Archive for the 'The Art Of…' Category

The Art of Asking

Most people know from experience or through intuition that there is a right time and a right way to ask important or sensitive questions. You don’t usually just blurt out requests for raises or marriage proposals, for example.

In many areas of life, knowing when and how to ask difficult questions is viewed as an extremely valuable skill, for example in criminal investigations and in journalism.

In some cases this kind of skill can even make you a media star: Interviewers like Barbara Sawyer, Oprah Winfrey and Howard Stern are more famous and better paid than most of the celebrities they engage in intimate conversations in front of their national or world-wide audiences.

This year, the US presidential debates have been said to require unusual savvy from their moderators and their performance may even affect the outcome of the election.

Why is it, then, that in health care so little value is placed on when and how you ask sensitive or important questions?

In healthcare, we are constantly told that we must ask the most personal and intrusive questions of anyone who walks through our doors before we even ask what brings them to the doctor in the first place. And, unlike other interviewers, we must use “standardized” and “validated” questionnaires, because our work isn’t like other forms of fact or truth finding; our purpose is to collect data and to apply statistically proven interventions. No room for tact or finesse here.

When Autumn, my nurse, checks in a new patient, each one has already answered questions about gender identity and gender at birth. Autumn, along with doing the usual vital signs, has to administer a depression screening, inquire about alcohol habits and smoking, along with readiness to quit. For people with a BMI over 30, she has to ask what they are planning to do about it.

In many practices, the patient’s “History of Present Illness” and “Review of Systems” are asked and documented into obtrusive computers by freshly graduated medical assistants with limited medical and psychological training or experience. But that’s okay, because we use validated instruments and people always open right up and tell us the truth, and they always present their most important symptoms to us on a silver platter, the thinking goes. So, therefore, professional skill and experience may be valuable in rare cases, but there is just too much variability in that.

So, let’s imagine that our mandates applied in other areas of life:

What if criminal investigations were conducted by administration of nationally established “Criminology Assessment Protocols”?

What if lawyers could only use validated questionnaires and weren’t allowed to cross examine witnesses?

What if all celebrity interviewers could only ask the same set of questions?

What if the presidential election was determined by having our citizens vote for candidates based on their answers to a standardized and validated “Presidential Fitness Inventory”?

No, that would seem ridiculous, most people would say. So why is that the way we have to ask questions in medicine?

Unlike detectives, journalists, lawyers, bureaucrats and politicians, doctors just don’t know how to ask the right questions to figure things out.

The Art of Antibiotic Selection

Jacques Johndreau did not look like his usual self when I saw him in the office a few weeks ago. He looked part retired bank manager and part Disney cartoon chipmunk.

He spoke with hardly any facial movements:

“Holy Boys, my wife said to me this morning, you look like you’ve got the mumps again!”

I was aware that Jacques had an atrophic testicle from catching the mumps as a teenager. This time, it was not likely the mumps, but a bacterial parotitis. He was afebrile, and could open his mouth when asked to. I could not palpate a stone in Stensen’s duct and he didn’t experience any worsening of pain when eating acidic foods, so I wasn’t so sure he had a stone.

This was an early, mild case of parotitis and I thought he had a good chance of beating the infection with oral antibiotics. The majority of these infections are caused by staphylococci, but sometimes gram-negative bacteria are the culprit. Whatever I chose, I needed to consider that Jacques takes a blood thinner, warfarin, which interacts with many antibiotics, particularly ones with gram negative coverage.

I e-prescribed a high dose of Ceftin, or cefuroxime, a second generation cephalosporin with good coverage for both staph and gram-negatives and no effect on warfarin.

“If you get worse instead of better on this”, I explained, “you’ll need intravenous antibiotics. So, by Saturday, 48 hours from now, you’ll know if you need to go to the hospital or not.”

Monday morning came. There were two ER reports with accounts of late Friday and Saturday visits with intravenous administration of ceftriaxone, a third generation cephalosporin. There was also a CT scan report with a hedged opinion that there was no frank parotid abscess. The third ER note, from late Sunday night, described how the doctor on duty had selected clindamycin and instructed Jacques to see me Monday morning for a referral to an otolaryngologist.

Monday morning Jacques definitely looked worse than the week before. His cheek was bigger and firmer, although not red. It seemed warm, but he didn’t have a fever. He had trismus; his mouth opened very little.

“Wait right here”, I said. “I’m going to call Dr. Ritz, the ENT specialist over at the hospital.”

I logged on to UpToDate and quickly looked at half a dozen treatment regimens for parotitis, and all were multi-drug intravenous protocols with oral step down alternatives.

“He’s in Danderville today, seeing patients at the Outpatient Clinic and tomorrow he’s in surgery all day”, his nurse said. She agreed to double book Jacques for Wednesday morning.

I called the Danderville clinic and asked to talk to Dr. Ritz.

After reassuring me that he never minded taking calls from a colleague, he listened to my story, and said “you’re old enough to remember Duricef, cefadroxil, right?”

“Sure”, I said. “I haven’t used it for years, though.” I remember we used to think of it as having better tissue penetration than other first generation cephalosporins.

“These are all staph. And Duricef works better than any other oral antibiotic. In thirty seven years, I’ve never had to operate on one of these.”

I thanked him and mentioned that I had scheduled Jacques to see him two days later, just to be safe.

“Oh, I’m happy to see him, but he’ll be fine”, the old otolaryngologist told me.

I related my phone conversation to Jacques and told him about his Wednesday appointment with Dr. Ritz at his office, thirty five miles away.

“If I can make it there. It’s going to storm, you know.”

Jacques’ usual drugstore didn’t have any cefadroxil in stock, but the other pharmacy in town did, so I e-prescribed it there.

“I’ll see you back here if the roads are too bad, but if you spike a fever or feel worse, go back to the hospital”, I concluded our visit.

I had a vague, uneasy feeling about just switching from one cephalosporin to another, but Ritz has a lot of experience and he’s the only ENT within a hundred miles.

Wednesday morning brought eight inches of snow with a thin layer of ice. After a slow commute in four wheel drive, I stomped the snow off my boots inside the clinic back door and hung my thick leather coat on the back of Autumn’s and my office door. I changed to my indoor shoes and booted up my desktop and tablet computers.

“Jacques Johndreau is coming in at nine”, Autumn told me, “he didn’t dare driving down to Dr. Ritz’ office.”

At nine o’clock I knocked on the door to room 2 and entered. Jacques stood up from his chair and greeted me with a handshake.

“I wanted you to confirm”, he said, and paused to show me how far he could open his mouth. “But I am definitely better.”

There was no question. His gland was half the size it had been 48 hours earlier.

“You didn’t need me to tell you that, even. This is very good news, that such an old drug worked better than two newer ones that I and the ER tried, even intravenously. I’ll call Dr. Ritz to let him know just how dramatic the difference is”, I said and patted Jacques on his broad shoulder.

The experience of an almost seventy year old solo doc beat the Boston medical Brahmins this time. I was fortunate to have my senior consultant to back me up.

And as for antibiotics, too, sometimes newer isn’t better.

Osler said “Listen to your patient, he is telling you the diagnosis”. Duvefelt says “Listen to your patient, he is telling you what kind of doctor he needs you to be”.



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