“She makes the mistake of talking to patients.”

— Overheard from a fellow discussing the consult attending’s rounding habits

Is there such a thing as spending too much time with a patient? The question seems preposterous, when recent time motion studies showed that physicians in general, and residents in particular, clock embarrassingly few face-to-face minutes. The quote above was said with a wink and a nudge, but there are situations when it can be true, particularly if you talk to a patient—or get talked to—instead of having a conversation.

Two groups are at highest risk of talking too much—trainees and consultants. Many an internist remembers having to pick up the pieces after a consulting physician flew by the bedside to throw an unasked for opinion bomb. Think hematologists talking about insulin regimens, cardiologists about causes and treatment of back pain, or orthopedic surgeons about code status. “But one doctor said…” and a perplexed look is the usual outcome, more so if the consultant debated him or herself out loud.

Fellows are even more efficient sowers of confusion. Unlike some of their superiors, they still remember other fields well enough to a) have a valid opinion, and b) keep it to themselves. Where they are at highest risk for foot-in-mouth is the area of their future expertise—picking up just enough from the attendings to sound knowledgeable, yet not knowing enough to tell the patient what they don’t know. Even at later stages of training, a fellow’s best plan shared with the patient may tumble down when the attending gives a diametrically opposed recommendation. The common scenario is one in which there is no evidence, and clinical judgment rules. You can either not share your own view, or punctuate every conversation with “But we’ll see what my attending says.” More time wasted, and for nothing.

Patients themselves can be talkative, sometimes to their detriment. The reasons are many, and understandable: they have much to say about themselves—relevant to why they are in the hospital and not so much, they might not have anyone at home listening, they may have some level of delirium, dementia, or other cognitive disorder. Being able to identify such a person, and then knowing how to direct the conversation, is an unknown skill for most trainees and goes against today’s dogma of giving patients time to talk. No harm done to the chatty ones, but there are only so many hours in the day, and some of them should be spent thinking.

To be clear, we don’t have an epidemic of young doctors staying in the hospital until 2am while demented World War II veterans regail them with half-made up stories from Normandy. If only. But more isn’t always better, and physicians need to know when to speak up (to get their patient back on the topic), and when to stay quiet (not to overwhelm them with half-baked ideas).

First they came for the nerds.

Now they are coming for the doctors (see What’s New in Version 3.0.5). The makers of MedCalc, the best medical calculator app out there, explained what happend in detail¹. This was the rule they were supposedly infringing:

22.9 Apps that calculate medicinal dosages must be submitted by the manufacturer of those medications or recognized institutions such as hospitals, insurance companies, and universities.

Nevermind that many doctors view themselves as institutions—this is an idiotic rule. Is University of Baltimore, which has no biomedical science courses or programs, allowed to publish a drug dose calculator? Is GEICO?

The FDA has issued guidance for mobile medical apps. It specificaly allows calculators that use generally available formulas, and forbids apps which calculate radiation dosage, but does not mention drugs. Where, then, did this rule come from?

It is, of course, the same App store rules that allowed these pearls of quackery.

It’s madness, and it’s maddening.

A key skill to have during oral exams back in med school was never to admit not knowing. Avoid the areas you’re uncertain of, dodge the examiner’s field of expertise as much as you can, and never ever say “I don’t know”.

These sage words were passed on from generation to generation, propagated by everyone, including me. Only, this wasn’t what I or any of my friends actually thought. It was a poke at the climate of intellectual dishonesty at our school, not a guide to success in medicine.

Starting residency, though, flips the sarcasm switch somewhere and the funny guidelines become instructions to be followed verbatim. The knowledge in question is different—patient data instead of textbook medicine—but the idea is the same. Observe the modern American intern’s vocabulary:

• Not that I know of (means I don’t know).
• I wasn’t aware of that (means I didn’t know).
• I don’t think it is (means I don’t know if it is).
• I belive so (means I have no idea, but yeah, maybe).
• It probably was (means I don’t have a clue but I did a D6 roll in my head and it was a 5).

I used all of the above, and more, during internship, but still get frustrated hearing it from others¹. If you are an intern, or anyone reporting patient data to a person above you in the pecking order, try using “I don’t know, but I can find out in a second” instead. Then start practicing your EMR skills to trully make it a second.

Observe George Carlin discussing how euphemisms are invading the English language:

I first heard a version of this years ago, back in Serbia, while I was still a med student. It hadn’t left much of an impression, but I can imagine myself nodding my head and thinking ha ha, yes, stupid Americans, ruining their own language, or something comparably obnoxious.

Well, I’ve, erm, matured since then. True, some euphemisms now inspire rage instead of vague amusement, like my two favorites:

• “I just wanted to let you know” instead of “I’m telling you”, and its relatives “Please let me know”, and “Thank you for letting me know”. Physicians are particularly fond of this, for we are the gatekeepers of knowledge, and the only reason you know something is because we are letting you. Don’t worry though, it’s not just you, we say that to each other all the time.

• “I don’t feel comfortable doing xyz” instead of “I don’t want to do xyz”, as mentioned here.

Most of them, though—particularly ones we use with patients—have a good reason to exist. The Radiolab segment which inspired this post made fun of “making someone comfortable” being used for dying ICU patients. Instead of… what, exactly? Euthanasia? There is a difference between giving someone drugs usualy meant for comfort—opioids, primarily—in order to kill them, and giving them opioids for pain and comfort knowing it may shorten their life.

Then there are turns of phrase used because they are euphemisms. “You should get your affairs in order”, “your time is becoming limited”, “at this point we should concentrate on quality of life, not quantity” are all ways of saying “I don’t know when you’ll die, but it will be soon, so start planning the funeral”. I am sure Mr. Carlin would appreciate getting it straight, but not every patient is as stoic. We can easily be more blunt if asked to do so, but you cannot un-hit a patient with a sledgehammer like that. So the default is to err on the side of softness.

Then again, most of the euphemisms we use with patients also make us more comfortable with the sitation. What I wrote above may then just be my rationalizing it away with a convenient it’s-best-for-the-patient mantra. In truth—to use another common phrase—euphemisitis is a multifactorial condition (as in, I have no idea what the reasons are, but it’s probably a little bit of everything).

Did you hear the one about not prescribing angiotensin receptor blockers to patients with ACE inhibitor-induced angioedema? I’ve had heated debates with residents in my old clinic who did not want to even consider ARBs for a patient with worsening diabetic nephropathy who’s had lip swelling while on an ACE-I ten years ago.

Or the one about not giving these patients amlodipine, since there are two—yes, two—case reports on amlodipine-associated angioedema? Should we also stop giving them water?

Then there are shellfish allergies and iodine contrast, fever and atelectasis, morbid obesity and hypothyroidism… No matter how many studies show these associations to be too weak to be clinicaly significant, or just plain false, there will always be an attending somewhere giving them as his or her pearl of the day.

We need some medical mythbusting for physicians, not just the lay public.

This has become the mantra of every medical student, intern, and resident wanting to appear smart on rounds and conferences, of every attending intent on shooting down a team member’s suggestion. Five, ten years ago it might have have signaled genuine interest. Now it means, usually, “I don’t know anything about the subject, but I’m still calling you out on (what I think is) your BS. Here, look at me! I am evidence-based!”

No, nobody has posed me that question in quite a while, and I don’t remember ever asking it in any context¹. But, honestly, except for a few very well-known examples listed in this excellent post, you can find “evidence” in the medical literature to back up any claim. Off-the-cuff conversations during lectures and rounds are not the best place to dissect them, especially when one side has seniority.

If you have a Google+ account—and you might not be aware that you do—anyone using Gmail can now email you without knowing your address. You can disable this “feature” in the settings, but having it be opt-out shows yet again how little Google cares about privacy.

Not that there’s anything wrong with that—privacy is a relatively modern invention that younger generations might not care for as much as we do. But you should understand the implications of patients and random strangers being able to leave messages in your personal inbox. Suing P.,,,,,,kmmmmmqmmmdoctors is not a modern invention.

This is why I stopped using all Google services—search included—years ago. The company has become so large, with so many users, that it doesn’t need to cater to fringe interests. And for a business with billions of users, doctors are a fringe group—one that hates change-for-change’s-sake, having to [re-learn an interface][ n. Nnjm interface] “just because”, and not being the true customer¹.

Also, the number of people at Google who may access my data is huge. FastMail², my email provider of choice, has fewer than 10 employees. Gmail alone has hundreds. Not that anyone would be interested in me in particular, but if I ever inadvertently send or receive private patient information through my personal account, I’d rather as few people as possible see it.

Email is fine, but why abandon search? First, I have googled enough ailments and substances, common and obscure, that the add network thought I was an elderly female recovering heroin addict with more than one paraphilia. The adds I would get were in that sense appropriate. Second, because of SEO the only valuable page-one results I would get were Wikipedia entries. Everything else was a hodgepodge of useless Livestrong, Huffington post and five-pages-per-500-word-article-AND-behind-a-login-wall Medscape links. Duckduckgo and, yes, Bing at least help with the first problem while not making the second one any worse.

Google calendar is the only service I would consider using. It is fast, reliable, omnipresent and easy to use. There is, however, that constant nagging fear that they will find some way to integrate it with Google+ and yet again sacrifice functionality to force people into its circle³. This is why I use Apple’s iCloud calendar, its horrendous web interface and all.

Also: Reader. I use FeedWrangler now, but man.

Doctors’ concerns aside, Google is all set to become the network TV⁴ of the internet—large, bland, and largely not relevant to the people who are. It is already two-thirds of the way there.

• I don’t feel comfortable doing that.—I don’t know what you’re asking me to do (nurse to intern); I’m too lazy to do it (intern to resident); I think it’s a stupid idea and there’s no way you can make me do it (resident to attending); You’re not paying me enough to do this crap (attending to administration).
• It’s a light elective—You don’t need to show up.
• Needs to read more. (on a written evaluation)—I have no idea how much medicine this person knows. I barely know any myself.
• The family is reasonable.—Family members don’t ask too many questions and will agree with anything you say.
• The patient has xyz.—I’ve read in an old discharge summary that the patient has xyz, but have no idea how they established the diagnosis, what stage it is in, or what the hell xyz even is.
• The head is normocephalic, atraumatic. Pupils are equal, round and reactive to light and accommodation. Sclearae are nonicteric.—If I were to report the physical exam I actually did it would take five nanoseconds, so take these fillers to make it seem like I’ve put in some effort.
• Thank you for the thorough presentation.—Why did you waste my time with all that useless information?
• That’s an outpatient work-up.—Administration is already breathing down my neck because of this patient’s length of stay and you’re worried about a mild anemia and a positive hemoccult!?
• That’s her new baseline.—Her disease is worse and we don’t know why, so I guess she’s stuck with it.
• Please let me know if you have any more questions.—This is the end of our conversation, so please stop talking. I shall now leave.

I don’t care much for spelling or grammar. My native language, Serbian, has no concept of the former thanks to its being phonetic. As for the latter, few people in my home town and the surrounding area cared too much about it, flinging tenses, forms and declinations around carelessly. I proudly continue this tradition.

What gets to me is semantics. Misspelling tachypnoeic is unfortunate; saying that the patient’s head is normocephalic means either that it had grown a head of its own, or that the speaker had no idea what the word they were using signified¹.

So anyway, lots of big words and a sizable footnote just to introduce something I’ll likely be doing on a weekly basis—-complaining about today’s youth and their improper use of medical verbiage².

Carry on.