Anything you’ve noticed (and if there’s something that you didn’t notice, what do I imply?)
More bleeding/changes in bleeding? (Are you losing more parts of yourself? Is there more blood inside your skin, or out of it?)
. . it goes on.

Anything else I haven’t asked about or that we haven’t discussed? Anything else you think I should know?*

*What should I know? What do you want me to know? I hear about divorces, children in jail, someone sick at home, someone dying or dead, a house being repossessed, an upcoming trip, evening plans. I hear family history and favorite colors, I hear how much they like my shoes (especially all the bright red ones) .

As we move ahead in medical training, we have to move faster. It does become easier, to take less time, elicit the needed information, and establish a relationship with the patient. I don’t have to write everything down right away, I can chat as I do the physical exam, I can remember. But I have to move faster.

I want relevance-to-right-now. There are the patients who will tell me about the one episode of indigestion a week ago, how their ankle hurt last week and there was that one day they couldn’t sleep very well and there’s one bruise they got 3 weeks ago, they’re not sure why but it went away. . .and then a few days ago he felt like he had a fever, but maybe not, and maybe it was a little warm at night. . . oh, and then his tooth kinda hurt in the morning, and he kinda had acid reflux after eating spicy things, but that just happened the one time, and then. . .he gained two pounds in the last 6 months, should he be worried about that? And actually right now he’s a little bit tired, and maybe his foot is sore again. . .

(am I still listening? half. I’m also writing at the same time. Trying to pull out what I think I need to know. And I’m interrupting and redirecting, a lot. It’s necessary. The story – even if it’s a medically relevant story – is convoluted and confusing and I need to understand it in order) .

This is a patient who, in the ER, was told “he says” that he had the largest habitus they’d ever seen! on abdominal ultrasound. (Everything with him was largest/worst/shortest time to live any doctor had ever seen) . Habitus means space inhabited by the body. (Ie, in this case, abdominal fat seen on the ultrasound.) At least, here, I could assure him without a doubt, that, no, it wasn’t the largest habitus we’d ever seen (I tried to explain what it was. He kept insisting it was something pathologic) . Fine. But I promise we’ve seen larger habitus and that it’s not dangerous to him right now.
(Am I exaggerating? No.)

Problem with the above.

The patient (saying it’s one) actually has had a heart attack and actually has a potential mass on his liver. But who is going to listen, who is going to sift through the irrelevant for the relevant.
The patient doesn’t know what I want to hear. He doesn’t know what’s most important to me or what’s most important to his health. He wants to tell me everything – it’s what he perceives, and some is frankly medical. Some is not.

That he’s living in a trailer in his brother’s backyard and his brother might kick him out? Relevant, relevant, relevant.

And not just in psychiatry.
The head of the psychiatry department actually told me, “You might start out as something else. You might start out as an internist, and that’s fine. Eventually, you’ll be a psychiatrist.”
(do I think so? unlikely, but he’s a professionally perceptive person) .

He said to me, “If you don’t do psychiatry, there are whole parts of you that you won’t be accessing.*” In psychiatry, you bring everything that you are and all of your experiences into your practice. Everything you’ve done is important. Everything is relevant.” Everything you are reverberates. Reverent.

*reference to writing, arts

Relevant to patients: where I’m from? I’d venture yes, but also allow debate on that point.

My religion? I move that back to the patient. The “it’s important what you think. What matters to you.”

My politics? – there’s one I may cross the line on, sometimes – I can’t help but speak my mind. Only in relation to healthcare and immigration status. (And this one isn't generally asked). 

Are these irreverent? No. There have been almost no questions that I did not feel comfortable answering.

Diabetes, high blood pressure, high cholesterol, “lifestyle modifications”, medications? Most patients could care less about these, most of the time. But these (stress/tension) headaches. . . (I can’t do anything about) . Relevant to me. Irrelevant to the patient.

People look at me funny when I say what I’m doing next year. Pause. “and. . .how did you think of that?”


To end on a point that makes me irate everyday –
in many clinics, the patient’s insurance/insurance status is noted on the chart. Physicians have to prescribe by formulary, which is decided by each insurance company/Medicare and Medicaid.
Yet a lot of patients (my patients, past, present, and future) are not eligible for any of those programs. We’re deciding who might get to have a better quality of life or even live longer. I had a patient who was not deemed eligible for a kidney transplant because his wife, not him, was a polysubstance (drug) user, and you’re supposed to/required to have support to help you after the transplant. This counts for the transplant committee. He was deemed "futility of care." Nothing else to do.

Relevant? Yes.

Who are we prioritizing, as all the disqualifying factors are so complex and socioeconomically linked?

Should be irrelevant.


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