Saturday, December 24, 2011

Plans and Goals

I'm enjoying my vacation. I just finished 4 weeks of outpatient psychiatry, which was absolutely fascinating, but I've had this whole last week off and will have next week off as well, before starting a 4 week rotation of family medicine.

I love vacation, mostly because of the time I have to do things I want to do. My wife was shaking her head at me, because last Sunday I spent half an hour on the phone with a good friend, discussing how to schedule our vacation time to make the most of it. "We'll wake up at 5am every day, except sleep in on Wednesdays and Sundays." We planned to pray for 5 minutes when we woke up, before doing anything else. Then we agreed upon a Bible reading plan to work through every morning (the plan we're using can be found HERE). After that, I work for 2 hours on the curriculum for the Patient Centered Medical Home that I'm working on, while my friend (who will be starting medical school himself next Fall) studies microbiology. By then, my kids are waking up, so the next couple of hours is loosely make breakfast/hang out with them/read "Polio: An American Story".

Most of the rest of the day is unstructured, and I have been using it to take my son to the park, run errands, catch up on dishes/laundry and watch TV with my wife. Thus, I keep most of my vacation time unstructured and open to spending time with my family. But then, as the evening comes on, it's time to work on my physical goals. I'm planning on running a half marathon in 2012, so I go on a run every other night. I'm up to 4.5 miles! The other nights I work on strength training and working through my karate forms, since I plan to return to my dojo next Fall.

For the most part, I've been sticking to this! It helps having a friend to check in with, especially at 5am. Most of all, it helps to have planned out how to accomplish the goals I want to reach. My Sensei always says this time of year (as we make our New Year's Goals), "A goal without a plan is just a dream." So part of what I will be doing this last week of December, is compiling not just a list of goals for next year, but making plans for how to reach those goals. I hope you'll do the same! :)

Thursday, December 8, 2011

Ask the Right Questions

I made a rookie mistake in clinic recently. Let me give you a little background: for the last few weeks, I've been doing a rotation with a group of doctors who are board certified in both family medicine and psychiatry, since that's the path which I want to take as well. I've sure seen a lot of interesting things! Since the need for mental health care is so great, though, the majority of the patients we see are for psychiatric care. The patient I saw this time was no exception: she had been referred to us by her primary care doctor, because she'd had a hard time adjusting to a death in the family.

I started talking to her, and immediately began to see that there was a lot more going on than that. Her life was marked by transitioning between long episodes of depression and shorter episodes of increased energy, decreased need for sleep and hyperactivity, consistent with a condition known as bipolar disorder (many people have a mistaken idea of what bipolar disorder is, but that's a topic for another post). We talked at length about the problems these were causing her. We talked about the abusive relationship she'd been in, her use of marijuana, her mother-in-law, her financial and housing situations, and all about her kids. She'd been tried on many different medications for her mental illness in the past, and we talked at length about these. We discussed her prior attempts to take her own life, and her interactions with psychiatrists in the past. I probed into her childhood, and uncovered a history of physical and sexual abuse. After that, I found out that many of her family members also have had problems with mental illness, too. Then we started going into what her greatest current symptoms were, and they were actually anxiety. I asked a lot of questions about her anxiety, and how it fit into her extensive history.

That sounds like a great patient interview, right? In a way. My rookie mistake was finding out all of this information for it's own sake. I'm to be forgiven for making this mistake; curiosity is a large part of how I got to this point in my career and my life. When I exited the room, though, I realized that almost an hour had gone by. I was working with several other students and doctors in the clinic, but if I had been the only one, how many other patients would now have been waiting to be seen? I'm a big advocate for spending as much time as you need with each person to deliver the best care, but that then begs the question: did all that additional information really help me to provide better care? It really didn't. Of course, it's nice to have that extra context, and it might be necessary if we were getting into a therapy session. However, to help her with her anxiety and underlying bipolar disorder, I didn't really need to have all that extra background, and the time I spent gathering it could have been spent helping another patient.

As my medical knowledge base has increased, I've mostly gotten away from being a mindless data gatherer into someone who asks pointed questions. At first, I would take the above approach to each patient, with medical issues or psychiatric ones. This method involves gathering as much data as possible in hopes of stumbling across the information needed to make the appropriate diagnosis and treatment decisions. As I go on with my training, my mind is becoming more keen to realize what sorts of questions I need to ask. Instead of fleshing out the entire background of abdominal pain, I may ask "Does the pain change when you eat?" If it gets worse after a fatty meal, gallstones is higher on my list of causes. If it gets better after a meal, I'm thinking more about ulcers. I'm getting a lot better about doing this, but I need to apply this same approach to patients who have anxiety, depression or other psychiatric problems. It's fun to get into the whole life story of each patient, but it's in everyone's best interest for me to hone in on what's really important. I hope to get better and better at doing this, while still making my patient's see that I'm listening to them and care about what's going on in their lives.