Three Lessons

I finally have a moment to reflect on third year (phew!). The grades are in, Step 2 has been completed, and I've started to get comfortable in my new home in Linville (despite the lack of Internet at times, and absence of cell phone service almost all the time). I realize I've learned some very important lessons from last year. These are more the Art of Medicine variety rather than hard science. I'm sure there are many more, but a few have really stuck out as I have had to take more responsibility for my patients, and have been seen as a true provider. Most patients here refer to me as their "doctor" (despite my corrections), and I know that what I say, and how I say it, matters. So, if I could go back one year and teach myself three lessons, they would go something like this:

• All doctors practice as a subspecialists in Psychiatry. Every physician is a psychiatrist first, specialist later. I hope to be a "Shrink with Surgical Training" later in my career. So much about a patient's health revolves around where they are mentally. Unbearable back pain may just be back pain, but it often is also a cry for help. I just can't take this anymore. I'm suffering. I can't pay my bills, my marriage is strained, I'm depressed, and I just can't cope. I think a lot of the time something else is going on, and it is our job as providers to recognize this and treat it. Here in Surgery, I see quite a bit of Irritable Bowel Syndrome (IBS), in which psychiatric pathology may play a strong role. Taking out a gallbladder is not going to fix IBS, but often patients get nonspecific test results that point them in that direction. I think this is where the team-approach to health care is so important: working with the primary care provider, a shrink (if needed), and of course, the patient. I think because of the way we are taught psychiatry, it has been one of the most important parts of my review of systems, and I will try to incorporate it more as I go on. So thank you Dr. Buie and Dr. Meacham.
• Ask yourself: "What would I do if I were seeing this patient in the office?" I have a second year MAHEC Family Med resident to thank for this one, but it is one of my biggest pet-peeves in the hospital. A patient walks in to the ER for a very minor complaint. They end up getting a CT (which one of my attendings refers to as an "important emergency room vital sign"), CBC, CMP, and the works. In reality, they have a runny nose. But it's not just the ER, and I don't mean to pick on ER physicians, because it's everybody. If we were to all step back and say, "Hey, just because I'm in the hospital it does not mean I need to order a hundred tests. There's no reason to get a chest x-ray here. Maybe a referral or some Simply Saline is all you need (or a PCP...)." I think asking this is important not only for the patient, but it might eliminate a lot of waste to the system. And when in doubt, go back to Lesson #1. Why did coryza bring you in, today?
• The diagnosis of fibromyalgia is given out like candy. Don't get me wrong, I think there is good evidence for fibro, even though it frustrates many physicians. But, just because someone is in pain, it does not mean they need to be given a diagnosis of fibromyalgia (which they will read about on the Internet and then all hell will break loose). I recently saw a patient with horrible rheumatoid arthritis, complicated by even worse osteoarthritis. And, the gentleman was in severe pain. Of course he was in pain! He's got an extremely debilitating disease! Why the elderly man needs another diagnosis to skew the picture is beyond me. But, it seems like there are sooo many patients walking around with this diagnosis, and when you sit down and actually talk to them, it just doesn't make sense. Depression + back pain does not necessarily equal fibromyalgia. Carrying that diagnosis may affect how a physician treats the patient (unfortunately), so let's stick to giving that out only when it's appropriate. And when in doubt, go back to Lesson #1...

Food for thought. For more food, I leave you with my Week #2 Quote:

"Robert. There are two things I like talking about. My Lord and Savior Jesus Christ... and guns. So now. What kind of gun do you own?"