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Should US physicians learn Spanish?

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Last night I was having dinner at Charlie Palmer Steak and entered into a conversation (in Spanish) with one of the wait staff. He was surprised when I ordered in Spanish and we had a friendly conversation about the merits of whole grain bread. He asked me why I spoke Spanish. I answered simply, “porque soy doctora” – because I’m a doctor.

Dr. Richard Reece’s recent blog post tackles the issue of language barriers in the healthcare system. He gives some good advice for cross-cultural communications, reminds us that 25% of US physicians are foreign born, and quotes the inscription on the statue of liberty as the reason why Americans should remember to welcome foreigners. However, he also encourages immigrants to learn English and frowns upon illegal immigration.

As for me, I learned Spanish because I was worried that I’d harm a patient by misunderstanding what they were trying to communicate. Of course we try to have an interpreter at the bedside at all times, but in reality it just doesn’t happen consistently. Learning Spanish was my way of practicing safer medicine.

Now it is frustrating that some patients (at least in NYC) seem to feel as if their doctor is obliged to learn Spanish. They sometimes have an attitude of entitlement that I find hard to swallow. I try to put myself in their shoes, but honestly if I were ill in a foreign country I wouldn’t assume that it was my right to receive care in English.

Still, for me, learning Spanish was a wonderful thing. There is a certain caring that I can communicate, and a certain warmth and appreciation that I feel from my patients as they encourage me – that even though I make mistakes with my grammar, they can still understand my meaning quite well. We laugh a lot at the words I find to describe things – and it generally provides a lighter tone to the interaction. Laughter is good medicine, and if my version of Spanish brings laughter to others – then so much the better!

Do you think US healthcare professionals should make an effort to learn Spanish?

This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.

Wrong diagnosis: physician instinct may harm or help?

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A member of our editorial team kindly brought me some blog fodder last week – a recent article from the New Yorker. It was an inflammatory piece, describing four types of errors that doctors make in diagnosing patients:

  1. Representativeness error – when a physician fails to consider diagnoses that contradict their mental templates of a disease. E.g. thin, fit, young male with chest pain – unlikely to have heart attack, but did have one.
  2. Availability error – the tendency to judge the likelihood of an event by the ease with which relevant examples come to mind. E.g. a patient coming to the ER in the middle of a flu epidemic, with flu-like symptoms was diagnosed with flu but actually had aspirin poisoning.
  3. Confirmation bias – confirming what one expects to find by selectively accepting or ignoring information. E.g. “sub-clinical pneumonia” diagnosis given even though lungs are clear.
  4. Affective error – the tendency to make decisions based on what physicians wish were true. E.g. nice young patient has mild fever – physician presumes it’s a typical post-op fever rather than early sepsis.

Although these biases (I wouldn’t really call them “errors”) are indeed real, I thought the author went a little too far, finishing his article with a scathing quote from a Canadian physician:

“The implicit assumption in medicine is that we know how to think. But we don’t.”

Ouch.

I have mixed feelings about this – for as many examples they can think of that demonstrate how physicians got the wrong diagnosis, I can also think of examples of physicians getting the right diagnosis against all odds.

Consider the middle aged woman who came to the ER with a headache – one sharp physician had a “gut feeling” that this headache was not typical, and resisted the protocol to do a head CT to rule out a sub-arachnoid hemorrhage and send her home. Instead he got blood tests that revealed the underlying diagnosis: advanced leukemia. Her blood was so thick with dividing leukemia cells that it was causing her to have a headache. She underwent immediate dialysis and survived what could have killed her.

Or what about the man who complained of chronic sinusitis? Instead of giving him an antibiotic with outpatient follow up, one physician took a detailed history and realized that this man had been having sinus pain since a recent fall from a ladder (while using a nail gun) at a construction site. The doc got a head X-ray and found a nail lodged in his sinus! During the fall the nail gun had shot a nail into the corner of his eye, leaving no entrance wound. Because of the jarring nature of the fall, the man didn’t even realize he had been shot. The man had an ENT surgeon remove the nail, and she also cleaned out what could have become a life threatening abscess.

The truth is that doctors (like anyone else) are vulnerable to making false assumptions about people – and that we would all benefit from using a software program that would automatically generate a large differential diagnosis to consider each time we see a patient (just to keep other possibilities in the forefront of our minds). However, if you ask patients if they’d rather be treated by a machine or a human being – I’m sure the majority would choose the latter. I think we can all agree that instinct and judgment still have value in this information age. The trick is to marry accurate information with good instincts without ordering every single test in the book to rule out rare diagnoses on everyone! That’s a tough balance to achieve.

Do you know of any examples of a physician making an unexpected diagnosis based on gut instincts?  I’d love to hear about it.

This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.

Does good research get buried?

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We had a problem in our pregnancy forum today – there were so many forum posts submitted so quickly that people didn’t get the chance to answer a post before it was buried underneath an avalanche of other questions. This left the people asking the questions quite frustrated.

A few hours later I was peer reviewing an article for the AJNR. I did a Medline search as part of a background check for my review. I found 30 pages of research articles. I was reading through their titles when, glazing over on page 28, I realized that a very similar study had already been conducted… in 1979.

It suddenly occurred to me that good questions (and good answers) can be buried by time. They say that history is doomed to repeat itself… the Internet is beginning to help me understand why that’s so.

What do you think?

This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.

The secret to long life and good health

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My dad is 76 years old. He takes one baby aspirin a day and has no medical conditions. He looks about 10 years younger than his age, and his mind is sharp and clear. How does he do it?

I think the secret is the time he spent working on a farm. At age 40 he retired from his consulting firm in Manhattan and bought some land in rural Canada. Without realizing what he was getting himself into, my dad bought some cattle to work the farm. When winter came he had to keep the animals in the barn, and he soon discovered that each steer and cow produced its own weight in manure every 2 weeks (that’s about a half ton for those of you city slickers out there). So all winter long my dad shoveled manure. He did this for 35 years.

My dad now keeps fit with regular sit ups and push ups in the morning and long walks every day. But to me, the secret to his success was the shoveling. Life is full of little ironies – sometimes “crappy work” can result in amazing health benefits.

Although the New York Times wrote a fairly scathing review of my mom’s book about their adventures in shoveling (which ultimately led to a yogurt business) – I think my dad got the last laugh.  Healthy and well, he can look forward to a long and enjoyable retirement.  I wonder if the folks in Manhattan (who choose to spend their lives shoveling a less physically challenging BS) can say the same?

This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.

Metabolism: does exercise boost it?

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Well, I always hoped that the rumors were true – that gaining muscle mass would increase one’s resting metabolism. How many times have you heard fitness gurus tell you that if you bulk up with muscle you burn more calories even when you’re sitting around, watching TV?

Unfortunately, the truth is that even the most impressive muscle gains result in only a tiny increase in resting metabolic rate. In one case I recall a man who lost ~40 lbs of fat and gained ~20 lbs of muscle. His metabolism increased by a mere 50 calories/day.

In my experience, metabolism seems to be more a factor of nature rather than nurture. You’re born with a certain internal engine – and not much changes that (at a given body weight). However, exercise burns calories – and that can lead to weight loss, etc. It’s just that the baseline metabolism doesn’t change all that much.

Stay tuned for my next blog entry where I’ll explain why metabolism may be linked to diet failure.

This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.

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