Abruptly changing the subject: Empathy from doctors

The man diagnosed with lung cancer sounded dispirited when talking about what cigarettes had done to him.

"I was always told I had a good strong heart and lungs. But the lungs couldn't withstand all [those] cigarettes…asbestos and pollution and secondhand smoke and all these other things, I guess," he said.

"Do you have glaucoma?" the doctor responded, abruptly changing the subject.

In her recent study in the Archives of Internal Medicine, Dr. Diane Morse recorded physicians’' appointments, and noted 384 times when patients mentioned concerns or emotions about mortality. Doctors responded with empathy only 10% of the time.

Advice: Find a doctor with both empathy and excellent technical skills.

Read a story on compassion.

Thanks to Will Dunham for the source article in the Boston Globe of Sept. 23.

A pictogram in return for another pictogram: Diabetes patient education

Consultations with Mrs. L are difficult: sometimes, she comes
without her diabetes logbook, or forgets to have the requested
HbA1c assay. Above all, she comes either alone or accompanied
by someone who, like herself, speaks nothing but Chinese. All I
can do, in order to understand her repeatedly high HbA1c
levels, is to look at her logbook and try to understand the
documented insulin doses and the blood glucose concentrations.

Recently, I admitted her to hospital. Firstly, we verified that
the technical aspects of blood glucose determination and
insulin injection were perfectly correct. I also told her that
I needed an interpreter. A Chinese neighbour who was fluent in
French came with Mrs. L on the following day. I first checked
with Mrs. L the basics of adapting insulin doses and began to
ask her questions through the interpreter. No answer. I
therefore asked the interpreter if he, himself, had understood
the meaning of the questions. He was positive. I then asked Mrs.
L to tell me what she thought of insulin. No answer. I realised
that she knew nothing about it and that the treatment made
absolutely no sense for her.

This situation reminded me of John Searle’s "Chinese room"
argument. Imagine a Westerner, speaking English but not
Chinese, in a room with a window. Through the window, a Chinese
person shows Chinese pictograms. The Westerner has a manual,
written in English, instructing him how to show a pictogram
specific for the pictogram he sees through the window. He is
not aware that the pictogram he sees is a question, and that
what he then shows is the correct answer. The Chinese person
outside cannot work out that the Westerner does not understand
Chinese.

In the case of Mrs. L, we doctors were the Chinese. We had no
direct way of recognising that the blood glucose determinations
or the insulin injections that she performed impeccably had no
meaning for her.

I decided to start her education from scratch. What is
diabetes? What is a normal glucose concentration,
hypoglycaemia, hyperglycaemia, etc? Repeatedly, I asked the
interpreter whether he understood and whether he thought that
Mrs. L understood. He was affirmative. I arrived at a problem—
how to verify that the dose of insulin was correct. At this
point, I was unsure whether the interpreter understood the
question, and I decided to stop the session, giving him another
appointment for the next day. In fact, I doubted the
interpreter’s comprehension of the real sense of what I had
said. It seemed to me that the Chinese room was now separated
from me by two walls and windows.

The next day, a different person accompanied Mrs. L to the
appointment—her nephew, also perfectly fluent in French.
Needing to go through my explanations all over again, I decided
to use another strategy and asked the nephew to imagine that he
was diabetic, and that he had to listen to my explanations as
if they concerned him, in order to give a meaning to the
therapeutic education. Only then would he translate the
information to his aunt. I had the sensation of trying to enter
the Chinese room by climbing through the first window.

To a lesser degree, this story may be relevant to many
consultations, even when there is no obvious language barrier.
It is vital that the patient understands the message as a whole
and not just the words, or else the treatment routines may be
analogous to nothing more than showing a pictogram in response
to another pictogram.

Advice for speakers of a foreign language: Get a good interpreter.

Thanks to Dr. Gerard Reach for the source article in the Feb. 16 issue of the British Medical Journal.

I killed her: My first malpractice suit

I stared down at my name neatly typed next to the word "Defendant." And just below the heading: "Complaint: Wrongful Death Based on Medical Negligence."

Oh my God. Deceased. It was me. I killed her. That's how I heard about my first malpractice suit.

I was the new doctor in the group. I had joined fresh out of residency two years before. I was the first woman doctor in the clinic, and one of only a handful of women physicians in semi-rural Clackamas County.

My last note in Helen Simmons' chart [not her real name] was from last August, a visit for chest pain. I had first met her in my first year in the practice, in December of the year before she died. She had gone to the Emergency Room of the local community hospital with chest pain, and had been admitted overnight for observation by one of my senior partners. Covering for him, I met Helen the next day.

Her chest pain had not been a heart attack, according to blood tests overnight. Her pain was gone. But she was a time bomb, I realized. She had heart disease up and down her family tree, she smoked, and her blood pressure was high.

I told her I was glad she hadn't had a heart attack, but that I was worried she was going to, sooner or later. She could save her own life, I said, by quitting smoking and taking care of herself. She wasn't worried about all that. She wanted to go home and have Christmas with her family.

Her EKG (electrocardiogram) showed she may well have had a prior heart attack, not previously discovered, but that she had not had one just now. Heartburn was the more likely diagnosis, so I sent her home with a prescription for medicine to block stomach acid.

She had scheduled her two-week post-hospital visit with my partner, who had admitted her to the hospital. She told him her pain was better, and the way she described it fit the heartburn pattern. A special X-ray called a barium swallow confirmed acid irritation of the stomach, so my partner gave her another acid blocker prescription.

Two weeks later her time bomb went off. In mid-January she came to clinic with bad chest pain, and I sent her right up to the hospital. It was her first official heart attack. She had quit smoking a few days before. Trying to change her lifestyle, she had tried to exercise.

A few days later, the cardiologists reopened a cholesterol-plugged artery in her heart. After that she could exercise without chest pain and joined a health club. She lost some weight and stayed off tobacco. I saw her every month or two through the winter, spring and summer, congratulating her at every visit for her progress. She was 44.

She came in for a final visit in August, complaining of chest pain. It fit the pattern of stomach pain rather than heart pain. I ran an EKG on her at that last visit, and it was normal – normal for her, that is; it showed nothing new, and even some improvement. I switched her to an even stronger acid blocker. And I never saw her again.

Ten days after that last appointment with me, Helen had died in her sleep. What probably killed Helen was her heart suddenly jumping into a bad rhythm, that didn’t pump blood forward – sudden cardiac death. We don't have any good way of predicting whose damaged hearts are more likely to do that, or when. I couldn't have diagnosed, predicted, or prevented it.

At the trial, there were some surprises. Helen had quit smoking. But her family and friends hadn't, exposing her to secondhand smoke that can increase the risk of abnormal heart rhythms. And in her last visit with me Helen had said she had been able to work out in the gym for hours without chest pain. But her daughter and a friend testified that Helen could only stay on those exercise machines a few minutes before she had to stop and rest until the chest pain went away.

She lied to me. She was playing a role, the role of a good patient. She was telling me what she thought I wanted to hear. Maybe she wanted to hear me congratulate her again on how well she was doing.

I didn't see through Helen's performance. That was the mistake I made. That was my negligence.

I "won" the case and went back to work. I say it was my first malpractice suit. There hasn't been a second – yet – but I don’t want to get overconfident.

Advice: Always tell the truth to doctors.

Browse for related stories in the index at the very bottom of this page, or read a patient-doctor miscommunication story.

Thanks to Dr. Merilee Karr for the source article in Creative Nonfiction, issue #33, 2007.

It's not 20th century: Electronic medical records and patient waiting times

Barbara Duck:

"I've always loved [my medical practice], they treat you like family," says patient Josh Dryman, a 33-year-old who lives in Laguna Niguel, California. "But I had to wait an hour in the lobby and wait in the exam room another half-hour. Now [that they have an electronic medical record], when you go in, they get you in right away and the staff seems a heck of a lot friendlier."

Most of the time it is pretty easy to detect once you walk in to a lobby of a practice, those still using paper seem to possess an atmosphere of chaos to some degree, and the entire staff appears rushed and somewhat stressed, whereby those offices using electronic records have much of this information at their fingertips on the computers, thus less physical movement in pulling charts, looking for faxes, etc. and this in itself allows the office to focus better on patient care and not chasing information.

"The average consumer takes it as a given that doctors have these systems in place," says Peter Lee, chief executive of the Pacific Business Group on Health, an employer coalition based in San Francisco. "They don't know how much medical care today is not 20th century, let alone 21st century, in terms of how much doctors rely on paper instead of computers."

Nationally, only about 20% of physician offices are computerized; the rest still rely on notoriously inefficient paper charts. But computers are an easy benchmark for quality. They can help a doctor not just keep track of files, but also send out prescriptions accurately and quickly, get lab results inserted into the record automatically and be reminded what the scientific evidence suggests is the next best step with a patient.

Advice: In choosing a physician, ask whether s/he uses an electronic medical record to look up lab results, allow lookup of your record during evenings and weekends when you are sick, reduce medication errors, foster email communication with patients, and generally join the 21st century.

Read a story on an exemplary health care provider with odd and useful electronic medical record recommendations for patients, or read more from the source blog post.