February 7th, 2011 by Bryan Vartabedian, M.D. in Better Health Network, Opinion
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It’s happening more frequently: Requests for medical advice by email. The more I do, the more people I meet. The network grows and friends of friends learn about what I do.
So junior has a little pain and shows at the local ER where the requisite CT shows a little thickening of the ileum. Someone suggests that the family drop me a line. Here’s the problem: There’s more to this than digital correspondence will allow.
While the statistical reality of this child’s situation is that this finding represents a little edema from a virus, the differential is precarious: Crohn’s disease, lymphoma, tuberculous ileitis, eosinophilic enteropathy.
A case of this type requires the thorough exploration of a child’s story and a compulsive exam that takes into consideration the problems in the differential. Worrisome considerations need to be framed and discussed in the context of the child’s total presentation and real likelihood of occurrence. The sensitive dialog surrounding our diagnostic approach to this child requires a relationship. And the various approaches require an element of negotiation with the family. All of this takes time, emotional intelligence, and good clinical judgment.
Children are complicated creatures. Parents are more complicated. Loose, off-the-cuff advice based on shotty information shortchanges both parties.
Of course the easiest response to these regular queries is that my employer, malpractice carrier, and the Texas State Board preclude offering medical advice without an established relationship or the maintenance of a medical record available for peer review. Everybody understands legalese. Few, however, understand the complexity of a properly executed medical encounter.
*This blog post was originally published at 33 Charts*
January 31st, 2011 by Bryan Vartabedian, M.D. in Book Reviews, Opinion
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A friend suggested she was tired of hearing about vaccines. Her comment and our subsequent conversation seemed to reflect an important shift in parent sentiment: The conversation about vaccines is beginning to get somewhere.
While much of this was born of the mainstream media’s newfound realization that the vaccine-autism connection was cooked, some of this is due to the tireless work of those like the Children’s Hospital of Philedelphia’s Dr. Paul Offit who get the story right.
As part of his passionate agenda to expose vaccine truths, he’s published “Deadly Choices: How the Anti-vaccine Movement Threatens Us All” (Basic Books, 2011). For those looking to understand the origins of anti-vaccine sentiment, read this book.
What struck me is the deep history behind the anti-vaccine movement. From Jenner’s smallpox fix to modern-day MMR struggles, Offit draws fascinating corollaries surrounding immunization that seem to defy the generations. Vaccine resistance was not born of Andrew Wakefield, but broader concerns rooted in religion, individual liberty, fear and propaganda. “Deadly Choices” puts the anti-vaccine movement in a historic sequence that reads like good suspense. I couldn’t put it down. Read more »
*This blog post was originally published at 33 Charts*
January 22nd, 2011 by Bryan Vartabedian, M.D. in Health Policy, True Stories
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So I’m in the exam room recently with a new patient. After some initial dialog with the child and family, I launched into the business of problem solving. Ten minutes into my history the mother politely asks: “I’m sorry, and you are?…”
I hadn’t introduced myself. I had left my ID badge at my workstation, and by order of some innocent distraction with the child or family, I hadn’t identified myself immediately on entering the room. This is rare.
Sometimes I assume people will know who I am. But I don’t wear a white coat and my stethoscope is concealed. I wear clothes only good enough to sustain the barrage of regurgitation, urine, full-frontal coughs, and sloppy hugs that mark a successful clinic day. A colleague once told me I dress like an algebra teacher. I haven’t quite processed that one, but suffice it to say it’s easy to fall into a mistaken identity.
So I apologized and made a proper introduction. What’s remarkable is how far I went without the mother having any idea about my identity. I can imagine that it took a certain amount of wherewithal to interrupt the person she suspected was the doctor to ask such a basic question. Read more »
*This blog post was originally published at 33 Charts*
January 16th, 2011 by Bryan Vartabedian, M.D. in Better Health Network, Opinion
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I used to think they didn’t, but they do.
Clinical judgment is the application of individual experience to the variables of a patient’s medical presentation. It’s the hard-worn skill of knowing what to do and how far to go in a particular situation. It’s having the confidence to do nothing. Clinical judgment is learned from seeing lots of sick people. Good clinical judgment is when the gifted capacity of reasoning intersects with experience. Some doctors have better judgment than others.
Aristotle called this phronesis — or practical judgment.
Patients have practical judgment. We often can tell when something’s amiss with our own body. Things feel different or look different. Taking action on these observations is how we exercise judgment as patients.
Parents of children with central venous lines, for example, can often identify the early signs of infection before fever has ever appeared. They know the subtleties of their child’s behavior. The same goes for children with epilepsy. People with diabetes increasingly have the latitude to apply judgment to the management of their disease. This tends to be quite defined, however, with fixed variables and limited options for intervention. Read more »
*This blog post was originally published at 33 Charts*
January 12th, 2011 by Bryan Vartabedian, M.D. in Better Health Network, Opinion
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I can’t say that I enjoy the patient encounter as much when it involves a translator. There’s just something about communicating through a third party that changes the experience. But there are some things you can do as a provider to bridge the language gap:
Look. Even thought the translator is doing the talking, look at the patient just as if you are asking the question yourself. There’s a tendency to let the translator act as a surrogate with respect to eye contact and visual feedback.
Smile. A smile doesn’t need translation. It conveys very clearly that have a sincere interest in making a connection.
Touch. I never leave the exam room without some type of sincere physical contact. A firm handshake or a hand on the shoulder go a long way in closing the language barrier.
Say something funny. Patients don’t expect jokes to come through a translator. And there’s nothing better than watching a silly, lighthearted remark make its way into another language. It’s powerful and fun.
It’s important to think about how we can recreate the elements of a one-on-one dialog. What do you do to make a connection beyond spoken language?
*This blog post was originally published at 33 Charts*
