When More Isn’t Better

It was the beginning of my third year of medical school. I had just started my first clinical rotation. My very first patient was Ray, a middle-aged man with pancreatitis.

I presented his case to the team. “What are Ranson’s criteria?” the attending physician asked.

My mind went blank. “Uh, I’m not sure,” I said.

“Next time, you’d better be sure,” the attending said. He turned to my colleague, who promptly gave the correct answer.

On that first day of medical training, I learned that “I don’t know” is not an acceptable answer. If you don’t know, look it up. Make it up you have to. Whatever you do, never admit that you don’t know.

Not surprisingly, doctors end up not tolerating uncertainty. In our high-tech era, this means more is done. A patient has seemingly vague symptoms, so the doctor orders some laboratory tests “just to get a baseline”. A doctor doesn’t know what’s causing the headache, so she orders a CT or MRI “just to see”. Medical students are rewarded for pursuing obscure diagnoses, so they order increasingly esoteric tests “just in case”.

This insidious practice has resulted in a culture of overtesting and overtreatment. Studies show that 30% of all medical care—at the tune of $700 million per year—is waste. Not only does this impose a heavy financial burden on society and on patients, it also results in avoidable harm. Every test has risks and potential side effects. A CT scan has a risk of radiation, for example, that may lead to cancer later in life. And one test often leads to another, even riskier, test.

Recently, my husband had an itchy rash on his arms. He mentioned this to a dermatologist friend, who recommended that he come into the office for a skin biopsy. I asked how the biopsy would change my husband’s management: regardless of what it showed, wouldn't he still use a steroid cream? Sure, the dermatologist said, but at least we’d have more information.

Nothing against our well-intentioned friend, but this is a case where more information isn’t better. Why get a biopsy—an invasive procedure with risks including bleeding and infection—when it wouldn’t change the management or the outcome? Yet, tests are done all the time to quench the insatiable curiosity inherent in medicine: we just have to know.

Here’s another common scenario. A young woman comes in with abdominal pain. She’s able to eat and drink and looks well, but has a pain in her belly that’s bothering her. Many doctors would order a CT scan of her abdomen to make sure there’s not something bad going on. But what is this bad thing—how likely is it? How does the patient feel about the risks of the test, versus the risks of watchful waiting? If she’s fine waiting, then why expose this young person to unnecessary radiation, when it would be just as reasonable to wait to see if she gets better the next day?

More tests and better technologies are not the solution to improving clinical care. In fact, we know that 80% of diagnoses can be made without any tests at all, but by carefully listening to the patient’s story. I’m an emergency physician, yet even in the emergency setting, it is rare that a patient requires one particular test, and that test must be done right now.

Here’s what to do instead. Doctors: talk to your patients. If you’re not sure, tell them. Patients prefer honesty to false reassurance. Instead of reflexively ordering a test, discuss the benefit of the tincture of time. Remember that our first principle is to “Do no harm”. I just met two doctors, Tanner Caverly and Brandon Combs, who started an educational initiative to encourage doctors-in-training to write vignettes of medical overuse. To them, and to a growing number of physicians including the Lown Institute’s Right Care Alliance (of which I'm a proud member), preventing overuse is an ethical imperative.

Patients: insist on being an equal and active partner in your care. Ask “why” and “how”. Why is this test ordered? How will this test change my management? Make sure you know your diagnosis. Assure your doctor that it’s OK if she is not 100% sure; you don’t demand certainty, but you do expect transparency.

It’s taken me nearly ten years to unlearn the bravado I acquired in medical training and to learn that uncertainty isn’t bad; more isn’t always better; and less can be more. As the great cardiologist and humanist Dr. Bernard Lown says, you should always feel better after having gone to your doctor. We need to focus on healing by teaching and practicing the art of listening, compassion, and kindness.

Four Years Later: Reflections From the Last Day of Residency

On July 1^st, four years ago, I walked through Mass General and Brigham & Women’s Hospitals with an odd mixture of fear, relief, and excitement. Now, as I leave the hospital after my last shift of emergency medicine residency training, I am filled with a similar hodgepodge of emotions and reflections.

#1. “You were terrified of being a doctor!” I mentioned this article to the attending who oversaw my first shift as a newly-minted doctor. That day is forever etched in my mind; did he remember it? Much to my great embarrassment, he chuckled and said, of course. “I kept telling you not to worry if you don’t know something, but you were scared of everything!”

Though I knew that I was there to learn, it took me a while to get over my insecurities about not knowing so that I could focus on learning. And the learning was everywhere—on every single shift, I learned from great clinicians not just about diagnosis and treatment, but also important lessons on how to lead a team, how to teach, and, most importantly, how to help people who come to us in their time of need. I’ve been incredibly fortunate to have learned from many colleagues along the way, including the amazingly skillful and compassionate nurses at Brigham & Mass General. As my mentors say, it is called the practice of medicine for a reason, and we should embrace, rather than fear, the learning.

#2. “Mistakes will happen.” Every doctor has made a mistake some time in her life. Whether it’s a technical error (i.e. inserting a long IV into an artery rather than a vein), a systems error (i.e. ordering a medication for the wrong patient), or a communication error (i.e. angering a patient or colleague), all of us graduating residents will have made some kind of error. I myself made all three of these errors, and more.

With the volume of patients we will see throughout our careers, being the cause of medical error and interpersonal conflict is a terrifying and humbling thought. A wise physician said to me that just as residency is the time to learn how to practice medicine right, it’s also the time to learn skills like how to disclose mistakes to patients, and how to deal with conflict. “Don’t shy away from difficult situations,” he told me. “Put yourself in the middle of them to see what others do, and then develop your own style.”

#3. “That man has a name, and it’s not ‘the chest pain in room 8.’” As busy residents with long to-do lists, we often fall prey to the tendency to dehumanize our patients and brand them as chief complaints to quickly decide their disposition. On the surface, this might appear to save time, but dig a little deeper, and such algorithmic, depersonalized medicine results in unnecessary tests, misdiagnosis, and worse patient experience.

Furthermore, practicing cookbook medicine is not why we chose to become doctors. My work became much more meaningful when I made a commitment to connect with each patient, no matter how busy I am. I learned that the “old guy with dementia” was a world-renowned philosopher, that the “the onc patient with fever and neutropenia” had ten children with her preschool sweetheart. As physicians, we are privileged to hear so many stories from so many people. Cherish this gift we’re given to share in our patients’ rich lives. Our healthcare system isolates patients and disenfranchises families; we have the power to practice real patient- and family-centered medicine.

#4. “Residency is hard, and you have to take care of yourself.” My best friend from medical school, who had just completed his pediatric residency, warned me about this before I started intern year. How right he was. Work hours may have improved since our forefathers trained, but residents still work a lot and are exposed to high-stress situations with life-and-death consequences. Studies have shown that rates of depression and burnout increase sharply during training, yet the “hidden curriculum” of medical training still favors bravado over openness. Residents are taught to “suck it up” instead of talking about difficult situations and taking care of ourselves.

This is not the way it has to be! I learned this lesson the hard way during second year of residency, when my mother died. I suppressed my emotions rather than seek help, and saw how easy it is to feel isolated. Fight this impulse and stay connected. Find peers you can reflect with and openly speak about your experiences. Nourish the other people in your life and recognize their critical role in helping you through this process. For me, it was my wonderfully supportive husband and my friends who sustained me and kept me grounded. Make time for these people in your life. I cannot think of anyone who regrets the time spent with our loved ones and laments, “if only I spent that day reading one more research article!”

#5. “Emergency medicine is a phenomenal field.” The first grand rounds lecture I heard as an intern was by Dr. Larry Weiss, then President of AAEM. He spoke about how emergency medicine is an ideal specialty for advocacy: as the frontlines of medical care who interact with every aspect of the healthcare system, we are the most well-positioned physicians to advocate for our patients, our communities, and our society. We see the problems with public health—smoking, obesity, gun violence, etc. We see the problems with under-, over-, and misutilization of healthcare. And we have the ability and power to act on these problems every day.

In my fourth year of medical school, I selected emergency medicine as a specialty because I wanted the ability to treat any patient, anywhere. Being one of the emergency providers who took of care victims of the Boston bombings made me grateful for my training and for the skills I’ve learned along the way. We in emergency medicine have the incredible opportunity to utilize our training to do what we love while making a difference to improve care for our patients and to transform our healthcare system.

What else can I say about these last four years? It’s been a rollercoaster ride. Now that I’m about to embark on the next journey as an emergency medicine attending physician, health policy professor, and Director of Patient-Centered Care Research at the George Washington University in D.C., I am filled with exactly the same emotions of fear, relief, and excitement that I came to Boston with. I have learned so much from so many incredible people along the way, and will forever be indebted to the amazing attendings, residents, nurses, physician assistants, and other colleagues at Brigham & Mass General Hospitals.

Now, what will the next years bring? I’ll be on leave for the next month, but stay tuned for more dispatches and reflections, soon to be from the nation’s capitol.

Happy Nurses Week: A Tribute to Nurses

It was my first shift as an intern, and I was terrified. I was assigned to the “Fast Track” area of the Mass General ER—a section designated for those with straightforward issues: lacerations, sprained ankles, etc. Overnight, though, I would be the only doctor in that area. I’d been away from clinical medicine for nearly three years, and was terrified of what that Saturday night would bring.

My first patient proved my ignorance. Mrs. R was a pleasant woman in her sixties who had gotten her left hand caught in the car door and was feeling pain in her third and fourth knuckles. I’d ordered x-rays of her hand, which showed a small fracture, and I was trying to figure out how to make a splint.

“Doctor, you might want to take another look at her hand,” her nurse, Kelly*, said.

I ran to the room. Even from the doorway, I could see that Mrs. R’s third and fourth knuckles had swollen to twice their size. The ring finger was turning a dark red, almost purplish, color.

This was an emergency! I couldn’t believe that I’d forgotten to take the rings off before the x-ray, and now they were compromising blood supply to the fingers.

But what do I about it now? Mrs. R was in obvious pain, but she was also crying that these were precious rings, given to her by her late husband.

I grabbed an ice bucket and some water-soluble jelly. Kelly frowned. “How about doing a digital block first?”

Numbing the finger…. that sounded like a great idea. But alas, digital block, jelly, and ice did not do the trick. “Maybe it’s time we get the ring cutter,” I said

“How about trying the string technique first—have you used that?” Kelly suggested. No…. but she had, and we succeeded in getting the rings off, without needing to damage them, or our patient.

The rest of the night was a blur. I remember my hesitation at ordering any medication stronger than Tylenol, and even Tylenol itself (“for God’s sakes; mothers give it to their babies!”.) I remember my first car accident victim, M, an intoxicated young man who had been struck while walking across the street. He looked fine to me, but his nurse, Ann, didn't think so. He was sweating and looked confused, not drunk. “Let’s move him to another area,” Ann said. She was right—he turned out to have a bleed in his brain and a large femur fracture. Her clinical acumen saved our patient.

Thankfully, I have matured as a clinician since that terrifying first day, though the training process was not without its bumps and bruises. I and my fellow trainees frequently credit the attending physicians and senior residents from whom we have learned so much. This praise is deserved, but I also want to acknowledge another group of people who have instrumental in teaching and guiding us: the nurses.

Over the last four years, I have had the honor and privilege of working with and learning from the terrific nurses at Brigham & Women’s and Mass General Hospitals. Time and time again, these nurses have saved me from making mistakes, big and small. They have taught me clinical judgment and clinical skills. They have demonstrated true patient-centered care, and shown me what it means to really listen. They have inspired me to always be vigilant and always care.

In my second year of residency, my mother passed away from metastatic cancer. Before she died, she told me that she wanted to make sure I thank her nurses, because it was they who she thought really cared for her.

It was they, too, who cared for my family and for me. After we decided to withdraw her life support, I was wracked with guilt. It was what my mother had wanted, but kind of daughter was I to end my own mother’s life?

All the doctors had left. Her nurse, Andy, came to find me at my mother’s bedside. He told me about how he had to make a similar decision to allow his terminally ill wife to die. “It’s what she would have wanted,” Andy said. “You are carrying out her last wish, to die peacefully.” I will never forget his words and his kindness.

As I near the end of my training at last, I am reminded of the Hippocrates saying that the goal of medicine is “to cure sometimes, to relieve often, to comfort always.” This, too, I learn through daily example from the amazing nurses I work with.

Thank you.

* Names have been changed, though I very much remember—and acknowledge—the actual people involved.

10 Things to Bring With You to Every Doctor's Visit

Most patients I see are surprised to find out that there’s something they should have brought to their doctor’s visit. Granted, I’m an emergency physician, and many of my patients come to me in emergency situations that they can’t plan for. However, most people have some heads-up for going to their doctor. Certainly if you’re going to your annual check-up or a routine appointment, you should bring these items with you. Keep this checklist readily accessible; even if you’re going to the hospital for an emergency appointment, aim to take the following 10 items with you:

#1. A medical card. It would be ideal for every doctor to have a full list of your medical history, but our country is not even close to having a nationally accessible medical record system. To make sure your doctor has your information available, carry a card with you. You can find many cards that easily downloadable on the Internet where you list your medical problems, surgeries, doctor’s names, insurance, and allergies. Especially if you are seeing a coverage doctor or visiting the E.R., he or she may not have your medical record. This makes sure that your doctor can see your most critical medical information.

#2. Changes to your medical record. If you have had recent test results since you last saw your doctor, bring these with you. Even if it was your doctor that you’re going to see who sent you to get the test, bringing the results will make sure that they are discussed during the visit.

#3. Your medications. Very often, patients come in and say that they can’t remember what they’re taking. “I think I stopped taking the pink tiny pill, but I’m still taking the white one and the blue one,” is not as helpful as actually seeing the actual bottles with the labels on them. Take all your medications, put them in a bag, and bring them with you. Tell your doctor if you’ve stopped taking any of your medications, and be honest if you haven’t been taking them as much as you were supposed to. Otherwise, your doctor may assume they’re not working, and prescribe you even more!

#4. A list of alternative therapies. The majority of our patients use some type of alternative therapy. It is better for your doctor to know about it. Most doctors are not experts in herbal therapies, but it’s useful for them to know what’s your taking in case there are some interactions with your other medications. Keep a list of fish oil, vitamins, and supplements that you’re using, and a record of any visits to chiropractors, naturopaths, or other practitioners.

#5. A journal of your symptoms. If you have a chronic condition, or if you have a new symptom you’re concerned about, you should be keeping a journal that documents your symptoms and how it is throughout the days and weeks. Your doctor may also ask you to keep track of your response to treatments you’re doing at home. Sometimes, there are objective measures that you need to write down, such as your blood sugar. Bringing the journal with you to your appointment can help remind you of your story, and allows for your doctor better understand what’s going on and how your symptoms affect your daily life.

#6. A list of your questions. You should always come prepared with a list of questions to ask your doctor. Brainstorm the list well before your appointment, and have a concise list of questions, starting with the most urgent that you must get answered. Don’t leave your doctor’s office without asking them.

#7. A notebook and pen. This may seem obvious, but your doctor may not always have writing equipment readily accessible, and it’s important to have a notebook and pen to take notes. Write down things that don’t make sense, and ask for clarification. If there are words mentioned that you’ve never heard of, ask your doctor to spell them. At the end of the visit, ask for a verbal summary. Make sure you write down and understand your plan.

#8. A family member or a friend. Having someone with you will give you support and company during the appointment. As importantly, they can help remind you of your questions and concerns, and is another measure to help ensure your doctor answers all the questions that you have.

#9. A smartphone. Everyone seems to have some kind of smartphone device: an iphone, a blackberry, an ipad. There will downtime when you’re waiting. Use this time to look up what your doctor has told you. The smartphone also keeps you busy if your wait is particularly long!

#10. Some snacks. Often, there are limited food options are the doctor’s office, and you may be waiting for some time. Unless you’re told not to eat, or have a complaint that you’re not sure how it will go, having something on hand can help make you feel better.

I hope this list is useful for you as you prepare for your next doctor’s visit. Please give me feedback: what’s on the list that you find helpful? What’s not on the list that should be? And what would you would like to hear about next?

“Inappropriate Use of the E.R.”: A Story of How an Emergency Physician Needed the E.R.

As emergency physicians who are trained in acute resuscitation and thrive in high-stress situations, we tend to roll our eyes at the less acute complaints our patients come in with. “Back pain for three months? Headache for a week? Why are they here now?” Patients, too, complain about this. “Can’t they see it’s not a real emergency and go see their primary care doctor? This must be costing our healthcare system a fortune!”

A couple of months ago, something happened that made me question this so-called “inappropriate use of the E.R.” Let me tell you about a previously healthy young woman, an emergency physician, who came back from her shift at the Brigham & Women’s E.R. feeling a bit under the weather. She was a little nauseous, but was able to eat the Chinese take-out dinner that her husband brought back. Right after dinner, she went to bed, but couldn’t sleep because she developed a gnawing abdominal pain. Then, she began throwing up, and kept throwing up at least ten times in the next hour.

Being a physician, she came up with a differential diagnosis. This was most likely stomach flu: a simple viral illness. However, stomach flu generally involves diarrhea, which she didn’t have, and she really didn’t have other viral symptoms. It could be bad food, but her husband ate the same thing (and she, being Chinese, was sick of Chinese food always being blamed as the culprit). Any woman could be pregnant, and though the suddenness of her symptoms made that less likely, an ectopic pregnancy was theoretically possible.

So she set about to self-diagnose and self-treat. She sent her husband to the local 24-hour CVS to buy a pregnancy test and to pick up a nausea medication that she prescribed herself. The test was negative and the medication made her vomiting stop, but as the morning came, her abdominal pain was still there. In fact, it was now localized more to the right lower side, and it hurt her to walk.

I’m sure you see where this is going. You’re probably thinking to yourself whether you would have bitten the bullet and gone to the E.R. to make sure you don’t have appendicitis. Well, this young woman was me, and I was trying to avoid checking in as a patient, getting the radiation from a CT scan, and burdening our overtaxed healthcare system. Fortunately, I was able to call and find out the E.R. attending that day was an ultrasound specialist. She did me a favor to ultrasound me, and found that my appendix looked fine, but my intestines looked inflamed—consistent with stomach flu. I got my diagnosis, and over the next few days, I recovered with no radiation and my appendix intact.

Had someone like me actually checked in as a patient, I could see how there might be grumbling from the providers. “A young woman with stomach flu who’s actually getting better—why is she here?”  “If she doesn’t want a CT, why did she come to the E.R.?”

What I learned from this experience is that it’s always easy to say in retrospect that the patient didn’t have to come to the E.R. In the moment, when the patient is scared and in pain, it’s not so clear. Even as an E.R. physician myself, I couldn’t tell if what I had was something benign that would go away on its own (stomach flu) or an acute process that required urgent intervention (appendicitis). How can we expect our patients to know whether their chest pain is the same angina as usual or a heart attack, or whether their swollen ankle is a sprain or fracture?

My flirtation with the E.R. has made me more sympathetic to our patients who come in with seemingly “non-E.R.” complaints. It also has me thinking on the larger scale about proposed policies that impose penalties to our patients for using the E.R. Don’t get me wrong; there is a need for more primary care doctors, and our patients will benefit from increased access to primary care. However, patients don’t always know whether they have primary care versus emergency complaints. So I turned out to have stomach flu, something a primary care doctor can address. But had I been a “normal” patient, I wouldn’t have been able to treat my own symptoms and then walked into get a favor from a specialist physician—surely, I would have had to check into the E.R. to be seen. Would it have been fair to penalize me for that E.R. visit when it turned out that I had a less-than-emergent illness?

It’s important that our policy-makers consider that even well-informed patients with good access to primary care need the E.R. For our part, we as emergency physicians need to stop complaining about our patients and embrace our duty at the frontlines of medical care, sorting out all patient presentations and working to diagnose and treat all of our patients.

Portions of this article appeared in my column for CommonSense, the newsletter of the American Academy of Emergency Medicine. Thanks for reading; I welcome your comments.