One of the things you have to learn in order to sound smart while presenting a case (in other words, telling a patient’s story) is how to make generous use of signs. In general, signs are objective manifestations of illness, as opposed to symptoms, which are subjective: for example, in strep throat, severe pain is a symptom while white patches on the tonsils are a sign. Obviously, it is very important to make note of these.
Lots of them are eponyms: for example, Lhermitte’s sign is a sensation of electricity shooting down the spine while bending the neck forward; it’s considered classic for multiple sclerosis. (It’s also technically a symptom, not a sign, if we’re going to be pedantic about it, which of course we are.) Kernig’s sign and Brudzinski’s sign are pain when the leg is raised by an examiner, and pain causing involuntary hip flexion when the neck is flexed by an examiner, respectively; both are classic for meningitis, and I can never keep them straight. Grey Turner’s sign, bruising in the flank area, indicates internal bleeding and is frequently checked for in cases of pancreatitis. (Most of these signs have not been exhaustively investigated and it’s unclear how useful they actually are, but we love them anyway.)
When reporting these, we generally say something like “The patient has a positive Brudzinski sign.” This formulation is apparently so catchy that it has spawned a whole slew of other signs, most not particularly respectful.
Some are flippant terms for actual helpful diagnostic findings. For example, patients with pelvic inflammatory disease usually exhibit exquisite cervical motion tenderness. This is sometimes referred to as a “positive chandelier sign,” as in, the patient is jumping up to the chandelier during the pelvic exam. Of course, no one would write this in a medical record, but it’s not uncommonly heard in emergency rooms.
Then there are some terms that grow up in particular institutions. One that I’ve heard several times is the “10 allergies” sign. Patients who list more than a small handful of allergies are much more likely than others to have multiple vague complaints that are beyond the powers of modern medicine to solve, and I’ve heard more than one resident grumble “positive 10-allergy sign” before going in to see a patient.
I think the best (and also worst, in some sense) of the irreverent terms is the “fish sign.” You see, our hospital has a big fish tank stocked with many beautiful tropical fish. There’s a camera which broadcasts a view of the fish on the hospital’s closed-circuit TV system. Patients who are comatose, severely demented, or otherwise unable to express their viewing preferences often have their TVs set to the fish channel. That’s a positive fish sign. It’s considered a poor prognostic indicator.
This article bemoaning what young doctors and doctors-in-training wear seems to have kicked up some controversy. It mostly just made me roll my eyes.
First, it took me a bit to figure out what exactly was objectionable about all the pictures at the beginning of the article. Obviously it’s inappropriate to display your navel or your entire sternum down to the xiphoid process (particularly if your ribs are countable), but I’m still not sure what’s so bad about the second picture. Open-toed shoes? Painted toenails? The pigeontoed pose? The slight glimpse, thanks to camera angle, of thigh?
Nearly a decade later, my impression is that more young physicians and students are dressing like that resident. Every day, it seems, I see a bit of midriff here, a plunging neckline there. Open-toed sandals, displaying brightly manicured toes, seem ubiquitous.
It’s true that open-toed shoes are a poor choice for any place you might be exposed to a biohazard; I wouldn’t wear them to the hospital (or probably to work at all, as I don’t find sandals comfortable for extended walking), but I wouldn’t think it strange if an internal medicine physician wore them. (And the biohazard objection is a bit flimsy anyway; nobody objects to doctors showing their wrists or ankles.)
Another complained about a male student who came to class unshaven, even though he hadn’t been on call the night before.
He came to class unshaven? The horror! I hope this physician never visits my school, where male students regularly have beard-growing contests during finals and females often turn up with wet hair (at least you know it’s clean!).
In a study published last year in The American Journal of Medicine, patients surveyed in one outpatient clinic overwhelmingly preferred doctors photographed in formal attire with a white coat to photos of doctors in scrubs, business suits and informal clothes — jeans and a T-shirt for men, an above-the-knee skirt for women.
Above-the-knee skirts are considered informal on the level of jeans and a T-shirt? I guess someone should have told me and thousands of other women before our med school interviews… (Very few people wore what I would call “short” skirts, but many wore skirts an inch or two above the knee. Your average twentysomething woman looks frumptastic in a suit with a below-the-knee skirt.)
Seriously, I know that the way we present ourselves is important, and I take care with my dress. When I’m seeing patients, I usually wear dress trousers, a shell, sweater, or button-down blouse, and closed-toed shoes. I don’t display cleavage or wear casual khakis, very trendy clothes, or jewelry beyond a simple necklace. I take note of what female physicians wear, and I always ask myself, “would I wear this to visit my grandma?”
The problem is, while my grandma is certainly a proper older lady, she doesn’t see anything wrong with her granddaughters looking attractive. Evidently, some of the doctors who will be evaluating me do:
Her research has also found that physician clothing can influence scores on board certification oral exams, in which a senior doctor assesses a younger doctor’s medical knowledge.
“You don’t want to look too attractive to be serious,” she said, adding that “a certain amount of the nerd factor” can help a doctor’s performance.
I’m nerdy, for sure. But I don’t always look like it (though the white coat helps). After having observed the nastiness that resulted when Jill from Feministe dared to dress in such a way that onlookers could tell she has breasts, I’m a bit concerned that simply dressing tastefully and seriously isn’t good enough. Who knows when someone is going to decide that I look too attractive? Maybe I should start shopping at Coldwater Creek.
Every week my summer research program has a Friday lunch talk meant to enhance our career preparation. Today it was about “Balancing Work and Family.” I was interested to see how they’d address the subject - I often get frustrated with these talks because they’re generally put on by women’s associations and feature only female speakers, which perpetuates the idea that only women have to worry about balancing work and family (because they’re the ones deciding to add work to their traditional task of running the family, presumably).
This one was actually quite good. It addressed the issues faced by dual-career couples, which is really the way to look at it. The issue isn’t being a woman who works, it’s being a person who works while your spouse also works. Men who don’t have stay-at-home wives also have to deal with it. Accordingly, there were two speakers, a male surgeon and a female gastroenterologist, both married to fellow physicians.
Unfortunately there wasn’t a whole lot of advice given (somehow they had the impression that the audience was largely made up of undergraduates and that nobody was actually trying to plan out when to have children or how to manage staying in the same city yet). But there were interesting statistics: apparently 22% of male physicians are married to physicians, and 44% of female physicans are. (I’m not totally sure how that works, maybe the percentages of physicans who are married, and fewer female physicians are married at all?) Comparing physicians in dual-doctor marriages to physicans married to non-physicians, the dual-docs were more involved with their children, made a little less money individually but more as a family, and felt their careers didn’t take precedence as often. I think that makes sense - when the other person is just as career-oriented as you are, things have to be equal and you can’t push all the childrearing duties onto the other person.
Both of the speakers were very encouraging, and I thought it was great to hear from people who were happily and successfully living in dual-career families. The surgeon mentioned that he and his wife make sure to be home by 6, they leave work at work on the weekends, and so on. And it sounded like maternity leave and that sort of thing is becoming standard even during residency.
At one point an audience member asked whether it’s common for people to take some time off while their kids are young. Both speakers said that it can be done if that’s a priority. Then the female speaker talked about the fact that women tend to feel a lot of guilt about not being there as often as their friends or neighbors who stay at home are. She said you just have to work that out and realize that nobody spends 24 hours a day with their kid, and children never get confused about who’s their mom, dad, nanny, or other caregiver. They love them all, but parents are always special. I thought that was pretty reasonable.
Then the male speaker said his wife had found it really difficult to deal with the guilt feelings, and ended up cutting down to working three days a week so she could be home with the kids some days, rather than always feeling guilty that she wasn’t taking them to play dates or whatever like the stay-at-home mom next door. He said she was very happy with her decision, which is great (and heaven knows three days a week as an academic surgeon is still a far more high-powered career than most people will ever have), but I think it’s really unfortunate that women still so often feel such guilt about having a career. It’s not like she was neglecting her kids before, but there’s still such a big cultural push for women to be primary caregivers that it’s difficult to ignore that.
Anyway, it was a good presentation and I found it mostly very encouraging. Though this was the second time a speaker told us they had brought in a newborn to sleep under the desk while they finished a grant application! I guess that is definitely a way to combine work and family.
For quite some time, I’ve been encouraging female friends to ask their doctors for emergency contraception prescriptions at regular office visits. Most people don’t wait until they’ve cut themselves to go buy bandages; they keep them in the medicine cabinet just in case. Similarly, any woman who’s of reproductive age should probably have emergency contraception (EC, available under the brand name Plan B) on hand. Thanks to politically-motivated decisionmaking at the FDA, emergency contraception is still a whole lot harder to get than bandages. (Even women who choose not to be sexually active should consider getting EC; there are plenty of reports of women who are denied access to the medication after being raped.)
The American College of Obstetricians and Gynecologists has just launched a campaign called “Ask Me” to encourage women to ask for EC prescriptions before there’s an emergency. This is a great move by ACOG. Of course, it would be better if physicians would ask their female patients if they’d like EC, but until that happens, patients should take the responsibility for asking. That way, you can fill your prescription ahead of time (by mail or out of town, if you live in an area where it’s difficult to obtain) and have it on hand just in case you need it.
Also, while I would of course never suggest taking medicine for which one does not have a prescription, it’s worth noting that the only reason Plan B is not currently available over-the-counter is the aforementioned political struggle at the FDA, and so there’s no medical reason why you couldn’t share your prescribed EC with a friend in need. I am sure, however, that the ACOG would not approve of such an action.
As an endnote, a very useful website about EC is maintained at Princeton. It offers peer-reviewed explanations, phone numbers to get EC if you need it, and instructions for using standard birth-control pills as an emergency contraceptive regimen.
Listening to NPR today, I learned that leprosy, which is now curable with modern medications, is currently more prevalent than measles in the United States.
Also, the disfigurement is partly just due to skin infection, and partially because leprosy attacks the nerves, causing loss of pain sensation in the extremities, and patients inadvertently injure themselves over and over, eventually leading to disfigurement.
Finally, leprosy is now officially known as Hanson’s disease, after the scientist who discovered the bacterium that causes it.
You know how the typical example of old-fashioned medical quackery is the practice of bleeding?
I learned this week that bleeding is actually a recommended (and proven) treatment in some cases, though it’s called “phlebotomy” and done with sterile needles rather than dirty knives and a basin. Evidently there are certain conditions in which you have too much iron or too many red blood cells in your blood. (Red blood cells contain a protein called hemoglobin, which contains iron and serves to transport oxygen from your lungs to your tissues. That’s why iron deficiency is a problem - not enough oxygen transportation.) In this situation your blood essentially becomes sludgy. Even though there’s more than enough iron, the hemoglobin is too crowded to work properly, and the patient literally turns blue around the edges.
The treatment for this is phlebotomy. They’ll remove several units of blood over a period of time in order to get rid of the extra stuff, and make sure the patient is well-hydrated so the blood just thins out. It’s quite effective.
(This may contain errors in the details; I’m summarizing from what a physician with a thick accent told me during a brief conversation during clinic.)
I have a very low-key teaching style. Today I was teaching a chemistry class and I made some comment about gas molecules zooming around, which made one student laugh and ask me if that was a technical term. I probably could come up with fancy-sounding words (though maybe not while thinking on my feet), but I think it’s more effective to use simple words if the fancy ones don’t add anything different - the easier it is for people to understand the vast majority of what I’m saying, the more likely they’ll be able to focus on the parts that are actually new material, rather than spending time deciphering blather.
People say doctors are really bad with the jargon, and it’s totally true. Half my classmates have already started up with MI for heart attack, hyperlipidemia for high cholesterol, diapheresis for sweating, and “Please move medially” instead of “Move to the middle of the row” to accommodate latecomers.
I realize that some of these offer more precision than the lay terms, and so they’re certainly useful in technical situations, but I’m amazed at how quickly people forget what is actually going to make sense to a normal person who doesn’t spend six hours a day listening to medical lectures.
And some of the terms appear to be replacing other technical terms: evidently, saying “urination” for what the less couth might call peeing isn’t technical enough! We have to call it micturition.
Every couple of months, each first-year medical student spends an afternoon with a primary-care physician in the community. The doctor I’ve been following around is really awesome. He has a wide range of patients with varying health problems, and his interactions with them are great to watch. I learn a lot from my afternoons in his office, and I try to remember what he does so I can use the same skills someday.
This week was the first time that he had me do things somewhat independently - I had just been shadowing him, but now he sends me in to talk to the patient and find out how they’ve been doing and what their current problem is, then I summarize that to him and he examines them, asks further questions, makes a diagnosis, and makes whatever decisions need to be made.
I had never talked to a real patient without a physician in the room before, and it felt great! I thought I would be really nervous, but he just pushed me in there so I didn’t have time for that. I was also surprised at how easily the patients talked to me - they listed all their symptoms and asked me questions about what was wrong. I was even able to answer a few of their questions, though of course I said something like “Well, that could be due to X; we’ll see what the doctor thinks.”
Feeling like I was actually providing care to someone, rather than just observing and staying out of the way, was very neat.
I observed a birth last week. It was amazing! The mother had put a fair amount of thought into the sort of birth experience she wanted, and luckily everything went more or less as planned with no complications. She had a few close family members there as well as a doula, a nurse, and a midwife (and me, but I was in the corner). She also had some new-agey music hooked up to the baby’s heart monitor so that the baby’s heartbeat became part of the music, which sounds goofy but was actually pretty neat (and it gave me a little more information when I couldn’t see the screens).
The birth itself went pretty smoothly; obviously it wasn’t painless but the pushing part of labor was pretty short. I was surprised at how much emotion I felt when the baby was born - it really seemed miraculous. Right away, the midwife did whatever suctioning thing they do to its nose and mouth, then placed the baby on the mother’s chest. That changed the whole mood of the room - the mother and baby were so wrapped up in each other and so peaceful, it was amazing. There was still quite a bit of action in the rest of the room (all the medical sorts of things that have to be done after the baby emerges, and the grandmother taking pictures and all that) but the mom and baby seemed completely separate from all that.
The next day I went to visit them and thank the mother for allowing me to be there. There were a few more family members around, and everyone was so happy and fascinated by the baby. It was neat to get to see something really happy in the hospital.