Tuesday, June 7, 2011

3 for 1 deal

So it's been 3 Sundays since my last post.

Whoops!  But I have good excuses!  The first Sunday was the Sunday before our double-header-exam: Endocrinology & Reproduction.  The Sunday after that was during the memorial day weekend.  This last Sunday?  Well, that was just me being lazy.

But to make up for it - I've put up three posts (including this one).  I've been working on the two bulky ones - here and here - for a while now.  Hope you like them.  I think my next two will be on time and responsibility.

My limiting reagent (heh, heh) a little while ago used to be lack of topics.  I didn't have anything deep to talk about.  I'm not sure I have deep stuff to blog about now, but I do have something to blog about.  These days it's the lack of time (yay medical school).

In other news:

I think people are starting to read my blog now.  I mean like, real people.

I apologize if you expect to find some deep / serious commentary on this blog.  I doubt you'll find that here.  But I'll try to make it entertaining (mainly by including pretty pictures)!

If you do a google search for Penn Med and scroll down a bit... this blog is now listed on the first page.  My reaction to this is: "what... why!?"  I know they say any publicity is good publicity, but I'm not sure publicity is what I'm going for with this blog.

If you want to see something really funny - google image search Penn Med.  My group was trying to find some Penn Med related images for a presentation.. and... well, we couldn't stop laughing at the results.

As a bonus scroll all the way to the bottom of the image search results.  You won't be disappointed - it's pretty hilarious.

Edit/Update: this info is not correct. When I google search, it tailors search results for me so my blog shows up on pg 1.  But this isn't true for the general population! So my blog does not show up on google yet - this is a good thing!  But the google images part seems correct though.

Ok, bed time.  I am very, very behind on sleep.

Monday, June 6, 2011

[1/2] Finding someone (or something) to blame.

When things don't go well, we often look for someone (or something) to blame.  You could say it's almost human to do so.  But that doesn't mean it's the right thing to do, nor does it excuse the finger pointing.

As with most things I blog about, I started thinking about finger pointing and blaming people when I made the mistake of finger pointing and blaming people.

We were in our endocrinology block and our lecturer was pointing out the strong correlation between obesity and type 2 diabetes. Absentmindedly (not an excuse), I remarked "hmm, well it's the patient's fault isn't it?  We suggest lifestyle changes and nutrition changes when we catch them in the prediabetic stage, but they don't do anything about it, and end up with full blown [type 2] diabetes".  

Harking back to an older post, this is when having good friends who will call you out is very important.  One of my close friends got on my case for having such a "blame the patient mentality" (which I don't, but I still deserved to be called out for my comment), and I got to thinking about the "blame the patient" mentality.  

I guess two things need to be clarified:

1. Blaming is just plain silly:
It doesn't do anything about the situation.  It just makes people feel bad and it causes resentment.  All of which are barriers to improvement - which is what we should all be struggling towards.

2. Blaming implies judgement.

No one is ever in a position to judge anyone else.  

2 (addendum): As doctors, our job isn't to judge: it's to heal and maybe even prevent.

But all of those have to be separated from the concept of a root cause.  You always need to search for the root cause.  But it has to be done without blame.

It's analogous to working very hard on something, but being detached from the outcome (as the buddhists and hindus say).  It isn't easy to do, since the work itself (eg. studying for an exam) tends to attach you to the outcome because the outcome tents to be a big driving force (eg. doing well and getting an A).  It is very easy to forget you are working hard because you want to, or because that's what the task deserves.  In the case of medical school exams - it's the idea that some patient in the future may need you to know that tiny detail that could change everything about his diagnosis and/or treatment.

It's similar in root cause analyses.  You work hard to find the root case, and when you get to the "end", it's very easy to try and blame the cause on something.  But it's almost always better to focus on how to deal with the cause.  Dealing with the cause doesn't mean you blame the cause.  In this situation, there's a tiny detail that might make it easier to not blame - to not get attached to the outcome.  The reason you started looking for and analyzing the root cause is to help a patient.

Blaming the patient does not help the patient.

Here's an example: obesity is highly correlated with T2db (type 2 diabetes).  One of the major reasons we have an obesity epidemic is because of the amount of junk food that's (cheaply) available coupled with low physical activity.  Blaming people doesn't do much.  But pointing out that it is something that can be controlled by each and every American is important - we need to empower people to do something about it.  But we have to do it without blaming them.

It is very important to tell our patients that controlling T2DB progression is in their hands.  Weight and exercise will prevent / prolong the onset of T2DB damage.  Contrast that to something like Huntington's disease: the patient has little to nothing they can do to halt it's progress.  So we need to present them with the information, urge them to follow it, but not blame.

I guess my point is it's a very thin line between falling into blaming the patient for something and pointing out these points to improve the patient's life.

I guess it's the difference between

"You have t2db because you are fat.  It's your fault, and you should change how you live"


"Your t2db is probably caused by your obesity.  I can give you some medications for this, but the best way to control and reverse this disease is by lifestyle changes.  But to do that, I'll need your help and your commitment to these changes. I am here to help you through this, so let's talk about what we can do to get you to a healthier lifestyle."

Not judging?  Check
Actually trying to help the patient? Check.

[2/2] Finding someone (or something) to blame.

In my other post, I talked about blame and finger pointing and why they are bad ideas on a philosophical level.  But does that mean fingers shouldn't be pointed?  Am I saying that people who make mistakes should get off without any repercussions?  No.  But I think it needs to be done in a productive way - I like to focus more on the end goal.

As doctors - you need to be hyper-aware of your mistakes.  The best way to describe it is "For everyone to whom much is given, of him shall much be required." -- Luke 12:48.  (Before people get confused, no I'm not Christian).  The "popular" way to interpret this is "to those whom much is given, much is expected".

Much is given to doctors: in many cases it is people's lives.  Thus (understandably) much is expected.  The only way doctors can hope to live up to these expectation is by being very aware of any mistakes that happen, realizing the root cause, fixing it, and making sure it doesn't happen again.  This is very important in the medical field because the question of mistakes happening is not an 'if', but a "when'.  I am not an idealist, so I understand that the steps I mentioned aren't always possible in every case.  For that to be possible, we'd need to understand how everything works... and we are far from that.  Medicine is called an art for a reason.

But this doesn't mean you don't try.

You don't point fingers at the doctor.  You talk to them - about what happened and about how to prevent it in the future.  As part of this process, the doctor has to own his/her mistake.  It's the only way they can improve.

As a side note - here's a good article about why mistakes are a very important part of the learning process. The only issue is that in medicine, mistakes are usually very, very costly.

Bottom line: the doctor, nurse, any healthcare worker (really anyone) who "points" at the doctor to blame him/her should do it in the spirit of trying to improve healthcare.  Not in the spirit of trying to find incompetence.  I'd like to think that most healthcare workers are pretty competent.  Or maybe that's just my naivety?

As patients - (this will be from the perspective of a healthcare worker more so than as a patient) as much as doctors try to help patients with health issues, at the end of the day it is up to the patient to meet us half way (usually it's more like 75% of the way).  Doctors cannot help patients who don't want to help themselves.

So ask yourself what you are trying to accomplish.  Blaming the patient is bad for quite a few reasons (the focus of my other post).  In my view, the main reason it's bad is because it doesn't encourage them to fix the situation.  If your job is to help people (and if you missed that in the job description, let me clarify: that is your job), healthcare workers need to find a better way.

Step 1 of that better way is to have an open and honest conversation about repercussions.  "I'm concerned about your LDL levels and triglycerides being so high because it really increases your chances of having major heart problems.  And there's a good chances they'll occur earlier rather than later in life".

Step 2 is working with the patient to figure out how they can fix the issue.  I'd love to have a one-size-fits-all approach to patients.  Take the issue of healthy nutrition / lifestyle for example: if we could just hand them a card that says "do xyz and abc, and you'll do great!" - that really would be great.  Problem is: it won't work for everyone.  As time consuming as it is, we have to work with patients - ask them how their lifestyle / diet is right now and what they would be willing to change (which usually means what causes the least inconvenience).  No one is going to massively change their lives.  This is especially true for preventative measures - few healthy people will take warnings seriously because... well.. they think they are healthy now so they'll be fine forever!

Bottom line: don't blame.
(1) Tell them you are concerned and what the consequences are
(2) ask them what their current situation is
(3) suggest (or refer to someone who can suggest) changes that wouldn't perturb their current situation too much.

Repeat as necessary.

These are just my opinions - a doe eyed first year med student.  I'm sure people have more advise on the matter (especially the more seasoned veterans - aka real doctors) - and if you do, leave a comment or two!