Social History

The social history is an interesting phenomenon. Most practitioners will ask about health-related behaviors such as drinking, smoking, and drugs. Even more detailed practitioners may ask about diet and exercise. But the social history also encompasses things such as marital status, profession, occupational exposures, life at home, etc.

When we first begin as medical students, the social history comes naturally to us. It is simply getting to know a person. We ask where they grew up, how they ended up in the Bay Area, what they do for work, how many kids they have, whether they have pets, what social support they have. It's fun and with the luxury of time afforded to a medical student, it's a natural thing to do. When we become interns and residents, the social history gets severely truncated. Our time is a premium and the social history rarely leads to diagnoses. As an intern, I ask where someone lives and who they live with, but only to understand discharge planning and needs. Occasionally I ask about social support for those who have a new diagnosis of a serious condition. But I omit the richness I once gathered as a medical student. Talking to attendings, though, the social history regains its place. Attendings have interns and residents to poke through the nitty-gritty, and they are able to focus on the patient as a whole person again. I've had multiple attendings who simply chat to patients about their life experiences.

I would never discount the importance of social history. Understanding the whole person is fundamental to building a sound therapeutic relationship. But it's hard to maintain that now when I am bombarded with too much information and too many things to do. Striking that balance between efficiency and patient-centered care is something to work on this year.

1200

By the time the 1200th blog is written, counting by 100s doesn't seem all that amazing, but nevertheless, I'm quite proud that in the fifth year (this all started in 2006), this corner of the Internet is still flourishing. One of the wonderful and frustrating things with the immense changes in technological access and ease is that there is too much information. There is so, so much on the Internet these days, and people are exponentially adding more and more. In reading the Google Blog, I learned that 35 hours of video are uploaded to YouTube every minute. It's quite incredible. But I keep chugging at my linear rate of a handful of blogs a week, trying to capture some of the color of medical training. As more and more impressive things get uploaded to the Internet, this blog's value will get diluted down and down, but for now, it is a calm constant in my life, and I will keep contributing to it as I can.

Akros Megalos

A 55 year old man goes to his primary care doctor with bifrontal headaches and is put on sumatriptan for migraines. The next year, he's diagnosed with diabetes and started on metformin. The following year, he is encouraged to exercise since he's gained 50 pounds over the last few years. He's also prescribed hydrochlorothiazide for a new diagnosis of high blood pressure. Then, because he has lower extremity swelling, a work-up for congestive heart failure is done. It's not very revealing.

He jumps from specialist to specialist, seeing his primary care doctor, a cardologist, a neurologist, and optometrist. His vision gets more blurry and he wears glasses, though he can't use his old frames because they don't fit. "I'm just getting older," he thinks. "You're just getting older," his doctors confirm. The next Christmas, his wife gets him new shoes and new gloves because his current ones don't fit.

(Do you have the diagnosis yet?) Most patients with this disease often do not get diagnosed for many years, and actually rarely is the diagnosis made by an endocrinologist. This patient continued to complain of daytime somnolence and nocturnal awakenings. He stopped his job because the typing exacerbated a new carpal tunnel syndrome. He started noticing skin tags on his chest. His libido started to wane.

Finally, the diagnosis of acromegaly was made. Acromegaly is caused by a tumor in the pituitary gland (deep within the brain, seated upon the "Turkish saddle") secreting growth hormone, causing this constellation of symptoms - new onset hypertension, diabetes, swelling, increase in hand and foot size, sleep apnea, jaw malocclusion, increased spacing of teeth, changes in the facial bone structure, etc. I saw him in endocrine clinic (the pictures above are from Wikipedia, not my patient, but they're representative) and it was really cool because acromegaly is a pretty rare disease and the physical exam findings are dramatic. Simply shaking his hand helped me make the diagnosis. He underwent transsphenoidal resection of the pituitary mass with great improvement. This was one of the more impressive cases I saw on endocrine.

First two images shown under Creative Commons Attribution 2.0 Generic License, last image is in the public domain.

Endocrinology

Endocrinology is a clinic-based specialty. Each day, we see a wide variety of outpatients, from diabetics managing insulin pumps to patients after pituitary surgeries to women with hypothyroidism planning pregnancy. Several things are immediately apparent. Endocrine problems cover every organ system; here is a specialty where the review of systems matters. The patient population is very different than the standard hospital patient population; the prototypic endocrine patient is a young woman. It's a heavily laboratory-based specialty, and we titrate our medications based on blood tests. The pace is fast and in general, patients are not sick.

In the afternoons, we field hospital consults for problems from diabetic management to hormone replacement to questions of adrenal insufficiency. At Stanford, even endocrinology is subdivided and we have attendings who specialize in diabetes management, cystic fibrosis, and neuro-endocrinology. As a result, I get to learn from a wide variety of specialists on their particular area of interest.

Step 3

The last U.S. Medical Licensing Exam, "Step 3" is a two day affair involving 11 hours of multiple choice questions and 4 hours of cases (though they go pretty fast and are actually fun). Despite that, the test was easier than the first two parts. While the first part involved the basic science, biochemistry, physiology, and mechanisms of disease and the second part involved a broad survey of clinical diagnoses, this part focused on common outpatient clinical problems. Every single question was framed as a real patient interaction, which I appreciated. In my mind, it actually does meet the objective - assessing whether a candidate can reasonably take care of family practice patients. But whether this is the right test to give to everyone, I'm not sure. By now, my pediatrics, gynecology, and psychiatry are pretty rusty, though to be honest, doing an internship in medicine helps a lot. I didn't study much at all (perhaps a handful of evenings) and it wasn't too bad. They say, study 2 months for Step 1, 2 weeks for Step 2, and bring a #2 pencil for Step 3 (though it is now computerized). Anyway I won't say much more about it, but I am glad to be done and back to blogging.

Neverending Exams

One reality of medical education is that exams pursue us our entire career. Thankfully, the frequency of exams has decreased dramatically such that there is only one big test left for me, and that is Step 3. I take this final licensing exam in a week and though motivation is minimal, I am going to take a break from my blog to study for it. I'll be back in a week.

Endocrinology

I have now moved from the VA wards to a month of endocrinology. Endocrinology, as best as I can tell, can be simplified to the diagram above. Hormone regulation is tightly modulated such that outputs change the strength of inputs. As endogenous steroids are released by our adrenal glands, our hypothalamus and pituitary sense this and downregulate those factors that trigger steroid release. This occurs across multiple axes in the human body, changes predictably with medications, and guides the principles of testing. For the engineering-minded, it's the perfect specialty. It's also a fascinating specialty for the general practitioner because it spans every organ system and covers both common diseases (hyperlipidemia, diabetes) and the rare (pheochromocytoma, craniopharyngioma).

Overall, it's a light outpatient elective rotation. Each day of the week, we have a half-day of clinic, seeing patients with diabetes, thyroid disorders, surgical resections of their pituitary, and other rarer hormonal imbalances. These occur at all the different hospitals, including Santa Clara Valley Medical Center. In the afternoons, we field endocrine consults for management of inpatient endocrine disorders; many of these are from the surgical services. Overall, the day is educational and moves at a fairly manageable pace.

Image is in the public domain, from Wikipedia.

Poem: Questions for the Doctor

Questions for the Doctor

Writer's block, pen hovering over
notepad and its small red font:
Questions for the Doctor.
Where do I start?
Was it the glass of wine my mother drank,
the one that committed her to AA
or was it my father with his alcoholic hands
or first grade, when I punched the teacher
or the time I left home?
Did it start with that first beer, age 14
or that first smoke, the first high,
the first drop out or the first pregnancy --
that first divorce?

Did it begin with the last time I believed
in social work, in welfare, in health and well being?
The last time I took my medications
or ate a warm meal
or remembered a day from start to finish?
Did it begin with the anorexia
or the skin popping
or the suicide attempts,
the broken jaw or the rash?

I erase everything I've written;
doctors write in pen, but I in pencil
for how could one live life without erasure?
This is the question I want to ask
and yet I don't know what to say
when she comes into the room
white coat, hair all business,
looks down at my wallowing face
flips through the chart for the number
I already know - less than 200 -
and tries to align resistances.
Oh, this will be the last time I get asked
that question, Questions for the Doctor
yet I am resigned to silence.

Birth

This picture is unrelated to anything in particular, only that I came across it and really liked it. It is a C-section in London, England, from Wikipedia, shown under CopyLeft Free Art License.

Last Call at the VA

On my last call at the VA, I admitted a handful of fairly interesting patients. My first was a direct admit from infectious disease clinic for the first use of doripenem in the VA system. Though clinic admits like this are often less educational because they are consult-driven (ID has already determined the patient's antibiotic regimen), I liked this because I used to work on Pseudomonas research, and that was the unfortunate microorganism involved. It's fairly impressive that the ID attending managed to secure a new expensive antibiotic for this gentleman because I've found non-formulary requests at the VA to be hard to push through.

I also admitted two patients with refractory angina; they were having concerning chest pain with minimal exertion. Normally, I know what to do with angina. But one of the patients had been revascularized so many times that cardiologists have said that he has no more targets for stents or bypasses. What do we do now? It was an educational experience to learn about interventions such as ranolazine, external counterpulsation, and spinal blocks as symptomatic therapies for these patients.

Finally, I admitted a patient with acute on chronic renal failure where we couldn't figure out the patient's volume status. Should we give him fluids? Should we give him lasix? He had history and exam findings that could go either way, and it was educational to see how an attending approached this case.

Overall, I was happy to be done with another month of call. With time, calls get a little easier. Now I have become efficient enough to get at least some sleep each night, even if I'm cross-covering or have sick patients. So it's not quite as rough as it used to be.

Selling the Story II

Here is the first scenario: A middle-aged gentleman with hypertension, diabetes, and a history of two coronary stents placed 2 years ago has had little physical activity since he injured his back last week. As he starts to increase his activity, he gets substernal chest pain, worse as he pants, radiating to his back, associated with shortness of breath and diaphoresis. An EKG en route shows ST depression in lead III and V3 and sub-millimeter depression in several other leads. The initial troponin is positive.

Here is the second scenario: A middle-aged gentleman with some chronic medical illnesses who has been bedbound due to a back injury develops acute onset shortness of breath and pleuritic chest pain. He is quite tachypneic and hypoxic. EKG is nonspecific, and a mild troponin leak is likely due to right heart strain.

Of course, these two patients are the same, but the stories are spun to suggest an MI in the first case and a PE in the second case. How do we approach such a situation? Two posts ago, I argued that clinical information cannot and should not be given impartially. The person telling the story ought to interpret it and make sense of that data. But of course, this puts the onus on the listener to find flaws in the logic or see incongruities in the story.

This is an actual instance that happened when I was on the coronary care unit. Possibly because we were on a cardiology rotation surrounded by patients who had heart attacks, we interpreted the data as the first scenario when it turned out to be the second. In the end, it was the attending who caught us, allowed us to backtrack, and redirected our clinical efforts. This is why clinical medicine is so hard; it is not cut-and-dry, and you have to go down one path in order to test the waters. There's no use in remaining stagnant in ambiguity. But when things simply don't seem right, it's always important to question your assumptions.

Inane Post

Happy 1/11/11 at 11:11! I realize this is a pretty silly post, and hopefully I do not do this too often. Back to your regular blogs tomorrow.

Selling the Story I

There is an interesting phenomenon with oral presentations. When we first start out as medical students - clear as the morning sky - we present all the information in an unbiased fashion. If we are good medical students, our histories are the telephone book; we have drawn out a family forest, we know the names of their pets, we can trace the history of their symptoms to the minute. But then our presentations become discombobulated and muddled. There's too much going on. What's important? What's not? As a medical student, we hope someone else will do the interpreting, that someone else will funnel that information into a pristine and obvious diagnosis.

But then we learn a very counter-intuitive convention and practice. When we present our patients, we should paint the story of the diagnosis we want listeners to conclude. We intend to bias them with the information we present. The great attendings and residents are able to see beyond the obvious and catch any mis-diagnoses, but we should still present the story as if there were one leading candidate. Since medical school, this approach seems more and more obvious. The person who collects all the information should attempt to interpret it; if they do not, the information is less helpful because it is a big mess. But then, your story is only as good as the first report, and how they sell the story can change everything. Some examples tomorrow.

Time

Time is a very funny entity. The fact that half of intern year is over baffles me. It's gone by so incredibly fast; indeed, each year seems to fly by more and more quickly. Each rotation seems so short, and I get the sense that things are passing me by. Yet, some individual hours seem excruciatingly long. On those call nights at 2am with 4 notes to write, I go crazy. I look at the clock every five minutes and it feels like an eternity. The psychology of time is so fascinating.

Physical Exam

Stanford's internal medicine program puts an emphasis on the physical exam. This is why.

Image shown under Fair Use, from A Cartoon Guide to Being a Doctor.

Just For Fun

Oh, there are so many parodies of the "Major General's Song" from Gilbert and Sullivan's Pirates of Penzance. In our undergraduate premed courses, we run into Tom Lehrer's "The Elements" which is quite amusing. Recently, I found another parody by a musical duo called the Amateur Transplants entitled "The Drugs." What surprised me is that I recognized about 90% of them. (And if you're browsing youtube, "The Anesthetist's Hymn" isn't bad either).

Not Appropriate

It is always a question whether I should write about "horror stories" or not. The truth is, for every mishap, I could name a dozen wonderful things I've observed, things I did not expect, things that were brilliant and kind and generous and altruistic. Furthermore, when I talk about things that could have been done better, I do my profession and the institutions I work for no favor. For the most part, there are many ways to skin a cat and a lot of different approaches to the same problem. But last night on call, we took care of a patient who was not treated appropriately by a transferring facility.

Interfacility transfers are a tricky business. A physician at an outside hospital, usually a community hospital without the array of resources of an academic center, identifies a need for a patient that can't be provided at that facility. She then finds an accepting physician at a facility which can provide that service. The patient is transported over, we provide that service and take care of him. Thus, we see transfers for a wide variety of patients: obscure cancers, organ transplants, complex surgeries.

Long story short, a patient was sent from a hospital several hours away in a regular gurney ambulance with 2 EMTs. Our accepting physician confirmed the patient's story and that he was stable for transport. However, it seems that immediately prior to transport, the patient's oxygenation requirements went up considerably from 2 liters of nasal cannula to 10 liters of nonrebreather facemask. The outside facility still continued to transport the patient, and instead of upgrading him to an ICU level ambulance, kept him in a gurney ambulance where his O2 sat could not be measured and a facemask could not be applied. They turned his nasal cannula up at the highest setting and sent him on this 4 hour ride. Near the end of the journey, they ran out of oxygen, and when they pulled up to our hospital, the patient was air hungry, breathing rapidly, and slightly confused with an O2 saturation of 60% (normal would be >95%).

This was a gross error, and we let that facility know. Transport issues are the liability of the sending hospital, but all of us involved want to do the right thing for the patient. We had to meet the patient in the ICU with an ICU team and nurses ready, knowing that his breathing might be in trouble. Again, as I have said many times in this blog, transitions of patient care teams are critical moments, and we really need to be careful to keep patients safe.

Changes

Sometimes I think New Year's Resolutions should instead be New Year's Changes for these are things I'd like to institute now than things to put off. One New Year's Change I'd like to make (at least from a medical side) is to rebalance my life. Intern year is always at risk for dominating everything I do and think about, and I have to stifle it from suffocating all the other facets of my life. William Butler Yeats said, "The intellect of man is forced to choose / perfection of the life, or of the work" ("The Choice"). This is incredibly true; to be a perfect intern is to give up everything else so that medicine subsumes us. There is no right or wrong here, but it's simply something I do not want for myself. Yet it is difficult. The frontier is vast and when we do not look, the shadows encroach upon our space like manifest destiny; I could read and read and read and know only a fraction of medicine; it is the beauty and the rapture of it that holds us enthralled. True - there are those topics to which we avert our eyes - things like genetic disorders of the newborn and renal tubular acidoses - but for the most part, all of us in medicine could find something that could tease us endlessly. But no! This is the New Year's change; I will set aside those problems and dilemmas and conundrums and fascinomas at some point each day so that I can actually enjoy a life separate and segregate from work. Though I say to myself each day I will learn something in medicine - and for the most part, this is true - I will also say to myself that each day I will do something completely unrelated, fun, necessary.

There are of course other things in medicine I resolve to change. For each patient I admit, I will learn something about them that is completely unrelated to their chief complaint - the length of their marriage or the name of their pet or where they grew up and got their accent. I used to do this as a medical student, and it has since faded. I will, from an efficiency standpoint, finish my H&Ps prior to the post-call morning, a commitment that is easy to say when sleep is abundant, but so far away when Somnus calls. And there are half a dozen other easy, sweeping, generic things to say - I will teach more, I will look at all EKGs, I will glance at CXRs and CTs, I will eat well on call, I will go out of my way for my cointerns. These are all things I would like to do, and I have 6 more months on medicine to make it happen.