Wednesday, September 19, 2007

Self Medic-ated

It's considered a truism: if you have a doctor or nurse for a patient, it's gonna be a horror show. I'm not convinced, but to the extent that it could be true, the fault -- as Shakespeare probably said -- is in ourselves. The problem is the nearly irresistible pull to treat doctors and nurses differently than we do the rest of our patients: to abbreviate explanations, to avoid recommending things that are inconvenient, to bypass the ordinary steps taken to get from encounter to conclusion.

In the formative days of this blog, I posted about operating on my partner when I was a very young pup. Any way you could look at it, it was a horrible experience; after removing a section of his bowel, he had a problem I'd never seen before, nor have ever again. Without question, had I closed his mesentery the way I'd always done (and still would do) instead of the way he liked to do it (I figured he'd be happy when I told him), I'm certain it never would have happened. By the time it was over (and before he made a complete and full recovery!) I was ready to push him out a window and jump after him. Amazingly, within a day of his much-delayed discharge, I was asked to see another fellow physician in need of bowel surgery. OK, I thought. You fall off a horse...

Fortunately, he was a pediatrician, which meant I could treat him like a person who hadn't a clue about surgery. Close as you can come, really, to operating on a civilian. (Kidding. I'm kidding. But I do admit to telling that to myself at the time, given my closeness to never operating on anyone again, let alone a doctor.) He did fine. Whether it played a role or not, I treated him exactly as I did my "usual" patients: explained in the same detail, using the same understandable terminology, saying the same things to him on rounds, in the same way, as I would have had I not known him at all. During surgery, I simply put who he was out of my head. Operating on "Doug" early in my practice, horrible as it was, may have been a good thing: it taught me to wipe away any assumptions and treat everyone the same. (It must also be said: many doctors and nurses have an expectation of and/or try to wheedle their way to exceptional treatment. Myself included. I'm not opposed to giving and receiving certain perks -- fitting in a visit, removing a lump or bump off the clock, off the record. It's the big stuff that needs discipline.)

Until I saw the mystifying choices some of them made, I used to consider it a compliment whenever a nurse or doctor came to see me or sent a family member. OK, maybe it was. Still, I'm not sure -- with the exception of people who actually worked in the OR -- what they really knew about me. (I'll never forget my shock at hearing an excellent recovery-room nurse mention who her OB/Gyn was: a guy constantly under scrutiny for poor decisions and outcomes, who was -- happily -- at the time only weeks from his eventual banishment from the staff.) For whatever reason, I did operate many times on colleagues, co-workers, and their families. And notwithstanding that early horror, it never again bothered me. When red flags flew, it was for the same reasons they unfurled for "regular" patients: co-morbidities, unpleasant personality, weird behavior. Not, in other words, because they were medical folk. But after my ugly initiation, I did make it a point always to eschew short-cuts or shorthand, speaking and behaving in my usual manner, drawing the same simple diagrams. Some even made it a point to thank me for it. The ones that lived.


shadowfax said...

I've taken care of a number of docs from The Clinic and otherwise as they come through my portal. It's hard to explain the feeling of dread that accompanies having to care for another physician - the sense of doom, that this is bound to go wrong somehow. Once I had to care for a CMO. No stress there.

You are right, though. I have from time to time had to shake my head at the crazy self-treatment and odd VIP treatments they got prior to seeing me.

As a doc, I use my status (when I am in patient mode) to cut through the red tape -- get appointments, get a call-back from the doctor, etc), but I have generally avoided the urge to self-treat too much.

I love the graphic. I want to know where I can get one of those stautes.

rlbates said...

Good post, Dr Sid. Don't think I can add anything. I try (and I mean TRY) to treat fellow nurses, doctors, and family members like other patients, but it is often hard to stick to that course. When I am the patient, I try (again I mean TRY) not to ask my doctor to deviate from his/her normal course.

Anonymous said...

Your blog is one of two that I read daily. The nice balance of personal, practical and professional make for enjoyable reading.

Todays topic describes a wonderful take home message on the down side of varying ones practice based upon ones relationship with the patient.

Several years ago my PCP pulled the pin and fled California, requiring that I find a new physician. I chose someone whose work I was familiar with and he was happy to add me to his practice under the following terms:
Don't ask for shortcuts or deferrals of certain exams/procedures, as that limits my ability to my best for you. If you want me to be your doctor, then let me be your doctor.

Elaine said...

I love the last sentence of your post ;-)

Sid Schwab said...

elaine: thanks for noticing. You seem to pick up the good stuff, which I appreciate!

Dr. Rob said...

I spoke with a malpractice defense lawyer who said that one of the most common errors made is where the doctor treats his staff or other physicians "on the side." Since my job consists of listening to the patient, I always make them sit in an exam room and take a good history like I would anyone else. There is a balance, but generally they don't gripe about being treated "normal." They think I am working harder for them.

Dr. Rob said...

I am kind of partial to the 7th and 11th sentences.

MedFriendly said...

Dr. Sid: When you do surgery, do you think of the person as a person or do you have to completely detach yourself to do the job properly and focus on the organs.

Dominic A. Carone, Ph.D.
Founder and Webmaster of and The MedFriendly blog.

Sid Schwab said...

Dr Carone: I've tried to reflect on that in various posts in this blog; I don't think I can answer it completely even still. When operating, I think for the most part one needs to attend to the problem divorced from the human in whose body you are intruding: always to be aware, foremost, of who it is could be paralyzing, I think. Still, there's always that sense of wonder and awe at being given that profound trust. Not to have than in your head at some level is probably impossible; and to be completely able to put it aside might lead to danger.

Midwife with a Knife said...

I have periodically fallen prey to the urge to self treat. I prescribe my own ocps. I tried to treat my own UC with prednisone once (who has time to call a doc, who has time to be sick?), then my GI doc kinda asked me not to do that (she said, "You can call the office, page me, whatever, but I want to know if you're sick."), so I obliged. I did use my MD abilities and contacts to cut through some red tape to get a colonoscopy done sooner (earlier this year, first UC flare, I couldn't work, couldn't eat, and could barely drink and my hct was 27, my pcp wanted to admit me to the hospital, but I declined.)

I really like that my internist sort of treats me like a patient. She has a nice way of acknowledging that I'm a doc, and may know some stuff, but also takes some time, really to explain things, and she doesn't omit screening or counseling about stuff because I'm a doctor.

Greg P said...

I fully agree with this idea of explaining more or less the same way to a physician as you would a nonmedical person.
One thing one learns quickly is that just because someone can toss around a lot of technical language about a disease or its treatment doesn't really mean they know what they're talking about. When you start taking shortcuts in the explaining you soon regret it. This is especially true in the history-taking. Even with a physician, you can't be sure they're using the terminology to describe their symptoms correctly.
Oddly enough, there's a similarity between seeing a physician and seeing some of these folk who come in obviously having done some extensive (and sometimes pretty good) internet research on a medical subject.

Anonymous said...

Just curious, if a doctor, nurse or VIP is operated on in a teaching hospital, would the attending physician allow the residents and medical students the same participation in the operation that the "unconnected" patient gets.

Sid Schwab said...

anon: it depends entirely on the individual surgeon, and the patient. In other words, sometimes yes, sometimes no.

Lynn Price said...

Boy, and I thought it was tough to have a fellow author critique my writing...yeesh.

Great post as always, Sid. You gave me another great idea to a chapter that was giving me fits and starts.

SeaSpray said...

Interesting post Dr S.!

I have a slightly different perspective as someone who has worked with hospital staff for 20 years and at times was a pt.

"I" never wanted to bother them when I was a pt because I knew how hard they worked. Second to that I didn't want to seem weak or demanding. So, on the one hand I usually got the extra attention because I worked there but on the other hand, I would hold back and not ask for help that I normally would have asked for because I didn't want to be a bother.

I kind of felt like we were doing this dance around unspoken thoughts. This is the reason along with the privacy factor that I opted to go to a different facility outside of our hospital system.

That being said, I am now planning to work in that facility but I don't believe it will matter because I have already been a pt there many, many times - so the barriers are down.

You Said,"For whatever reason, I did operate many times on colleagues, co-workers, and their families." and "When red flags flew, it was for the same reasons they unfurled for "regular" patients: co-morbidities, unpleasant personality, weird behavior. Not, in other words, because they were medical folk."

I have wondered what surgeons did when it came to co-workers in an office or the hospital. Do you think it is the same for all surgeons? Or do you think there are some who can't separate their personal feelings enough to operate?

All the surgeons I worked with at the hospital most definitely performed surgeries on the staff.

Would you draw the line with family?

A red flag went up with co-morbidities, but did you still operate?

I am thinking you got more thank yous than not. ;)

P.S. Your picture for this post? I have to look scares me. (never was good with scary movies);)

SeaSpray said...

I meant would you draw the line with your family?

dima said...

super boy...

Sid Schwab said...

dima: by which, I assume, you mean "molodyetz." (stidno mnye, nye mogu из российского алфавита)