Bringing Water and Tissues for the Patient

Sometimes as doctors, we can all get too wrapped up in the medical aspects of the patient, focusing on just the medical history, the examination, the medicines that the patient can take to fix their ailments, and so on.

In medical school, we learned about the “biomedical” model. Essentially, this model assumes that illness can be explained by likening the human body as a machine. If something is wrong with the machine, you implement mechanical fixes, so in humans, if something goes wrong, you can do surgery to fix the problem, or you can give medicines to treat the underlying causes of disease. This model however, is not the best model in that it ignores the human mind and the fact that illnesses can be made worse by a patient’s poor state of mind and social situation.

A much better model then, would be the “biopsychosocial model” which also considers a patient’s state of mind and their social situation. It looks at the patient holistically, seeing how their health can be affected by diseases and by both their mind, looking at the interactions between the two to contribute to a patient’s state of health.

But throughout medical school, we learn all about the fancy disease names, the mechanisms and the pathways for producing the disease. There is some education about psychosocial issues, but by far, there is way more emphasis on the “biomedical” model, where the pathology, physiology, and anatomy are honed in on, and which students spend more time studying.

We are trained to view patients in terms of their medical illness. Doctors may refer to a patient when presenting to another doctor as “that guy with appendicitis”. The name isn’t given, but the disease he has is given instead.

In focusing on the medical illness, it can be too easy to forget the human aspects, such as how the patient is feeling, how they are dealing with their illness. In fact, the other day, I saw a patient who had recurrent chest pains, had anxiety attacks, and had a lot of social stressors lately. After excluding possible cardiac chest pains with an ECG, and taking a history, it sounded like this patient was just very stressed. The patient was teary throughout, and spoke in a soft withdrawn voice. To be honest, I couldn’t offer much treatment other than referral to mental health, and just some paracetamol for her headache. In the meantime, by offering a listening ear, a box of tissues, and a cup of water, the patient became more settled, and their partner was full of gratitude at just these simple gestures. In medicine, sometimes just showing compassion and having a listening ear are therapeutic in themselves, and really does help to show the patient that we are not just treating their medical illness and seeing them as a machine, but as a genuine human being with stressors and problems, and with feelings.

When You Don’t Know, Just Say “I Don’t Know”

In the practice of medicine, there are a lot of things one doesn’t know. Even though medicine in the 21st century has come a long way from the practice of medicine in ye olde 14th Century, there are still lots of things that in general, medicine does not know or does not have an answer for.

The thing with dealing with your seniors as a junior doctor, is that they will press you on knowledge. You’ll be quizzed about things eg “what interleukins are responsible for fevers?” and the such. The senior doctors will naturally have the answers, since that’s why they asked you the question right? For me, I’ve gone through several embarassing moments of trying to “fudge up” the answers. I guess a part of my nature, is that I’m competitive, and don’t wont to be seen as ignorant, but that competitive nature makes me look foolish when I’m called out on my “fudged up” answers.

Saying “I don’t know” in medicine is perfectly acceptable, especially since medicine is full of uncertainties. Saying “I don’t know” means that you are recognizing your own limits of knowledge, and just because you don’t know now, doesn’t mean that you won’t know forever.

I was told that the only certain thing in life, is death. So too in medicine, the only certain thing is death as well. But the point of medicine, is to try and prevent this certainty occurring to the best of our abilities.

So, it’s perfectly ok to not know something, provided you are taking steps to know it later on, and to retain that information in your database. What you don’t know now, you’ll soon get to know. It’s about growth of oneself, and the ability to recognize our limits in medicine.

It’s All About Observation

A good doctor will treat the presenting complaint, but an excellent doctor will not only be able to treat the presenting complaint, but also other issues not obviously apparent. Sometimes, this takes observation and clinical experience to see.

I had the pleasure of seeing this in action the other day with a patient that presented with a sudden onset confusion, and feeling cold. When I was taking the history, I noticed that she spoke sentences very rapidly with very quick pauses between sentences. To me, it looked like she was anxious, that’s why she was speaking so quickly.

Examination revealed crackles bilaterally of the lower lobes of her lungs, and an X-ray showed she had pneumonia. The confusion and feeling cold were probably a result of the pneumonia she had. Her urine tested clear.

On review with my senior doctor, he noted that her rapid sentences were no because she was anxious, but probably due to shortness of breath. On questioning if she had previous DVT, she mentioned that she had a previous DVT following a knee replacement. So, what I had just initially thought was some anxiousness, turned out to be a possible shortness of breath (SOB) from a possible pulmonary embolism (PE – a clot in the lungs).

We gave her a shot of clexane (blood thinners) and referred her to her private hospital.

In essence, observing some vital clues may lead to an alteration of management strategies, in this case, a possible PE. Although I would have liked to know whether the patient did in fact have a PE from further investigations, ED is not a place where you get follow up of patients, so unfortunately, I have no idea.




Always Studying…

As a junior doctor, you would think that after going through 4 years of medical school, I’d be pretty knowledgeable in treating people right? Wrong! The reality is, I still almost know nothing about treating people. If you turn to me for help in treating an illness, I’ll turn to a more senior doctor for help. That’s how it’s working out for me now, and I havn’t got in trouble yet for this. In fact, that’s one of the expected duties of us junior doctors; if there is something you don’t know, you go and seek for more senior help. At the end of the day, it’s doing no harm to patients, so if you’re not sure of something, look it up, or find help.

The great thing after graduation however, is that I don’t need to study for exams. I get to actually practice medicine by seeing real patients and contributing to their management in hospital. That’s something I never got to do as a medical student. It’s much more effective reinforcement of learning when you actually apply what you know as opposed to just regurgitation for an exam.

Whenever I go home (and I’m not too tired) I’ll usually look up concepts and information about patients and cases I’ve seen at hospital so I can learn from what I see at the hospital. That’s one of the things I love about medicine – you’re always learning something new everyday, so you won’t get stale.

Working as an ED Intern

Hi everyone!

This will be my first post on this brand spanking new blog I just created. I got a fantastic website address: livingmedical. Brilliant isn’t it? I mean, everyday I’m at work, I’m living medical. Even when I’m not at work, I’m living medical, because if someone had a medical problem like a VF (ventricular fibrillation) in front of me, I have a duty of care to attend to that person.

So anyway, back to the topic of being an ED intern. ED is a scary place!!!!!! The environment is hectic, you have different triage categories, you have people who come in with any type of presentation! Anyway, as an intern in ED, I have to see patients – I take a history, do clinical exams, order appropriate investigations, and provide initial management such as pain relief, oxygen etc, and then discuss this with the senior doctor who will advise of further management as necessary. Sometimes, I may have to refer the patient to the surgical or medical team, which involves talking to sometimes intimidating doctors who can at times be rude.

Well, it was a steep learning curve in the first week of work, but you get used to it. Hopefully, my knowledge and confidence in procedures will increase over time, and I’ll be a great doctor later on. 🙂