fellowship

Sunday rant

“Can I ask you a personal question?”

hate when people say this. Because you know what’s coming — a socially inappropriate, irrelevant question about your age, your income, your marital status, your ethnicity, or your personal appearance — and the question-asker knows this, and is basically asking your permission to be let off the hook for their rudeness.

It’s also a question without a free choice, because either you say “yes” (and validate the inappropriate follow-up question) or you say “no” (and then YOU become the impolite one.)

So there’s a weird awkward pause while you try to figure out how to respond, and then you finally give up and say “…sure” because it seems easier, and then you have to deal with several layers of increasingly inappropriate follow-up questions.

Next time someone asks me “Can I ask you a personal question?” I’m just going to say, “Only if I can ask you one too.”

fellowship

Know thy audience

PATIENT
What’s dystonia?

RESIDENT WORKING WITH ME
It’s the sustained co-contraction of agonist/antagonist muscles.

PATIENT

[I found out later that the reason he was so far behind with the previous patient was that when the patient asked “What causes Parkinson disease?” he drew the direct and indirect pathways. For a demented patient with a 10th grade education.]

Greater than 50% of this visit was spent in counseling and coordination of care.

fellowship

Bad Leadership

I’m not sure I know how to be a great leader, but I can tell you how to be a terrible one:

When your state has declared a disaster emergency for snow, you should tell your subordinates that they better come to work tomorrow for their routine clinic patients (who may or may not show up), and declare that you’re going to be home playing in the snow with your kids. And when your staff expresses doubts about the feasibility of making it to work in 2 feet of snow and 60 mph winds, tell them they are not team players.

And then leave an hour early, to get a head start on those snowmen.

[Bonus points for blaming a staff member for poor documentation in a note that was written more than two years before she started working there.]

fellowship

Get off my lawn!

Led a small group of first year med students through a couple of clinical cases; first one was sudden onset headache in a young man. We talked about how to generate a differential diagnosis, thinking about what’s urgent and what’s most likely.

One of the students goes, “What about epidural hematoma?”

“Good thought,” I say, writing it on the whiteboard. “What do you think about the fact that the patient’s talking to you and lucid?”

Blank stares.

“OK, so epidural hematomas can have a lucid interval, where the person might look and sound ok until the hematoma hits a threshold size and they decompensate quickly.”

Click-click as they type away (I would rather have said *scribbles* but kids these days with their laptops and snazzy equipment, they wouldn’t know a pen if it hit them in the face.) They seem disengaged; how can I make this relevant for them? Diseases mean very little unless you know, or know of, someone who has it.

“You know, like Natasha Richardson.”

Blanker stares. Finally, one of the students goes, “Who?”

*sigh* “She was skiing and fell, and when the paramedics got there she sent them away, then she went back to her hotel room and died.”

Later on, during a case of parkinsonism, I mention post-encephalitic parkinsonism, Awakenings and Oliver Sacks — no recognition. And when we were talking about dementia with Lewy bodies, I tell them, that’s what Robin Williams had, and they are like “huh?” So I decided not to tell them that Dudley Moore had PSP, because I don’t want to have to explain who Dudley Moore was.

Then after class, I submitted my application for an AARP card, because clearly I’m an old lady now.

fellowship · health policy

RIP Hans

I learned the other day that Hans Rosling, Swedish public health professor, died earlier this month of cancer.

I was walking down the street minding my own business, and I was so shocked by this that I stood stock still in the middle of Hamilton St listening to the rest of the podcast (BBC’s More or Less, if you are a fellow podcast fiend).

I never met Dr. Rosling, but everything I learned about global health in medical school, I learned from his videos on YouTube. (I think this says quite a lot about the quality of the global health curriculum at my school….) Yes, his presentations always had snazzy graphics, but his most important points were sound — that the data tells a story, and that the story challenges our preconceived notions about structural inequalities in wealth, health, and life.

Much of his work and legacy live on at Gapminder.org, but the world will miss you, Hans.

fellowship

Hickam’s Dictum

The second thing you learn in medical school (right after “the patient is the one with the disease”) is Occam’s Razor: the simplest explanation is the best one. If the patient has five symptoms, give him one disease that explains all five, not five unrelated problems.

What they don’t teach you, at least not right away, is Hickam’s Dictum: the patient can have as many diseases as he damn well pleases. I always thought this was the product of a straight-talking New Yorker, probably a Brooklynite, some larger than life Sir Lancelot Spratt who didn’t mince words and ate interns for lunch. But no, the internet tells me that John B. Hickam was a real person, chair of medicine at Indiana.

Anyway, I was thinking about old Dr. Hickam today, because I had a referral who had essential tremor, generalized dystonia, myoclonus, parkinsonism, two symmetric ditzels where his nigra ought to be AND a hummingbird sign. He was like a grab bag of movement disorders! I had two different attendings see him with me (and they both agreed with me that the primary problem was X but couldn’t explain problems Y, Z, and Q). Ended up videotaping him for future reference, but geez Louise! Why don’t patients read the textbooks??