Friday, November 5, 2010

We See This Sometimes

Have you ever been to the doctor only to be let down with the words of the unknown/unexplainable "we see this sometimes." In Dr. Groopman's book, he presents a case of another doctor seeing a pediatric patient. He is uneasy at his findings but doesn't know exactly what to make of it. He even consults with a pediatric doctor who tells him, "we see this sometimes." The patient eventually ends up being diagnosed with acute lymphoblastic leukemia. The original doctor makes the following comment, "When you hear that sentence ('we see this sometimes'), reply, Let's keep looking until we figure out what is wrong or know the problem has passed." This is excellent advice.

If your doctor ever utters the words (or something similar), "we see this sometimes" and wants to leave it at that consider using the reply above. Another is to ask "what 's the worst thing that this could be. In asking what the worst thing this can be is, you are not being difficult or pessimistic but helping the doctor to generate at least one alternative diagnosis. A third question that could be posed to the doctor is "What body parts are near where I am having my symptom?" Be cautious in accepting a we don't know what is causing your symptoms diagnosis.

Dr. Groopman makes another excellent point when he says, "what we say to a physician, and how we say it sculpts his thinking. (This) includes not only our answers but our questions."

Do you have a story to share about having an unknown diagnosis?

Wednesday, November 3, 2010

Errors in Thinking

Have you ever seen someone and immediately jumped to a conclusion about him/her? Sure, we all have.

Dr. Groopman discusses some types of error in a physician's thinking. One of these is representativeness error. This error occurs when "thinking is guided by a prototype so you fail to consider possibilities that contradict the prototype and thus attribute the symptoms to the wrong cause." He gives the example of a man who presents to the Emergency Department with chest pain. From the look of him, he was a real outdoors man who was in great shape. His blood pressure and pulse were absolutely normal. A work-up for heart issues was all negative. The doctor diagnoses a muscle strain. The next day this same man comes in with an acute myocardial infarction (aka-heart attack). This is representativeness error in the physician's thinking. The man didn't fit the normal profile of a heart attack victim and his tests were all negative.

A second error in thinking that Dr. Groopman discusses in attribution error. He believes this is a more common error that occurs when a person fits a negative stereotype. You know, the guy who fits the bill perfectly for an alcoholic. However, this can be a mistaken stereotype. Perhaps, as the case presented in the book, the man has a rare disease. If the doctor just blows him off as another alcoholic, he will not diagnose or treat him properly.

Dr. Groopman makes an interesting statement in this chapter of his book. He says, "It (is) my job to be complete in my exam, and my charge to monitor my feelings when they might break my discipline."

As a health care provider, it is my job to be thorough and not to let my feelings cloud my judgment. I think we can all learn a lesson from these errors in thinking as we all fall prey to them at one time or another.

Any thoughts or stories of your own to share related to errors in thinking?

Thursday, September 16, 2010

What If You Can't Breastfeed

You have probably heard that "every woman can breastfeed her child." Well, I'm here to tell you that that is simply not true. Many of you may disagree but I can speak from firsthand personal experience with this.

I was so excited to be pregnant, and, like many pregnant women looking forward to breastfeeding my son. After a very difficult pregnancy and delivery I tried to get my son to latch so that we could start our breastfeeding experience. He wouldn't I had the lactation consultants at the hospital try to help me. I was told that my son had a high palate and my nipples were short. They had me try a nipple shield and start pumping. I should have known something was not right when I was barely getting any colostrum. I kept pumping faithfully and trying to get him to latch with the nipple shield. We started supplementing with formula because his blood sugars were low. By the time my milk should have come in I was lucky to be able to pump 20-30ml of breastmilk at one time (from both breasts combined). Needless to say I was devastated. I even saw a lactation consultant after I left the hospital. She told me she thought I had insufficient glandular tissue and would probably not get a full supply and she didn't know how much I would get. She thought the ounce I was getting at times was probably the most I would ever get. Again, devastation struck.

My mom told me that my grandmother had not been able to breastfeed any of her children (she didn't know why but I suspect this was the reason). Insufficient glandular tissue is thought to be genetic (although my mom breastfed me). In doing some research I also found that glandular tissue in pregnancy is tied in with progesterone. With some of the problems I had with my pregnancy I wondered if perhaps my hormone levels were fluctuating. There is no way to really know now. I have decided to talk to my OB/Gyn doctor at my next visit about this. Perhaps I will need to try something like natural progesterone cream in my next pregnancy (should the Lord allow me to have more children). I have read that natural progesterone cream used during a subsequent pregnancy has helped some women with insufficient glandular tissue. Of course, the lactation consultant also said that it improves with each subsequent pregnancy, but there is no way to know if I would ever get a full supply. I suppose I will have to pray about it and leave it up to the Lord.

My son is a happy, healthy infant who has thrived on formula. So, to those other women out there who have not been able to breastfeed because of this type of issue know that you are not alone (although it often feels that way). To those who can breastfeed, please don't judge those of us who are not because you never know why some women are not breastfeeding.

Sunday, August 29, 2010

The First Surgery

Genesis 3:18-24 (ESV)
The the LORD God said, "It is not good that the man should be alone; I will make him a helper fit for him."
So out of the ground the LORD God formed every beast of the field and every bird of the heavens and brought them to the man to see what he would call them. And whatever the man called every living creature, that was its name.
The man gave names to all livestock and to the birds of the heavens and to every beast of the field. But for Adam there was not found a helper fit for him.
So the LORD God caused a deep sleep to fall upon the man, and while he slept took one of his ribs and closed up its place with flesh.
And the rib that the LORD God had taken from the man he made into a woman and brought her to the man.
Then the man said, "This at last is bone of my bones and flesh of my flesh, she shall be called Woman, because she was taken out of Man."
Therefore a man shall leave his father and his mother and hold fast to his wife, and they shall become one flesh.

I'm always amazed when I read this story in the Bible. Who could ask for a better surgeon than the Great Physician?

Wednesday, August 25, 2010

Question & Think Like a Doctor

"Patients can learn to question and to think the way a doctor should," according to Dr. Groopman. Hopefully many of the posts to follow will show how to do this. I know, you think "there's no way I can learn to question and think the way a doctor should." But you may be wrong. Sometimes doctors rely too much on the "obvious" cause without really exploring all the possibilities. Don't be afraid to do some research on your own before you visit your doctor. If he/she seems to be dismissing what you say gently ask about other possibilities. Remember you are your own best advocate.

What do you think about learning to think the way a doctor should? Is it possible?

Friday, August 20, 2010

A Good Listener

According to Dr. Groopman, “How a doctor thinks can first be discerned by how he speaks and how he listens.” In the last post I gave the true story example of how one doctor listened. Let’s focus on how to tell a good listener. What characteristics would you give to describe a good listener? The following are a few of the characteristics I thought of in response to this question:

A good listener is active in the conversation. “I follow you.” “Uh-huh.” “Go on.” These statements all show that the listener is actively involved in the conversation. They also show that what you are saying is important.

A good listener will maintain some eye contact with the speaker. How often have you gone to the doctor and found that he/she was more intent on your chart than on what you were actually saying to him/her? This doesn’t mean that the doctor shouldn’t be making notes but you should notice some eye contact. I have actually seen doctors who have had their head buried in the chart or anywhere but on the patient for almost an entire visit. This drives me nuts!

A good listener asks open-ended questions. An open-ended question is an invitation for you as the patient to give your story. “What brings you to the office today?” is a good open-ended question. While you may have already told the nurse why you are there it is good for the doctor to give you a chance to tell him/her this information. Don’t get irritated by this and wonder “well, didn’t I just tell the nurse why I was here?” because this is a sign of a good doctor. I found this to be a most useful question when I was practicing as a nurse practitioner because not all patients are up-front with the receptionists or nurses about why they want an appointment. In contrast, a closed-ended question allows for only simple, usually one word answers, like “yes” or “no”. For example, “Do you have a fever with your sore throat?” This does not mean that there is never a time for closed-ended questions, but they should not be used the majority of the time. They may need to be used to ascertain more information once your story has been told.

A good listener avoids “why” questions. “Why” questions lead people to become defensive. There is always a different way to phrase a question to discover the same information without asking “why.” Try this with your kids sometime when you are tempted to ask a why question. Does it make a difference in how they answer you?

How did I do in my list of characteristics of a good listener? What would you add?

Wednesday, August 18, 2010

How Should Doctors Think

How did the book How Doctors Think come to be? Dr. Groopman participated in doing rounds with medical students and residents at the hospital. In the process he realized that the students and residents were relying a great deal on algorithms and evidence-based medicine. If you don’t know what an algorithm is think of a decision tree. You ask certain questions and if you answer “yes” you go on to a certain pre-set question and if you answer “no” you go another way and either stop asking questions or ask an entirely different pre-set question. You continue doing this until you reach a conclusion (diagnosis). This realization caused him to ask himself, “how should a doctor think?” In response he was forced to evaluate his own way of thinking and reasoning.

As an example of how doctors think he relates the true story of a woman who has been repeatedly diagnosed with anorexia and bulimia. Her family doctor finally sends her to a gastroenterologist (GI ). For the first time, this specialist really listens to her story and gives her hope. She has horrible stomach pain, nausea, and vomiting after eating and has been losing weight. She relates what she is eating to the doctor. It actually totals about 3,000 calories a day. Now, the specialist can choose to believe her and explore further to find out why she still isn’t able to gain weight, or he can choose not to believe her and label her with the same diagnosis of anorexia and bulimia. In the end, he believes her and asks “what am I missing”? She has some further testing done and receives the diagnosis of celiac disease. She is allergic to gluten which is found in many grains. After modifying her diet she finally starts to gain some weight and feeling better. This true story shows how a doctor’s thinking can radically affect a situation.

How does your doctor think? Does he/she think like the doctor in the true story?