Well-Women Visits Are Critical to Your Health

As an emergency physician, I tend to work on the other side of preventive care services. I see what happens when women don’t know about safer sex and birth control, and end up with complications from sexually transmitted infections. I see what happens when women do not get routine screening for cervical cancer and struggle with life-threatening cancer. I see what happens with out-of-control hypertension and diabetes, and the heart attacks and strokes that are detected far too late.

These experiences have shown me that prevention is the best medicine. That’s one big reason why the Affordable Care Act provision requiring new insurance plans to cover women’s preventive care without any extra charges or co-pays is a real victory for women. These requirements, which go into effect Aug. 1, will be phased into existing insurance plans over time.

Because of this change, women will be able to obtain complete contraceptive care, screening for sexually transmitted infections, and screening and counseling for intimate partner violence. This builds upon earlier requirements that insurance companies cover – at no additional cost to women -- mammograms and screenings for cervical cancer. It’s clear to me that these mandates will significantly improve women’s health and lives and ultimately lead to a reduction in health care costs.

The Well-Woman Visit
One of the easiest ways to obtain preventive services is through a well-woman visit. These visits, which will soon be covered with no co-pay, give you the opportunity to ask key questions about birth control, sexually transmitted infections, and other reproductive issues, along with questions about diet and exercise and any health concerns you have. You can also discuss changes in your family’s medical history that are important for your health care provider to consider. For example, when my mother was diagnosed with breast cancer, my doctor recommended that I get earlier screenings.

Along these same lines, your health care provider may have questions or issues to discuss with you. Smoking, drinking and recreational drug use can create and contribute to health problems, and often need to be discussed and addressed multiple times before change happens. Well-women visits also give your health care provider a chance to screen for potential high blood pressure, diabetes, depression, domestic violence, and more.

The well-woman visit is important for another reason: it gives you and your health care provider a chance to get to know each other. Most people go to their provider or to a clinic only when there’s a problem, but the best time to get to know your provider isn’t when you’re in distress from a painful or troublesome condition. Studies have shown that health care providers make more accurate diagnoses when they know their patients and can put the symptoms in the context of your life. A well-woman visit is a precious opportunity to build this trusted relationship.

As an emergency physician, I am excited about the new provisions taking effect Aug. 1, which include annual well-women visits for those who want them. I would much rather women regularly visit their health care providers than come to the E.R. later suffering from preventable problems. So please take this opportunity and make an appointment with your provider. The importance of investing in your health is too crucial to ignore.

I wrote this article as a guest blogger for Our Bodies Our Selves. This post also appeared as part of the National Women's Health Network blog. I welcome your comments and your emails!

How to Find a Good Doctor, Part 2

My previous posts addressed the difficulty in finding a good doctor and how such a doctor is one who makes you feel better. In this post, I describe some characteristics of such a good doctor:

1) Your doctor should care about you as an individual. Every patient has her own story--not just of illness and symptoms, but also who she is as a person. Your doctor should make an effort to get to know you. Not only is this the best way to actually find out about your illness and thus to help you, hearing your story shows that your doctor genuinely cares about you. The time you have with your doctor may be limited, and sometimes you may even be meeting your doctor for the first time. However, you can get the sense pretty quickly if the doctor is simply filling out a checklist or if he genuinely cares about you and your story.

2) Your doctor should value the partnership she has with you. Medical care should not be about the doctor telling you what to do; rather, your doctor should involve you in your care as an equal partner. She should listen to your story, answer your questions, and actively involve you in every step of the diagnostic and decision-making process. This isn't just lip service; you should feel that your opinion matters.

3) Your doctor should see medical practice as a life-long learning process. Medicine is a constantly evolving field. Your doctor should be willing to learn and to refine her practice with each patient, striving to get better rather than to stagnate in cookbook patterns and algorithms. 

4) Your doctor should be willing to ask for help. This is not to mean that doctors shouldn't think for themselves; there are many times when a primary care doctor can resolve an issue and you do not need a referral, for example. However, if there is a particularly complex or puzzling case, your doctor should be willing to look up information and/or seek assistance from others. Asking for help does not equate incompetence; rather, it should increase your faith in your doctor's ability and humility.

5) Your doctor should prioritize your diagnosis. As we talk about in our book, When Doctors Don't Listen, your diagnosis is critical to your understanding of your illness and to everything else that follows. Your doctor should make sure that you are provided a diagnosis at the end of your visit.

6) Your doctor needs to be available. During the visit, you need to feel that he is available to listen to you and that he actually hears what you are saying. He should be available to answer your questions. It might be unrealistic to expect that your doctor is also there for you 24/7; however, you should know, before you leave your doctor's care, how you can get help. Make sure you understand your followup. When are you supposed to come back? What are things to watch out for? What should you do if something new or worse happens?

7) You should feel comfortable with your doctor. This trust is perhaps the most fundamental of all. If you do not feel at ease with your doctor, you might not share critical information, and important pieces of the puzzle might be missed--leading to misdiagnosis. 

 

This is the ideal doctor who will guide you through the process of making your correct diagnosis and lead you to the right treatment. This is the ideal doctor that you can trust, who will be your partner in your healthcare, who communicates well, and who really values you as a person. 

Not all of us are as fortunate to have this ideal doctor, but if we do not, there are things that we can do to help make our doctor into the ideal doctor that we have always wanted. Our book talks about the steps patients can take to advocate for better care and a patient-centered approach to your medical care. Stay tuned for more; in the meantime, I'd love to hear your comments.

How to Find a Good Doctor, Part 1

My husband Sebastian and I had two of our good friends, Kao and Sara over for dinner tonight. Kao is a Chinese-American pediatrician and health policy researcher in his early thirties; he uses an "evidence-based" approach to everything. On the other hand, his partner, Sara, a petite and fiery environmental advocate, operates by intuition.

All of us were discussing dream homes and how we would go about finding one. Kao very rationally laid out all the criteria he had: location, value, cost, size, etc. Sara rolled her eyes. 

"It's not that complicated," she said. "You know it when you see it."

For some people who similarly pride themselves on their intuition, this statement will ring true when it comes to finding their doctor. You know a good doctor when you see one. You also know that there are good doctors who may just not be the right ones for you. That's all quite possible.

But what about those who are more inclined to go by criteria, like Kao? Or what if you just don't know what you are looking for in a doctor? My last blog post talked about how difficult it can be to find a good doctor. What are the things you should be looking for?

I'll be addressing this in a series of posts. Here's a story I want to relate, that we discuss in our book:

One of our heroes, the Nobel prize-winner, humanist, and cardiologist Dr. Bernard Lown, likes to talk about how he went to an international conference and met a rather large Eastern European woman who was dressed in garish and what he thought was inappropriate clothing. Who is this woman at this conference of doctors and humanists, he grumbled to himself.

One of the questions posed at the conference was what makes a doctor a good doctor? This woman raised her hand and answered that a doctor is someone who makes you feel better after having seen them. Dr. Lown said that at that moment, he realized that she must be a doctor. A real doctor. A good doctor.

You go to your doctor because you want to feel better. You should find someone who helps you accomplish this goal. Some people will know it when they see it; the rest can at least begin to focus on whether your doctor is helping you to reach this very basic of demands.

More to come soon. I welcome your comments!

The Search For the Good Doctor

When my mother was first diagnosed with breast cancer, we went on the hunt for a doctor. A good doctor, of course. She lived in Los Angeles, a major city with a lot of medical centers and a lot of oncologists; we thought it would be easy to find an doctor. But we were naive.

First of all, there were a lot of doctors who wouldn't accept her insurance. Many were booked for months--there was no way we wanted to wait that long. We didn't come from a network of doctors; my mother's primary care doctor was the one who had misdiagnosed her for two years and she could hardly trust him to make a recommendation.

After a few days of frantic phone calls, we found an oncologist who had an opening. He had a great pedigree; he graduated from excellent medical schools and a top residency and fellowship. How lucky that he was available!

Pretty soon, we figured out his problem: he couldn't spare more than five minutes to talk with us. After a perfunctory hello, he cut my mother off at every turn.

"It's surgery and then it's chemo," he declared. But how did he know that? What were the risks? What should she expect? "We won't know until you get more tests," he said as he walked out of the room.

It was probably just one abrupt doctor, we reasoned. The search continued. My mother's second doctor had less than stellar credentials and an even less stellar manner. He nearly brought her to tears with his explanations, then yelled at her for not being able to commit to a treatment plan right away.

The third? This doctor spent a good 30 minutes with us, but for the entire appointment, he wouldn't look my mother in the eye. My mother remarked that it was disconcerting to have a conversation about breast removal surgery and not be able to know that your doctor saw you as a person.

This was nearly a decade ago. I was in my second year of medical school, and this was my introduction to the U.S. healthcare system from the patient perspective. Since then, I have seen firsthand how difficult it is to navigate the maze as a patient. The costs are hidden and opaque; the diagnosis is often not given (or is wrong); the options are inadequately explained; the list goes on and on. My mother was eventually able to find an oncologist who did care for her and who did spend time with her (and who was able to look at her in the eye), but I am always reminded from this experience of how hard it is sometimes for patients to find a doctor--a good doctor.

My next blog post will be on how to recognize a good doctor. Stay tuned--and please post your thoughts on this topic.

An Unsettling Question

A few days ago, I received a question that stopped me in my tracks. I was giving a talk to a local church group on the importance of patient advocacy, and most everyone was nodding. Yes, doctors don't always listen--let's do something about it! Yes, we need to control of our health!

Then someone raised her name. Her name is Susan, and she is the owner of a mom-and-pop grocery in South Boston. "I don't understand why the responsibility is always on the patient," she said. "What about doctors--why don't they have to change anything? Patients are the ones who are sick, who are coming to a professional for help. Yet everything that's coming about is about how patients should read more and do more research. Now you're telling us that patients have to stand up to their doctors--well, shouldn't it be the doctors who need to aim to do better instead?"

This question gave me a lot of pause because Susan is right. It is the doctor's duty to do right by the patient, and that means, if there is a problem, that doctors should be the ones to improve their practice. Many doctors are extremely caring and provide excellent care to their patients. Unfortunately, there are some who, for whatever reason, do not.

In the ideal world, such doctors would choose to educate themselves and voluntarily work to improve their practice; or else, patients would choose to go elsewhere. Neither of these is not entirely realistic. First, we know that doctors are slow to change. Second, patients don't always have a choice of doctors. You may encounter a doctor in the E.R. who you don't choose, or your insurance may prohibit you from going to other specialists. If this is the case, you can't exactly wait until your doctor chooses to improve. So why not make your healthcare experience as good as it can be?

Ultimately, improving medical care needs to involve the doctor too. To that end, education must begin early. As past president of the American Medical Student Association and now as a senior resident, I have met thousands of medical students, and can attest that virtually all medical students enter training with the right mindset. They want to help people; they want to listen; they want to care; they want to do the right thing. Something about the medical training dissuades them from these noble intentions, and when medical students become cynical residents and then hardened attendings, it is often too late to change them back. Medical education reform is critical to ensure that we are producing doctors who are empathic and socially accountable to our patients and communities.

Medical education reform takes a long time to happen. Health systems change takes a long time too. These need to happen--but it's going to take a while, and your health can't wait until then. This is what I explained to Susan. While we work on education and reform of doctors, patients can make the most out of our healthcare experiences and ensure that we and our loved ones get the best care possible for us. The message of our book is tailored to patients not because we are putting all the pressure on them, but rather because we believe each person can make a difference in their healthcare today--starting with their next encounter with their doctor.

Some Advice on Partnering With Your Doctor

My last post was about Lisa Nash, a breast cancer patient who found out six months after her tumor removal surgery that she had metal placed in her breast without her knowledge or consent. Lisa is an extremely articulate woman who, in addition to being a software specialist and the mother of two daughters, has training in counseling and patient advocacy. If Lisa had difficulties getting her doctor to listen, what hope is there for the rest of us?

The bad news is that we may not be able to eliminate every negative experience. The good news it that there are some practical things you can do at your next doctor's visit to advocate for better care. Here are five:

1) Ask questions. Always start by asking for your diagnosis. What is it that you have? If your doctor can't tell you a diagnosis, what is it that you're treating?

2) Know what questions to ask. Do your research. There are many websites for your condition or your symptoms. Not every website is going to present accurate information, but looking through them will help you build your knowledge base and help you formulate questions.

3) Don't be afraid to challenge your doctor. If there is something you don't understand, ask about it. If there is something you don't agree with, speak up. Be respectful, but also remember that it is your body, and your doctor is there to help you.

4) Know the plan and ask about alternatives. The benefits and risks should be clearly explained to you, along with alternatives to the treatment plan. Informed consent means that you need to understand exactly what is happening. The doctor is busy, but this is your body and your health at stake.

5) Insist on being a partner in your care, every step of the way. You doctor will have more medical expertise than you, but you are the expert about your body.

I will continue to write articles about your stories and offer advice for you. Some more tips are on our website. As always, I welcome your feedback and comments on this blog post.

"My Breast, My Body, My Decision"

Today, I spoke with Lisa Nash, a 49-year old software manager with a story to tell. Lisa's mother, like mine, died of breast cancer. In 2006, she herself was told that she had an abnormal mammogram, with microcalcifications that were concerning for cancer on biopsy. She found a prominent hospital and breast surgeon who performed a lumpectomy to remove the microcalcifications.

Soon after the surgery, she began experiencing breast discomfort. Though she kept getting reassured that the pain and itching was due to "normal" postoperative changes,  she knew that something wasn't right. Some six months later, she found out her surgeon had left 5 titanium clips in her body. This was the hospital's standard of care in order to "mark" the area in case of future radiation therapy--but it was a significant problem, because Lisa is allergic to titanium.

"I was never told that I was going to have titanium placed in my body. When I asked my doctor about it, she said that it was a standard procedure, that's why they didn't have to inform me," Lisa told me. She had also specifically said to her doctors that she was not going to have radiation therapy, something her surgeon appeared not to have heeded.

I don't know about you, but if I'm about to have metal clips be left in my body--for a procedure I didn't want--I would want to know about it. Had Lisa been told about this before the surgery, she would have told her doctors that she actually has a documented allergy to this type of material. She would have reinforced that she didn't want radiation later, so there was no reason for the clips. She would have been able to avoid months of discomfort and uncertainty--and the subsequent disfiguring surgery required to remove the clips.

Lisa's story disturbs me on another level too. Lisa is a professional, highly-educated, and very articulate person. She has had a number of healthcare experiences in the past and is not afraid to speak up for herself. If someone as informed and empowered as her can be blindsided about their treatment, what about everyone else? What can we all do to stand up for ourselves, make sure our doctors listen to us, and involve us as an equal partner in our healthcare?

My next article will provide practical advice for what you can do. Some more tips are on our website. As always, I welcome your feedback and comments on this blog post.

Physician, Seek Help--Don't Just Heal Thyself

In my second year of medical school, I attended a reading by Dr. Abraham Verghese, a physician, writer, and humanist. He had just written a book, The Tennis Partner, that was about his friend and then-medical student who lost a slow battle to drug addiction and mental illness. The book was about how their relationship developed—and how he found out about his friend’s problems, then failed to act on it. The reading was poignant because of his obvious emotional involvement, and because the topic hit close to home.

How many of you know medical students, residents, and doctors-in-practice who have been depressed? Who have thought about harming themselves or tried to numb their pain with alcohol and narcotics?

Studies have shown that physicians have a far higher rate of depression, substance addiction, and suicide than the general population. Medical students start out with similar mental health profiles as their age-matched peers. During medical school, one in four medical students become clinically depressed. One in ten entertain thoughts of suicide. Despite their ready access to healthcare, physicians-in-training seek help with lower frequency than other young professionals.

Researchers have come up with various hypotheses to explain these findings, including social isolation during training and greater tendency towards perfectionism. In a New York Times op-ed, surgeon-writer Dr. Pauline Chen discussed the problems with the “survival of the fittest” mentality that is prevalent in the medical profession. While in training, who wants to be the “weak” person who seeks help? Who wants to admit they want more support than someone else, or burden others with time off or shifts to cover?

I faced this issue myself in my second year of residency. My mother died after a long battle with cancer. She had fought it for years with surgery and aggressive chemotherapy until finally she was in remission. Then, during my internship year, we found out that the cancer was back. The last few months of her life were filled with terrible suffering. She fought despite the pain because she wanted to make sure my then-16-year old sister was OK. Finally, she agreed to enter hospice care, but she never quite made it home. She died in the ICU, at age 54.

As much as my family was prepared for her death, and as much as it was welcome because it put an end to her suffering, it was a very difficult time for us. Coming back to work was much harder than I expected. Every cancer patient or critically-ill patient reminded me of my mother and her last days. I cried after every shift. I was on an emotional rollercoaster: things would seem to be getting better, then an issue with my family, or a patient, or a patient’s family, would set things off, and the rollercoaster would come crashing down.

My experience is a pretty specific example of grief and bereavement, but I think the lessons I learned are applicable to other physicians who are coping with their own challenging situations. I share them with you now:

1) Accept the support of family and friends. This may seem obvious, but I made the mistake of shutting people out and burying myself in errands and busywork just to keep occupied. Thankfully, those closest to me didn’t allow me to isolate myself, and I learned that losing ourselves in our training is never a good solution. It may temporize the pain, but will only serve to alienate us from those who care about us.

2) Ask for help. This could be as simple as letting your school, program or hospital know of your need for time off. In my case, I didn’t tell anyone in my residency when my mother got sick. I wish I had, because I would have been able to spend more time with her in her final months. When she died, I even resisted taking time off. In retrospect, I came back to work too soon. I thought I was being strong and wanted to prove—most of all to myself—that I could do it. But the result was traumatizing to me, and I probably ended up delivering less than ideal patient care. There is really no shame in admitting that we need help, whether it’s help for specific things like covering shifts, or if it’s referral to a counselor or support group. Both Dr. Verghese and Dr. Chen wrote about how silence is what leads to deadly outcomes. “Physician, heal thyself” is a mantra that fosters bravado, not compassion.

3) Recognize and help address challenges that others around us are facing. Prior to my experience, I hadn’t realized how prevalent depression and addiction are in our profession. The Tennis Partner describes a very plausible scenario that could happen to any of us. After all, if one in four of all physicians-in-training are depressed at some point in their training, it’s likely that a couple of our friends or colleagues are having problems at this moment. As physicians—indeed, as humans—we have a duty to make sure that those around us are OK.

So do your part. On a personal level, reach out to your friends. If you suspect they are in trouble, reassure them that you’re there for them and that it’s OK to seek help. Make use of student support services in your medical school or hospital. Start your own support groups if none exist. In my residency, I helped to start the Emergency Medicine Reflection Rounds (EMRR) where residents meet to discuss personal reflections and give advice and support for each other. EMRR has been successful so far, and the feedback we’ve received reinforces the importance of establishing and fostering community. 

Medical training is not an easy process, but we are not alone. We can each do our part to preserve humanity, promote wellness, and approach each other, and our patients, with respect and compassion.

Parts of this article have been published in AAEM's Common Sense magazine and on Medscape.  I welcome your feedback and comments on this blog post.

Putting the Focus Back on Diagnosis

One Friday, Jerry got the scare of his life. 

Jerry is a 48-year old mechanic who is in good health. His parents are healthy, and he recently got a “clean bill of health” during his annual check-up. Over the weekend, he helped his brother move across town. Monday morning, he woke with tightness in his chest. He described it as a “spasm” and thought that he might have pulled something while he was lifting the sleeper sofa. But someone in his neighborhood had a heart attack recently, and Jerry’s wife persuaded him to go to the ED to get it checked out.

A generation ago, Jerry’s family doctor would probably have told him that he had a muscle strain. He would have left with some Motrin and felt better. Not so on this particular day. The nurse who greeted Jerry noted his chief complaint of chest pain and quickly called over a tech who helped Jerry take off his shirt and attached him to a cardiac monitor. He was given 4 baby aspirin to chew on. He was brought to a treatment room where a young doctor came in and asked a series of questions about his chest pain while a second nurse drew several vials of blood and then sent him off for x-rays of his chest.

Hours passed. Finally, the doctor in charge, we’ll him Dr. M., came in and told Jerry that everything looked OK so far, but that he needed to stay overnight for some more tests.

Jerry didn’t want to stay. He had already missed his son’s lacrosse game; he didn’t want to miss his daughter’s choir performance too. Dr. M. told him that he could still be having a heart attack, and that sounded scary. So Jerry dutifully stayed the night. The next morning, he found out that he hadn’t had a heart attack. That was good news, but his ordeal wasn’t over yet. Dr. M. told him that they still could not be sure what was causing his chest pain or that there weren’t problems with his heart. “You should see your primary care doctor to follow-up on this,” Dr. M. cautioned. “He’ll probably want to order some more advanced tests.”

Jerry went home, far from reassured and more confused than ever. If he didn’t have a heart attack, what could it be? The discharge instructions just said that he had a diagnosis of “chest pain.” But isn’t that a symptom, not a diagnosis? His chest was still a little sore—it got worse after his kids pounced on him when he got home—should he be worried about this? Is it OK to keep working, what with crawling under all those cars? Is he going to be OK?

***

Doctors are taught to always think about the most dangerous things that our patients could have. Headache? Most likely it’s something benign, but we need to think about subarachnoid hemorrhage. Back pain? Probably it’s something chronic, but we always ask about continence and assess for saddle anesthesia and such to make sure it’s not cord compression. Chest pain? Even in a patient who probably pulled a muscle, we do have to think about a ripping in the aorta and a heart attack.

It’s the nature of our job to make sure that we assess for potentially life-threatening conditions. It should also be part of our responsibility to provide our patients with a diagnosis. Too often, we focus on the “rule-out” of the really bad stuff: the head bleeds, the strokes, the appys. When we find that our patients don’t have these (admittedly quite bad) diagnoses, we are relieved. We tell our patients that they don’t have something terrible, and for a second, they are relieved too. Then, they wonder what it is they actually have. To treat a problem, it helps to figure out what the problem is. It’s part of our duty to provide a diagnosis of not just what patients don’t have, but what they have, and to tell them what to do about this less-than-life-threatening condition.

“How can I do this? We’re really busy; I can’t sit down and go over every single thing on the differential and what to do about that! Besides, we often can’t offer any diagnosis at all.”

I would argue that there often is a diagnosis or a “most likely” diagnosis. We as providers always leave with a provisional diagnosis: the working diagnosis. Why not share this with our patients? It's critical that we involve our patients in the thought process. Tell your patients what you are thinking. Involve them in your thinking through the differential diagnosis and the decisions about what tests to do. We can say that tests so far show it is unlikely you have this terrible life-threatening condition. Based on your symptoms and physical exam, we think that this working diagnosis is most likely this diagnosis. This is what you can expect in your symptoms based on the natural history of your disease. This is what you can do about it to alleviate the symptoms. This is why you should follow-up with your primary care doctors, and here are danger signs to look for that should prompt you to seek care sooner. Our patients are our partners, and it’s part of good care to provide them an answer that guides their treatment.

In Jerry’s case, think about how differently he would have felt if Dr. M. had involved him in the decision-making from the beginning. His symptoms starting after the moving and feeling like “spasms” and his lack of significant risk factors might not have even prompted a workup for heart attack in the first place. Instead of being frightened about the risk of a heart attack, Jerry could have been involved in the decision-making from the get-go and could have avoided staying for lab work. At the very least, he could have been told after the two sets AND stress test that his diagnosis was not just “chest pain”, but musculoskeletal chest pain. He could have been told that the pain could worsen in the next 24-48 hours, but that it was safe to resume work and exercise. He could take ibuprofen 600mg every 6 hours with food to help with the pain. He should see his regular doctor to follow-up in a week if symptoms persist, and to come back to the E.R. if he has warning signs of something worse (i.e. crushing chest pain, shortness of breath, etc). If he had been given a diagnosis followed by these explicit instructions for treatment, Jerry would have gone home sooner, happier, and far more reassured.

Patients come to their doctors to feel better. Let’s make sure that even in the busy, often uncertain and unfortunately litigious environment of modern medicine, we strive to figure out not just how to rule out the bad stuff, but to provide patients the answer of what is actually causing their problems. Let’s put the focus back on diagnosis.

Parts of this article have been published in AAEM's Common Sense magazine and on Medscape.  I welcome your feedback and comments on the form of patient-centered care that I discuss.

The Perils of Cookbook Medicine

I have a confession to make. I am guilty of practicing cookbook medicine.

I make this confession with much angst and embarrassment. In my daily practice, I actively rail against making diagnoses by using "cookbook" recipes. I believe that doctors need to pay attention to the art of medicine that prioritizes the individual's story. In fact, I am writing a book on this topic!

Yet, this is a true story of what happened last week. It was 5PM, and I just started my evening shift.  The E.R. was in black “crisis” mode. The waiting room had been converted into patient bays, and there were patients out in the hallways stretching to the main lobby of the hospital.

I rolled up my sleeves and went to work. First, I met Mr. A, a middle-aged man with atypical chest pain for a day. Never had heart problems before but his father had an MI at age 50. Normal vitals and EKG. Check! Here was an easy dispo for low-risk chest pain. I sent off for cardiac enzymes and put Mr. A. in our observation unit for a second set and stress in the morning.

Next patient. Mr. B., a man in his seventies being treated for lung cancer who came in with fever and a productive cough. He was tachycardic, looked weak, and his lungs sounded junky. Again, easy dispo. Labs, x-ray, antibiotics for pneumonia, and oncology admission.

And the next. For kicks, let’s call her Mrs. M. A. a well-appearing woman in her sixties transferred from an outside hospital to get an MRI for a one-hour episode of aphasia eight hours ago. When I saw her, she talked fluently and had no neuro deficits. Once again, I knew what to do. I ordered an MRI, called neurology, and put her into the observation unit to await the scan and neuro consult.

My shift started just 15 minutes ago, and I had dispos on three patients! But something was wrong with this picture. While a lot of attendings would have applauded my actions as “efficient” and “having solid plans,” my very astute attending that day frowned. “You’re seeing patients fast and that’s good,” she said, “But think about what they have. Don’t let your practice become algorithmic.”

She was right. In my misguided attempt at becoming faster to and help with ED flow, I was evaluating my patients based on how quickly I could send them somewhere else, instead of stopping to figure out what they actually came in with. My reaction to each patient was reflexive, almost as if I were doing a multiple-choice board exam. Low-risk chest pain? To the observation unit Mr. A. goes. But had I even heard him talk about how the pain got worse after eating, how it came and went, how it traveled to his right side and back? Fever and productive cough? Must be pneumonia. Or maybe not. After Mr. B. undressed, I went back and saw that he had raging erythema covering one of his legs. He’d been telling me about scratching his legs but I hadn’t listened—and I could have missed diagnosing and treating a bad cellulitis.

And Mrs. M. When I went back to ask her what exactly happened, she said that she and her husband were driving on the road when she forgot the names of two streets she had lived on when she was young. She thought they were on the tip of her tongue but she couldn’t quite remember them. She panicked and her husband drove her to the nearby hospital. An hour later, she finally recalled the names of the streets. Never during this time did she have slurred or unclear speech. This was the “aphasia” that the other hospital had sent her in for, that was not actually aphasia and definitely not a stroke! But the joke was on me—I hadn’t done my own evaluation, and had asked for a consult and ordered a scan that Mrs. M. didn’t need at all.

By its high-stress, high-intensity nature, emergency medicine is a challenging and demanding profession. We have to make quick decisions with limited information, while seeing many complex patients at once. Being efficient is important, and we often feel the temptation to take shortcuts on the history and physical and call a consultant to figure things out instead of working things out for ourselves. But this practice of reflexive, algorithmic medicine doesn’t lead to better outcomes, and, I would argue, isn’t any faster than thoughtful, common sense medicine. Having our patient be "ruled out" for a heart attack while he has gallstone pain doesn’t help anyone. Missing a raging infection in could lead to bad outcomes. And doing hours of unnecessary tests in a woman who doesn’t have a disease based on history alone is a waste of time and resources, and potentially harmful to the patient.

So how can we avoid the tempting low-hanging fruit of cookbook medicine? One tip is to always think about your patient’s diagnosis. “Chest pain” and “abdominal pain” are symptoms, not diagnoses. Ask yourself each time what the patient has. Most of the time, there is a diagnosis. Some of the time, you may not know the exact diagnosis after your evaluation, but at least thinking about the diagnosis—and not just what the patient DOESN’T have—forces you to break out of comfortable cookbook pathways before ordering tests and thinking about dispos.

Something else that’s helpful is to explain your thought process to the patient. Patients like it when you talk to them about what tests you are ordering and why, and what diagnoses you are considering and why. If you find yourself unable to justify these tests to your patients, you might want to consider why you want them in the first place—perhaps you’ve unwittingly entered a cookbook practice and are reflexively (rather than thoughtfully) putting in orders.

Another tip is to try to figure out what the patient has before calling a consultant. The E.R. is the modern home of diagnosis; it’s exciting to take the first crack at a diagnosis and to send a patient to the floor with a diagnosis in hand! To that end, make sure to follow-up on your patients. You will learn an awful lot and be satisfied—and humbled—by your diagnostic acumen.

As we residents advance another year, it’s a good time to remind ourselves of the perils of cookbook medicine. Not only does it dehumanize our patients, cookbook practice leads to unnecessary tests and missed diagnoses, not to mention dissatisfaction—by both the patient and the practitioner. Let’s try our best to uphold the excellent standard of care that we are so proud of in our field, and practice the type of medicine that our patients deserve.

Parts of this article have been published in AAEM's Common Sense magazine and on Medscape.  I welcome your feedback and comments.

In Honor of July 1st: a Reprieve to Intern Year

Today is July 1st, a monumental day in academic centers around the country. It is the day when newly minted medical schools put their new M.D. to use as interns, when interns become junior residents, when junior residents become senior residents, and so on and so forth. In honor of today, I am reposting an article I wrote two years ago, at the end of my own intern year. This was initially published in AAEM's Common Sense magazine and on Medscape.

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“Excuse me… um… how exactly do I order the Tylenol?”

I look up. In front of me is a young man wearing a pressed shirt and striped tie. “I’m Ben,” he says, introducing himself to me as an intern on his very first day of residency. It’s not really statement that needed to be said; none of us would have mistaken him for anything but. How to order Tylenol is a seemingly self-explanatory action, but last year it was me asking that question. As I lead him through the order entry system, I reflect on the past year. How have I grown in this notoriously grueling yet life-changing internship year? What advice would I impart to the new cohort about to impart on this same journey?

Clinically, I am stronger than I was a year ago. Clinical training in a supervised setting is indeed the purpose of residency and why tens of thousands of young people in the prime of our lives devote many long hours to our hospital. Internship is all about becoming more comfortable with management of everything from routine urgent care presentations to medical resuscitation of very sick patients. Throughout this year, I’ve seen my classmates and I progress from asking “what next” to thinking through and acting on most treatment decisions ourselves. Part of that clinical development is knowing how much more there is to learn, and it remains daunting and inspiring to see that, as much knowledge and skills as we have gained, there is still a long way to go.

Professionally, I feel more comfortable in my role as clinician and resident physician. I remember on my first day of internship practicing my introduction in the mirror. “Hello, I’m Dr. Wen, your doctor,” didn’t seem quite right. Too curt, yet oddly redundant. “Hi, I’m Leana, your doctor.” Not right either. Too informal. “Nice to meet you, I’m Leana Wen, one of the doctors.” OK, but who are the other doctors? The struggle with something as basic as introducing myself is symbolic of my biggest challenge in intern year: feeling at home as a resident. Our training is at two main hospitals and two other affiliated sites. Not only were there dozens of residents and attendings and literally hundreds of ED nurses to meet, each month was a different rotation with more new people and new ways of doing things. It took me until the end of intern year to feel at ease with my colleagues. Being part of AAEM-RSA has been instrumental for me to feel at home in my specialty—now, not only do I know my 60 co-residents, I am connected with thousands of residents across the country.

Intellectually, this has been a year of alternating disappointment and growth. So much of medical school was about memorization and pattern recognition; I was afraid that residency would teach more of the same. I did not want to be an automaton who did nothing more than input data and run algorithms like a “Choose Your Own Adventure” book. EM, perhaps more so than other fields, has the potential to turn into an algorithmic exercise. However, there are plenty in our field who believe that EM is far more than figuring out a disposition. As my mentor, Dr. Josh Kosowsky, likes to say, EM is the modern home of diagnosis. What other field presents so many diagnostic puzzles in any given day? Checklists have their place, but algorithms should never replace the art of healing. One of my most valuable lessons this year, one that has kept me intellectually challenged and emotionally engaged, is to make sure to hear each patient’s story as their narrative, not just as a chief complaint followed by yes/no answers.

Personally, one of the battles each of my classmates has struggled with is finding balance. Internship is pretty far from a “normal” life: it throws off anyone to work under fluorescent lights for six days a week, to eat nothing but hospital food for three meals a day, and to not see family and friends for a day and a half. Our days are so long that by the end of a shift, it’s often hard to find energy to do the things that used to make us happy. Yet, as busy and as tired as we get, we shouldn’t make residency just about working, sleeping, and eating. I’ve watched each of our classmates emerge from survival mode to making time for the things that matter to us, from training for triathlons to watching sci-fi flicks to getting a scuba-diving certificate. As for me, I’m ballroom dancing and playing the piano again, and a much happier person for it.

Despite finding better personal balance, one of my classmates said during our end-of-the-year intern retreat that he wasn’t sure he liked the person he was becoming. This resonated with all of us. In intern year, each of us can recall instances when we’ve become more abrupt with family, short with sales clerks, perhaps impatient or even disdainful with patients. However, as difficult as our lives may be at times, as grueling as it may be to work night shift after night shift, we cannot lose track of our fundamental purpose of being healers and advocates for our patients. It’s a profound privilege that we have to take care of patients in the time of their greatest need. It’s a profound honor that families place care of their loved ones in our hands.

“That was an awesome day. Thanks for showing me around!”

I smile. It’s the end of Ben’s first shift. His hair, impeccably groomed ten hours ago, sticks out in the back and strands point towards the ceiling. His face bears the telltale imprints of mask and eyeshield. His blue tie is flecked with blood. (I feel sure that from now on, his attire will consist of scrubs.) I wonder what Ben’s reflections after intern year will be. I know that he, too, will develop clinically and grow into his professional role. I hope that he finds his intellectual pursuits rewarding and his personal balance satisfying. Above all, I hope he retains his humanism, his ideals for why he chose to enter this healing profession of medicine.