Sunday, August 21, 2011

A Physician With ADHD

Attention Deficit Hyperactivity Disorder is a malfunction in the brain. A simplified explanation is that there are several regions of the brain that all work in tandem to keep you alert and mentally functioning, as in reading, talking and watching out for wolves and lions.

Let us say that each region of the brain produces a certain amount of energy that if added equals 100mV of electrical current. If the frontal lobes (where this disorder resides) contributes 50mV and the other regions 50mV we’re okay. If the frontal lobes decide to produce only 10 mV then the other lobes have to gear up and contribute 90 mV. The adjacent regions that step up to the plate are usually the areas for motor function, like in Billy hanging from the chandelier, hence hyper-motor-activity. The idea is that the brain needs to maintain a level equal to 100mV.

It’s not common for people with ADHD to reach the level of academic achievement to become a physician, because paying attention and learning are severely compromised from an early age. Making up lost ground from a deficit in early childhood education is very tough even for those who don’t suffer from ADHD.
We’re learning more about the plasticity of the brain that can increase our intelligence. They once thought that by the age of 5 or 6 there was no improvement in basic intelligence. We now know this to be untrue, those test scores and our functional capacity can be increased with study aids and other tailored learning techniques. Medications make a big difference and give hope to children and adults who suffer from this malady.

I know because I am an example of brain optimization-(this is an article of inspiration so I can use that word.) So how did I become a doctor with this handicap?  I mean I failed miserable in school, the fact I could read was a miracle; though I was attracted to words; like when my Mother would say, “stop that incessant bickering.”

In fifth grade we would stand in front of the class for spelling bees and when you got a word wrong you returned to your seat, embarrassing!  So I would just plan to keep my seat warm until one day I had to spell corroboration and I was like still standing-where did that come from?  I knew it was a fluke, but it gave me hope. After high school I started to read Time, Newsweek and The Minneapolis Tribune, albeit with a dictionary by my side. At the age of 19 I went to community college for what they called “bonehead math” yes 1+1=2.

My rebirth came when I read The Study Game by Laia Hanau. Then I stumbled upon the study technique SQ3R- Survey Question Read Recite and Review, using flashcards. That’s it, next thing you know I’m giving the commencement speech at the hooding ceremony for medical school.  Well you say, “you really didn’t have ADHD,” trust me (I’m a doctor) I did and do and deal with it daily. There is hope, we can change the brain in many ways; we are not doomed to failure.

I think when it’s all said and done and you’re an adult with ADHD, having missed opportunities coupled with misfortune you must aim for a rebirth. Embrace a certain comfort in humility, and find no shame in reading a children’s book to learn.  If for nothing else learning is a pleasure, it builds confidence and feels good. Your struggles build character and insight that make you special, combine the two and you’re a winner.

Saturday, August 20, 2011

The Physician As Mediumistic

Physicians acquire, organize, evaluate and dissipate essential medical knowledge. We must possess an ethereal predisposition, a highly refined and delicate sensitivity to recognize the unspoken emotional impact of illness, tragedy, and death; like a sixth sense that can detect something beyond what’s objectively present.  Where does this talent come from? Do we leave this to God, a higher power or the mystics to give us insight?

I am aware of how missteps in treatment can derail a patient’s path to wholeness. When I see a patient exhibit pain inconsistent with and unsupported by actual underlying pathology, I explore this hidden dimension where pain and anguish reside. A little personal sensitivity and understanding of the human condition will often reveal something related to the emotional shock of an injury; “I can’t believe this happened and it’s happening to me,” though it’s usually disguised.

Unresolved emotional conflict goes something like this; Billy and Johnny are playing in the sandbox when Billy hits Johnny. Holding his wounded part, Johnny runs to mom who is talking on the telephone. At that moment, mom can do one of two things. She can stop her conversation and address Johnny with “there, there honey it’s all better,” and Johnny, miraculously cured, returns to the sandbox and resumes playing because “my mom made it all better.” Mom could choose to wave Johnny away and dismiss his complaints in which case, having not addressed the incident Johnny was not able to let go of the pain, he runs back and tries to hit Billy.

Much the same is true for an injured, ill patient; we are trapped in the moment of insult to body and mind. Most of us have seen the commercial where Betty tells us that a doctor came into her hospital room informs her that she has cancer with 3 months to live, turns on his heels and walks out.  Five years later, Betty looks healthy, but tears are flowing and her voice cracks as she repeats her story. We feel her pain. She beat the odds for survival, however, she will never get over the emotional trauma of it was presented. She has desperately tried to rid herself of this torment and despite repeating it to millions upon millions of people she has no relief, no emotional peace from a moment caught in time to play out forever.

An emergency room physician comes to the waiting room and delivers the news that their loved one is dead, “we did all we could,” turns and walks away. At the funeral do they talk of the wonderful life this person had? No, they can’t get over the shock of how the news was presented and now they wonder did they really do everything?

Through a keen understanding and appreciation for the impact of presentation, we guide patients through the experience and aftermath of these traumas. We must facilitate the process for them to assimilate reality. We need to talk them through and palliate the shock of the suddenness and overwhelming rush of confusion and confrontation with our own mortality. It seems all other aspect of their life come to a halt. If we missed the opportunity to do this at the time we must retrace the experience and take them step-by-step through it.

 I cared for an 18-year-old boy who ultimately died in my hands; his 17-year-old girlfriend was dead on arrival. Two weeks later I received a letter from his mother who inquired: “Doctor I was with my son for every event in his short life, every first day of school, sickness and times of joy, but I was not there when he died. Could you tell me please, did someone hold his hand, did you wash his face? Was he in pain? Did he happen to ask for me?  I can’t get through this unless you walk me through those last moments, all of it.” I did and she was lead to the moments of his last breath. She was afforded the ability to visualize and then slowly let him go and learn to embrace those moments to say goodbye.

When I conduct a code, I often call family members into the room to visibly partake in the process of resuscitation, often they will hold hands and pray; when it’s time to stop, I will turn and say “there is little left to do,” they acknowledge it’s time to let go.  How fortunate we are to partake in life and death, how intimate does that get for any human? We can change the experience for the Betty’s of the world so they can leave behind some of the emotional pain with the dead cancer cells. Is it mystical? I think not!

Tuesday, August 9, 2011

The Power Of Touch

Though I had a less than comforting childhood,  I really didn't know what I missed in nurturing until I played football at around age 10. The coach, a big burly man, with a voice as huge as his girth, put his hand on my shoulder as he explained something to the team.

I have never been able to explain the feeling that went through me that day, that moment, like a thunderbolt. It was so foreign, I was so overwhelmed and afraid of what I was experiencing I ran into the sparse woods near the field and began to cry, crouched behind a lone tree I wept, when no one looked for me I sobbed uncontrollably. This was the beginning of a connectedness to the world. It was as if a spirit had entered my body and now I was aware, aware of life.

From that point on I became acutely aware of how other kids were treated by a loving parent. I became  keenly aware to how their lunches were wrapped and bagged. I felt an appreciative envy when I saw a folded napkin, and homemade pastry, I could feel the love.  I was drawn to mothers attending to their children, especially when they held their hands or touched them in some way. A classmates pants were always just the right length and I inquired about how this was so. He showed me the tailored hem of each leg where the facile hands and warm heart of his mother painstakingly made him look so kept.  When I saw a father with a sleeping daughter in his lap, I would smile and get comfort myself. Rather than feel disconsolate or jealous I felt connected, I too had an idea of what that felt like.

With no thoughts of medicine as a career I chanced upon a picture of the pediatrician, author and poet, William Carlos Williams. He stood over a very young child who appeared  asleep. The infant had been kicked in the head by a horse, her wound sutured, the bleeding stopped. Dr. Williams hands were cupping her head much as you see St. Francis of Assisi, depicted in art, as he holds a dove.

His face weary and grim as he waited for her to wake and once again bound about with energy and life. I knew from experience his hands were the conduits of life itself, an energy from his magic to her tissues and soul. This, not the sutures or hemostasis, was going to make her better; I knew then where my life was to be. Somehow by being a doctor I could supplant a mother and father and then administer that magic offered in touch. Being a doctor would keep me connected to that day, that moment on the field.

I immediately understood the art of medicine and the power of human touch. Occasionally, when listening to a patient's frustrations about a previous encounter with another doctor or healthcare provider, they would mention…...”and he never even touched me”. They reach out from the sick bed to make contact with us in a plea for help, as if they will not be taken seriously until they transfer their tacit need by touch, this request not confirmed until we touch back.

I am prone to touch a sick patient on the forehead much as a mother would to check a child’s fever. I rest it there for a few seconds at the hairline, just enough to let them know I'm connected; you are not alone, I will care for you. I will try to give a little spark of life to each patient, much as that first touch did to mine. They do not teach this in medical school, nor is it born from a functional duty or altruism,  it's because I feel the coaches hand when I touch a patient.

Friday, August 5, 2011

Clinical Rounds, Mnemonics and Pimping

Morning Rounds, Mnemonics And Pimping

I have always used mnemonics, mostly for tests, but for the clerkships and internship year a few were indispensible. Making the transition from classroom to the wards can be intimidating and difficult.

I was recently in the presence of a fourth year medical student when she was asked the differential diagnosis for dementia. Being an ardent student of the axiom, when in doubt mumble, she did.  I actually doubt the person asking knew much more than she, but it didn’t matter she was exposed. He, on the other hand, was a peacock in full colors parading in front of the group; chest expanded displaying a righteous indignation.

This is pimping, a tradition handed down through the generations of medical school and residency years. It’s a right of passage used for many purposes, usually to catch some guy who was late and then texts on the phone while he should be listening. But then I’ve tried to catch these guys and somehow they don’t skip a beat, never fails. (or it always does)

When rounds were done I pulled her aside and informed her that there was a great mnemonic for a differential on dementia and also one to discern the clinical features between this and delirium. She barely looked me in the eye, feigned some other important task and moved on. I wanted to tell her how these tricks allowed me to excel during those years, but she had no interest in hearing about that. I’m still puzzled to her indifference.

She didn’t want to hear how a chief resident pulled me aside one morning and said, “look your making me look stupid,” slipping into my Bobby DeNero impression with, “you talking to me?” Looking around I went into full acting mode with a repeat, “are you talking to me?” Inside I was going, “if you only knew.” I rarely had to pass mint before the resident would say that we better move on.

She didn’t want to hear, that to excel was mostly about presentation, and had more to do with thinking on your feet then really knowing the answer. When asked for a small bit of information I was never at a loss for words. I would spew things like, in evaluating this patient lets look at the metabolic influence, how are the fluids, electrolytes, nutrition, then infection and so on. All of these could be relevant and maybe not, let’s just think about it in a rational and systematic way.

By the time you get to be a fourth year medical student you know how to study for tests, but there’s a big leap to putting all that knowledge into a tangible working diagnosis. Someday you won’t get pimped, but you will always need to formulate a differential diagnosis. Despite the grandstanding, and when no resident or attending is near remember this, “a patient doesn’t care what you know until he knows you care.”

[1] Metabolic, Infection, Neoplasm, Trauma, Vascular, Congenital, Allergic, Drugs, Endocrine.

Thursday, August 4, 2011

The Difficult Patient

The other day I was running to catch the train-ten seconds to spare I turned the corner and could see the engineer and he saw me. “Whew I made it”, just as I reached the door it closed and the train moved away. Bleep! but I made a split second decision not to react to this injustice. Self-talk, "I will not get upset, just deal with it, I was late". With head low I began to walk back from whence I came.

As the Engine moved behind me I knew the engineer could see me and I played a wounded and forlorn traveler just dealt an unfair hand. With a posture of a rejected little boy, I was at least appeal to his sense of unfairness and if nothing else make him feel a little bad, I looked up to see this big grin.

Standing boldly with defiance, I immediately flipped him off. Oh what a relief, what perversive glee I got from that gesture and with perfect timing too. I felt good the entire hour waiting for another train. Like the other time on the bus when this standing loud mouth was on his cell phone, everyone rolled their eyes. He stood there for all to notice because there were no seats until the person next to me left. When he came over to claim his comfort, my hand defied his move and with a steady voice I informed him he could sit down but no phone, he stayed standing. That felt good too!

As a physician though, I must bite my tongue, mediate, cajole, patronize, and at times be so obsequious that I feel like a sycophant rather than a BMOC (Big Man On Campus). You know, I often need to do serious sucking up and play nice to the unpleasant.  Forget that their usually healthy, belong to 20% of the population using 80% of the healthcare and remain ungrateful despite saving their sorry @##.  What glee it would be to just let it out. Come on guys you know what I'm saying.

Can you imagine the dialogue? “Good morning Mr. Jerk what brings you in this morning? My car what ya think?  Oooookay, what seems to be the problem here? You tell me you’re the doctor”. My aggression fantasies go wild, just once I would love to say, “listen Bleep! get dressed and get the Bleep out of my office. I get relief just thinking about it, but, that’s not how it is.

I am always reminded of an emergency room resident who told me how he had a fight with his girlfriend, she kept calling and calling so finally he answered,  just ranted and raved, swore and rejected and was just down-right nasty. When he stopped to reload he could hear these whimpers on the other end, then this meek voice asks “is this Dr. Resident”?  OMG this was not his girlfriend, it was a patient he told to call if she felt suicidal.  I’ve learned that’s it not about me, its all about them.

I learned that a less than sweet disposition can be born out of pain, nurtured by fear and embraced by mistrust. So how do you, a young physician with your own fears, fatigue, anger and frustrations, deal with this. Trust me, (I’m a doctor) when I say you can handle the worst of the worse and do it with aplomb even when you're tired.

This Is How it Works
Before I enter the room I’m usually tipped off that so-n-so’s upset, but if not, I can usually detect it by the look in their eyes. Just stand back because then it's BAMB!!!, frontal assault, no mincing words, “I am so sick and tired of all this run around…for another thing…..I’m going to sue…. I’m calling The Board”.

DON”T  say  a  thing!  I mean it, put the chart down pay close attention to their lips, stay fixed on those lips. As this diatribe continues you must not react emotionally or allow yourself to feel anger, just look at them intently, focus on the lips. Let them get it all out until they’re just tired of talking.

Yes, this sounds like transactional analysis, but when there is a break in the action calmly respond with “I can see your angry… certainly are upset” – Just validate what their feeling, not agreeing with what their saying or how their delivering it, your just making an observation and often that's enough.  Do not argue, it does nothing but incite, you do not need to be right or look good. (It's not about you, if it is then you deserve it) When they have diffused their emotions, move right into addressing the medical problem (distraction technique); do a thorough history and exam, reveal true interest. True interest is when you tell yourself "I have a difficult patient, I better not over-look anything, because if anything will go wrong it will with patients like this". Your tendency is withdraw and protect yourself, wrong move, that's when you move closer.

Be matter-of-fact, skip all the noise, no mention of the issue/s, for the most part they just need to vent, but if it’s really important you can address it later when all is calm. Take it from a man, who as a teenager most of the teachers said I had a chip on my shoulder, whatever that means. This is how I have handled difficult to dangerous patients.  Often times I never resolve what they were upset about, I appear so cool headed and they leave saying “your the best, can you be my regular doctor”? (for real?) Then I calmly go to my office, with door closed I scurry about to make sure no stone is unturned and I take every element of their care seriously.