Tuesday, June 28, 2011

The Golden Rule

Treat others as you would like others to treat you.
That is a very simple rule. I know I remember learning it from my grandmother. I couldn’t have been very old, probably preschool age. And it was probably in response to fighting with my brother. I’m sure most have you have learned this early in your life too.
I was reminded of the Golden Rule recently when I was talking to my son about how he should be treating his friends at school. As I was giving him examples of how the Golden Rule plays out in everyday life, I was surprised at the number of examples I could give. Unknowingly, I realized that I commonly do things in my daily life based on it.
I hold the door for people. I try to stop for pedestrians trying to cross the street outside the crosswalk. I say hello with a smile to people I see in the hallway. The list could go on. But, I generally try to do these things because I know I would like it if someone did them for me.
The next example I gave my son, was that I treat patients like I would want to be treated. This one, I am conscious about. I will commonly try to put myself in a patient’s position before I go into the room. Doing this helps me to relate better to their particular issue. After interviewing a patient, I may also learn new things that completely change my understanding of their problem. I will then alter a bit the way that I interact based on how I would want my doctor to respond.
For instance*, I was once sent a patient for evaluation of gallbladder disease. The emergency physician had noted a rise in liver enzymes, and a gallbladder that had thickened bile, or sludge as it is called. The patient also had frequent bouts of vomiting. The scenario seemed to make sense on the paperwork that I was sent. So, I went into the room expecting to book the patient for surgery. But the tip off to me was that the patient smelled of alcohol. So, I researched old labs and found that his liver enzymes have been elevated for years. A little more research showed another recent ultrasound that was perfectly normal. So, I began to delve into the alcohol questions.
As it turns out, he only has episodes of vomiting after binge drinking. And he never really has pain in his abdomen, except after vomiting a lot. It was clear now that this wasn’t gallbladder disease.
But, probably more important than the medical facts of this patient are the social ones. He was actually glad that I asked him about his drinking, and what he was doing about it. He was happy for me to encourage calling his sponsor and getting back to an AA meeting. He really knew all along that it wasn’t his gallbladder. He told me that by the end of the conversation. He just wanted me to listen and support him.
That’s how I would want to be treated.
Leave it to George Bernard Shaw to have a problem with the Golden Rule. He famously contorted his own version of the Golden Rule, which honestly, I don’t understand. Suffice it to say that his argument was that not everyone wants to be treated the way that you would want to be treated. I can accept that. Sometimes, the way I would want to be treated isn’t exactly what my patient wants. And in that way, it is good to realize that Shaw wasn’t all wrong in pointing out that subtlety. 
I think the real key is to understand this and try your best to meet the patient’s needs. After all, we all want our needs met. 
Whether we are in the school yard or the doctor’s office, treating others as we would want to be treated really is a Golden Rule.

*As always, the details are changed so as not to indicate a specific patient.

Monday, June 13, 2011

What to ask your surgeon. A List.

Visiting your surgeon to discuss an upcoming operation can be quite stressful. Because of this, if you don't go prepared, you may forget to ask important questions. Also if you don't go with a piece of paper and pen, you might also forget the answers to important questions.

I was recently asked to come up with a list of questions that patients should keep with them when they make this important visit to their surgeon. In her blog about the importance of making lists for nearly everything in your daily life, The List Producer is managing to help simplify our lives by keeping us organized. Below is the list that I developed along with some extra information on each question. I hope you find this useful in your next trip to your surgeon.

1. What is my diagnosis?
            Surprisingly, this very simple question is not asked very often. In order to truly understand your operation you absolutely need to know your diagnosis. This will help you to explain your problem to your family, friends and any other physicians that you might have.

2. What is the operation you are recommending?
            Again, it is important to know the specific name of the operation. This will be on your consent form as well. Most hospitals will also ask you this question at least once during your interview process on the day of surgery to be sure that you are familiar with what is being planned.

3. How many of these operations have you done?
            If your surgeon has not done a large number of the operation that he or she is planning, it is important to specifically ask if he or she is comfortable with performing the operation. It is also not inappropriate to ask if the operation could be done better by someone more experienced in this particular operation.

4. How long is the in-hospital recovery?
            This is often difficult to predict, especially with bigger operations. Usually the answer will be a range of days to expect inpatient hospitalization. You're operation may also be outpatient which may be same-day surgery or an overnight stay that does not exceed 24 hours. Again, it is important to set your expectations for which of these options will be occurring.

5. How long is the out of hospital recovery?
            Recovery means different things to different people. For some people it means how long until you are pain-free. For others it is how long until you can get back to normal activity. Be specific with your questions and ask these specific things when talking about recovery period

6. Will I need a transitional period with rehab or home nursing?
            For bigger operations this is often necessary. Also for the elderly or for people who start the operation in a debilitated state, a rehabilitation hospital or skilled nursing facility may be an appropriate transitional facility.

7. How long do you expect me to need prescription pain medication?
            Commonly, surgeons will prescribe narcotic pain medication for a limited period after which you may be required to see your primary care physician for further narcotic prescriptions. It is also common to try to transition from narcotic pain medication to anti-inflammatory medication or acetaminophen as quickly as possible after the operation. This will minimize the side effects of narcotic use.

8. How long should I take off of work?
            Again, this can be difficult to predict and is largely dependent on your pain tolerance and your specific job. It is always better to try to anticipate this before the operation and your employer will thank you for an appropriate heads up rather than being surprised when you ask for 2 weeks of sick leave following your operation.

9. What are the risks?
            This is an absolute must-ask question. Most consent forms will indicate that your surgeon has discussed the risks of the surgery with you. Be sure that this has happened. It is often scary to learn the worst case scenario, but it is always best to be well-informed.

10. Are there alternatives to this operation?
            There are often alternatives to an operation. These can be medical alternatives, such as treatment with a specific medication, or there can be alternative operations to treat the same disease. Presumably, your surgeon is recommending a specific operation for a reason instead of the alternative therapies. Find out what they are and what their advantages or disadvantages are.

11. Is it worthwhile to seek a second opinion?
Any good surgeon will never discourage this. For simple operations or straightforward decision-making this may not be necessary. But for complicated issues, or if you just don’t feel comfortable with what you are hearing, a second opinion may be right for you. You can always come back and schedule surgery with your original surgeon after your second opinion.

12. Who will oversee my care while I’m in the hospital?
            Will the surgeon see you, you will you be seen by the Nurse Practitioner or Physician Assistant? Or, will there be residents and interns seeing you? All of these are reasonable options, but it’s nice to know up front what to expect in the hospital.

13. Will there be residents operating on me?
This is fine, but it is good to know beforehand rather than be surprised at the group of 20-somethings at your bedside.

14. What do I need to look for after the operation in terms of infection and wound healing and will I need sutures or staples removed?
            This may be covered at the time of your discharge, but ask just in case. If there will be a wound to take care of, it is good to buy supplies now. You won’t feel like shopping after the operation.

I hope this list helps with preparing for the stress of an upcoming operation. As Louis Pasteur once said, “chance favors the prepared mind.”

List Producer blogs at http://www.listproducer.com/ and is on Twitter @ListProducer

Wednesday, June 1, 2011

Overcoming impossible situations

Surgery, like life, can have complex problems. Not too long ago I was operating on a patient who we all believed had a ruptured colon cancer. He was quite sick and I was operating on him emergently*. As I explored the abdomen, it began to have the appearance of something different. I honestly had no idea what we were dealing with. 
It was clear that whatever this was, it was involving the colon, the spleen, the stomach and the tail of the pancreas. The entire left upper quadrant of the abdomen was completely cased in hard inflammatory crud. I have no better medical term for it. Every organ was plastered to the adjacent organ.
At this point in the operation, I remembered the words of a sage mentor of mine, Dr. Jeffrey Pelton. “Chris,” he said. “You will, at a few points in your surgical career get into a situation, which at the outset, will seem insurmountable. You will open the abdomen and find a tumor or other problem, which at first, will look like it is completely inoperable. My advise to you is this. Don’t look at the problem like it is one big problem. Take it one step at a time. Use the surgical principle of going from ‘known to unknown’ and start somewhere easy. Go and take down that easy part of the tumor. If you get to a place where you are stuck, go to another part and go until you get stuck. Eventually, this big problem will turn into a series of little problems, which, by the end, you will have solved. It’s like a jigsaw puzzle. Take it a piece at a time and eventually, you will have it solved.”
That is precisely what I did. Start at the colon. Move to the spleen, then the stomach. Finally, tackle the pancreas. Three hours later, it was all cleaned out. All the pieces that needed to be put back together were together. And the tumor, a nasty lymphoma as it turned out, was out. The big problem was taken care of one step at a time. The operation was a success, and the patient has seen me in followup, tumor-free.
As it turns out, Dr. Pelton was right. I have used his advise on many occasions. I have even taught residents the same thing. Take the big problems one step at a time and you will overcome situations that seem impossible.
*as always, details of this patient are changed so as not to indicate any specific patient