On a Personal Note

UNINVITED GUEST





Oh, Culex, you uninvited guest

Who kissed me, spreading your exotic gift

And leaving me weak, feverish, seeing double

And becoming suddenly a modern statistic.



Oh, Culex, where are you now?

What life are you going to challenge next?

Stay away. I'll be back.

And, you know, Culex, I have never been to Uganda.

Satisfactory and Effective Communication in Medical Care and Treatment

The medical humor in the last post virtually all point to the importance of and necessity for satisfactory and effective communication in medical care and treatment. As a member of a hospital ethics committee, I can attest to the fact that often what comes to the committee for resolution as an ethical conflict is not so much an ethical issue but a problem in communication between a physician and a patient or family or between physicians themselves or with their hospital nursing staffs.



In an outpatient setting, the study by Keating, Nancy L. MD, MPH; Green, Diane C. PhD, MPH; Kao, Audiey C. MD, PhD; Gazmararian, Julie A. PhD, MPH; Wu, Vivian Y. OTR, MS; Cleary, Paul D. PhD "How Are Patients' Specific Ambulatory Care Experiences Related to Trust, Satisfaction, and Considering Changing Physicians?" in the Journal of General Internal Medicine V.17, Nr. 1 pages 29-39, Jan 2002 statistically confirms the need for better doctor-patient communication.



The objective of the study was "To assess the relationships between outpatient problem experiences and patients' trust in their physicians, ratings of their physicians, and consideration of changing physicians. We classified as problem experiences patients' reports that their physician does not always 1) give them enough time to explain the reason for the visit, 2) give answers to questions that are understandable, 3) take enough time to answer questions, 4) ask about how their family or living situation affects their health, 5) give as much medical information as they want, or 6) involve them in decisions as much as they want." 2052 patients were contacted in a 1999 telephone survey. "Most patients (78%) reported at least 1 problem experience. Each problem experience was independently associated with lower trust and 5 of 6 with lower overall ratings. Three problem experiences were independently related to considering changing physicians: physicians not always giving answers to questions that are understandable,not always taking enough time to answer questions, and not always giving enough medical information."



In conclusion the authors state "Although most patients' experiences with their physicians are good, those that are not may have important consequences, including lower trust, lower ratings of physicians, and greater likelihood of changing physicians. More physician training in communication skills, particularly focused on answering questions in ways that patients can understand, taking enough time to answer questions, providing adequate amounts of information, and discussing differences in opinion about whether tests, procedures, or referrals are needed, may strengthen patient-physician relationships. This type of training is effective and should be a priority of residency training programs, medical schools, medical groups, and health care organizations."



Interestingly, though the importance of good communication is stressed in the business world and efforts are taken to improve communication skills with specific courses and consultations and there is some effort in medical school education to teach proper communication skills, virtually none is taught when the physician is in practice. There is a need for the medical community to show as much interest in improving medical communication as it does for improving diagnosis, medical drugs and treatments. ..Maurice.

Doctor Jokes: Reflections of Issues of Professionalism

For a change of pace, I am posting today examples of medical humor: "doctor jokes" from The Doctors Lounge where more humorous presentations are available. Notice how some of these examples of patient/doctor interaction seem to arise from professional issues which I have posted in the past month. If you know of some jokes that fit this point, click on comment and post them. ..Maurice.

· A man goes to his doctor and says, "I don't think my wife's hearing isn't as good as it used to be. What should I do?" The doctor replies, "Try this test to find out for sure.

When your wife is in the kitchen doing dishes, stand fifteen feet behind her and ask her a question, if she doesn't respond keep moving closer asking the question until she hears you."

The man goes home and sees his wife preparing dinner. He stands fifteen feet behind her and says, "What's for dinner, honey?" He gets no response, so he moves to ten feet behind her and asks again. Still no response, so he moves to five feet. still no answer. Finally he stands directly behind her and says, "Honey, what's for dinner?" She replies, "For the fourth time, I SAID CHICKEN!"



· "Doctors at a hospital in Brooklyn, New York have gone on strike. Hospital officials say they will find out what the Doctors' demands are as soon as they can get a pharmacist over there to read the picket signs!"



· The difference between a neurotic and a psychotic is that, while a psychotic thinks that 2 + 2 = 5, a neurotic knows the answer is 4, but it worries him.



· Doctor: I have some bad news and some very bad news.

Patient: Well, might as well give me the bad news first.

Doctor: The lab called with your test results. They said you have 24 hours to live.

Patient: 24 HOURS! That's terrible!! WHAT could be WORSE? What's the very bad news?

Doctor: I've been trying to reach you since yesterday.



· A man speaks frantically into the phone, "My wife is pregnant, and her contractions are only two minutes apart!"

"Is this her first child?" the doctor queries.

"No, you idiot!" the man shouts. "This is her husband!"



· A List of Things You Don't Want to Hear During Surgery:



Oops!

Has anyone seen my watch?

Come back with that! Bad Dog!

Wait a minute, if this is his spleen, then what's that?

Hand me that...uh...that uh.....thingy

What do you mean he wasn't in for a sex change!

Damn, there go the lights again...

Everybody stand back! I lost my contact lens!

Well folks, this will be an experiment for all of us.

What do you mean, he's not insured?

Let's hurry, I don't want to miss "Bay Watch"

What do you mean "You want a divorce"!

FIRE! FIRE! Everyone get out!



· A man goes to his doctor for a complete checkup. He hasn't been feeling well and wants to find out if he's ill. After the checkup the doctor comes out with the results of the examination.



"I'm afraid I have some bad news. You're dying and you don't have much time," the doctor says.



"Oh no, that's terrible. How long have I got?" the man asks.



"10..." says the doctor.



"10? 10 what? Months? Weeks? What?!" he asks desperately.



"10...9...8...7..."



· The seven-year old girl told her mom, "A boy in my class asked me to play doctor."

"Oh, dear," the mother nervously sighed. "What happened, honey?"

"Nothing, he made me wait 45 minutes and then double-billed the insurance company."

Medical Student Abuse

As I noted in a previous posting, there currently is a problem in the education of medical students about professional behavior including humanism. They may be given explicit information during their first two years of medical school but by the 3rd year and beyond this information may be degraded by their tacit learning attending to patients under supervision of their superiors. They may “learn” wrongs from their superior’s misbehavior and yet many students may find it impossible to avoid this in view of the pressures, self-interest and abuse they will encounter. Yes, I wrote abuse. You have heard of child abuse, elder abuse, spousal abuse and abuse on the job.. well, there is also medical student abuse which has been going on for years and years. Many older physicians have never looked at this behavior as abuse but only part of the initiation ritual which they themselves had to survive during their formative years.

From the American Medical Association News in 2000:

Mistreatment of medical students appears to have declined during the past six years, according to surveys of fourth-year students by the Assn. of American Medical Colleges.

But medical education experts believe statistics are misleading and that students continue to be subject to unacceptable levels of public belittlement, humiliation, and physical and sexual abuse, and have been denied opportunities for advancement because of gender or ethnicity.

"If you think abuse is gone, it is not," said Harry Jonas, MD, co-secretary of the Liaison Committee on Medical Education. LCME accredits the nation's 125 medical schools.

In a survey of 12,734 seniors conducted last year, the AAMC found that 26.7% had been occasionally belittled or humiliated compared with 28.1% in 1998. Slightly more than half, 51.1%, said they had never been subject to such abuse during their four years compared with 48.1% in 1998 and 61.7% in 1996.

As in past surveys, women and minority students recorded more incidents of sexual, physical and mental abuse than white men, the AAMC survey found.

As you can see from the above statistics, whether the situation is improving or not, the percentages are still large and may be incomplete. Ritual or not, either is destructive toward instilling the professional behavior we all would like to see in our physicians. ..Maurice.

Should Medical Students be called "Student Doctor"?

As I have noted on previous postings on this blog, there has been a change in recent years in how patients relate to the medical profession and vice versa. Along with the rise of consumerism, society has shown that it wants to deminish paternalistic behavior by physicians and assure informed consent on the part of the patients. Therefore the current ethical consensus is that there should be a clear understanding between patient and physician regarding all that is transpiring in medical care. This also means that any words or behavior on the part of the caregiver which may lead to deception is not right and may defeat attempts at informed consent.



Medical students have long been identified by the words "student doctor" or "student physician". Medical students, of course, have neither obtained as yet their M.D. degree nor have the legal responsibility of a physician. In keeping with the societal consensus described above, there is some concern whether using these words by medical students in identifying themselves either orally or on their name tag or by others identifying these students may itself be deceptive. The issue here is whether patients or families would misinterpret the qualifications and responsibilities of the student by these descriptions. Would you agree that these words may be deceptive and that medical students should only be identified by the words "medical student"?



My own opinion is that that "student doctor" or "student physician", as examples of student titles, are deceptive and only "medical student" should be used. I have posed this question to visitors to my "Bioethics Discussion Pages" website and I have received a number of responses. If you would like to read them, click here. ..Maurice.

Hippocratic Oath: Is it Necessary? Are the Words Right?

The Hippocratic Oath either in the classical form or in one of the modern forms has been a fixture in the graduation exercise of medical students in most medical schools. By repeating the Oath, medical students receiving their diplomas can then enter the profession of medicine and become physicians. However, particularly in recent years, there has been controversy as to whether the words are up to date in the Oath or whether the Oath itself is really necessary. This debate has been presented in the PBS Nova website including comments by physicians and non-physicians. Go to the site by clicking here but return and write your comments. (PBS is no longer accepting comments to be posted on their site.) For those of my visitors who just want to read the classical Oath and an example of the modern one, I have pasted them below. ..Maurice.

Hippocratic Oath -- Classical Version



I swear by Apollo Physician and Asclepius and Hygieia and Panaceia and all the gods and goddesses, making them my witnesses, that I will fulfil according to my ability and judgment this oath and this covenant:



To hold him who has taught me this art as equal to my parents and to live my life in partnership with him, and if he is in need of money to give him a share of mine, and to regard his offspring as equal to my brothers in male lineage and to teach them this art - if they desire to learn it - without fee and covenant; to give a share of precepts and oral instruction and all the other learning to my sons and to the sons of him who has instructed me and to pupils who have signed the covenant and have taken an oath according to the medical law, but no one else.



I will apply dietetic measures for the benefit of the sick according to my ability and judgment; I will keep them from harm and injustice.



I will neither give a deadly drug to anybody who asked for it, nor will I make a suggestion to this effect. Similarly I will not give to a woman an abortive remedy. In purity and holiness I will guard my life and my art.



I will not use the knife, not even on sufferers from stone, but will withdraw in favor of such men as are engaged in this work.



Whatever houses I may visit, I will come for the benefit of the sick, remaining free of all intentional injustice, of all mischief and in particular of sexual relations with both female and male persons, be they free or slaves.



What I may see or hear in the course of the treatment or even outside of the treatment in regard to the life of men, which on no account one must spread abroad, I will keep to myself, holding such things shameful to be spoken about.



If I fulfil this oath and do not violate it, may it be granted to me to enjoy life and art, being honored with fame among all men for all time to come; if I transgress it and swear falsely, may the opposite of all this be my lot.

Hippocratic Oath -- Modern Version



I swear to fulfill, to the best of my ability and judgment, this covenant:



I will respect the hard-won scientific gains of those physicians in whose steps I walk, and gladly share such knowledge as is mine with those who are to follow.



I will apply, for the benefit of the sick, all measures which are required, avoiding those twin traps of overtreatment and therapeutic nihilism.



I will remember that there is art to medicine as well as science, and that warmth, sympathy, and understanding may outweigh the surgeon's knife or the chemist's drug.



I will not be ashamed to say "I know not," nor will I fail to call in my colleagues when the skills of another are needed for a patient's recovery.



I will respect the privacy of my patients, for their problems are not disclosed to me that the world may know. Most especially must I tread with care in matters of life and death. If it is given me to save a life, all thanks. But it may also be within my power to take a life; this awesome responsibility must be faced with great humbleness and awareness of my own frailty. Above all, I must not play at God.



I will remember that I do not treat a fever chart, a cancerous growth, but a sick human being, whose illness may affect the person's family and economic stability. My responsibility includes these related problems, if I am to care adequately for the sick.



I will prevent disease whenever I can, for prevention is preferable to cure.



I will remember that I remain a member of society, with special obligations to all my fellow human beings, those sound of mind and body as well as the infirm.



If I do not violate this oath, may I enjoy life and art, respected while I live and remembered with affection thereafter. May I always act so as to preserve the finest traditions of my calling and may I long experience the joy of healing those who seek my help.





Written in 1964 by Louis Lasagna, Academic Dean of the School of Medicine at Tufts University, and used in many medical schools today.

Why Can't a Patient Be More Like a Doc?

Continuing with the consideration of the ideal physician and ideal patient…

Here is a satirical takeoff by Steven Miles, MD,Professor of Medicine and Geriatrics,Center for Bioethics,University of Minnesota on a familiar My Fair Lady lyric.



Thanks Steve.

A HYMN TO HIM





Why can't a patient be more like a doc?

Docs are so honest, so thoroughly square;

Eternally noble, historic'ly fair;

Who, when you win, will always give your back a pat.

Well, why can't a patient be like that?

Why does ev'ryone do what the others do?

Can't a patient learn to use her head?

Why do they do ev'rything other patients do?

Why don't they grow up- well, like their doctor instead?



Why can't a patient take after a doc?

Docs are so pleasant, so easy to please;

Whenever you are with them, you're always at ease.



One doc in a million may shout a bit.

Now and then there's one with slight defects;

One, perhaps, whose truthfulness you doubt a bit.

But by and large we are a marvelous lot!



Why can't a patient take after a doc?

Cause docs are so friendly, good natured and kind.

A better companion you never will find.



Why can't a patient be more like a doc?

Docs are so decent, such regular chaps.

Ready to help you through any mishaps.

Ready to buck you up whenever you are glum.

Why can't a patient be a chum?



Why is thinking something patients never do?

Why is logic never even tried?

Questioning me is all that they do.

Why don't they straighten up the mess that's inside?



Why can't a patient behave like a doc?

If I was a patient who'd been offered a cure,

Hailed as a miracle by one and by all;

Would I start weeping like a bathtub overflowing?

And carry on as if my home were in a tree?

Would I run off and never tell where I'm going?

Why can't a patient be like me?