The Medical Guide to Avoiding Ignorance

I believe there is no better place to see teamwork in action than the inpatient setting. As a medical student, the teams in question can often be ill-defined. Yet the whole hospital is, in theory, built on that contract between healthcare providers and their patients. Patients bring their their health to the table, and we bring our expertise and commitment to their service. From that foundation arises every other collaborative effort in medicine. 


After a year and a half of clinical rotations in medical school, I’ve grown familiar with the interactions between physicians: how different specialties operate and interact with each other, the valuable role of consults, and how different practitioners act given their rung on the teaching hierarchy.  Yet I still only have the faintest idea of how our nursing staff operates. Or what the day-to-day role of a clinical pharmacist is. Or how physical therapist perform their jobs. I know that collaborations between these different medical professions is essential – unfortunately my main interaction with any other field is limited to the electronic chart. Following nursing notes, PT/OT evaluations, respiratory therapists comments, etc.  I do think that for all the efficiencies brought on by the electronic chart, I’m missing out on the valuable interpersonal  interactions that physicians used to have with each and every essential personnel.

 Photo by EVG photos from Pexels

Photo by EVG photos from Pexels


In medical school the focus is on a successful evaluation of a patient and the knowledge needed to establish a differential and plan. But in learning all the theory behind our practice, we often overlook the reality of what we’re learning. I frequently catch myself not knowing what actually physically happens. SPEP? NAAT? I know when to order these labs, but have never seen the process actually performed. I’m ashamed to say that it had never crossed my mind how values like “moderate  blood” on a urinalysis are measured. When I saw it actually performed in a lab, I immediately remembered the term dipstick, and it made a lot more sense. I felt foolish in that moment, but even that quick interaction with lab technicians had a huge impact on my thought processes when working up a patient.


As far as medications are concerned, I admit I am still unfamiliar with the nuances. I was floored when I experienced how helpful having a pharmacist on rounds was. I distinctly remember a tough case involving a patient with HIV on antiretrovirals who was suffering from an adverse drug interaction. The pharmacist began talking and everyone from the attending to the medical students stopped to absorb his expertise and navigating the situation. The financial cost of these medications is another essential area in which pharmacists bring invaluable insight. No matter how theoretically sound my ideas might be when presenting a patient plan, real world factors such as cost and availability dictate what kind of management can be pursued. Even something as simple as the fact that certain pills are just too big to comfortably swallowed – or too small to be split. 


Nurses are the backbone of patient care. Whereas their roles may differ, the nurse is often the one actually carrying out the majority of medical interventions planned for the patient.  Though nurses also spend lengths of time charting their activities, they are still the ones that understand the patient best. One of the single best strategies I developed in my 3rd year rotations was talking to nurses about my patients. They always had insights to share that would leave me more prepared than spending that time recycling through the chart again. So why is it exceptional to have a physician that includes nurses on rounds? Perhaps it is time to change the standard.


My interprofessional experiences across two hospitals have been eye-opening, but I know that they are not always the norm. Hospitals around the nation still suffer from the ideal of “doctor knows best”. In the end, a collaborative patient-centered effort will always lead to better outcomes. I hope that medical training will push more toward exposing each field to one another. To those reading this article, I’d like to know more about my colleagues. The nurses, physical therapists, and pharmacists I’ll be working with to achieve the same goal. I’d especially love to hear feedback on the interactions you have had with physicians, the good and the bad! I am sure that we can collectively strive towards improving our team. 

 

 Neel Bhan, MS-4, University of Texas Southwestern Medical Center

Neel Bhan, MS-4, University of Texas Southwestern Medical Center

 

Bringing Diet to the Table in a Medication Driven World

Much like in primary care medicine, treating patients as a Registered Dietitian hinges upon creating a rapport with patients in an attempt enable them to make the necessary health modifying changes. Treating a person with obesity is much like treating a person with a substance use disorder. The patient is the sole individual in the driver’s seat and makes all of the choices that determine their success or failure. Getting a patient to “buy in” to a healthy eating pattern, just like eliminating drug use, takes significant time considering barriers to compliance. For treating obesity, barriers include long-standing untreated psychological coping mechanisms, time, financial barriers to eating healthy, social climate, and affordable access to qualified healthcare professionals. Physicians and many other practitioners simply do not have the time to elicit the necessary changes in their patients without appropriate support staff.

In my experience as a dietitian, even if time is taken by typical physicians to steer patients toward healthier eating habits, minimal nutritional advice is given. What little guidance is provided usually only includes following certain caloric restrictions or my personal favorite, “don’t eat anything white.” Much more is necessary to make changes in the arena of weight management.

Another challenge that compounds the time issue is that there is so much diet information accessible to the public that may or may not be true, accurate, or safe. There are so many pop culture fads that it is impossible to keep up. Physicians and other outpatient health providers already have to manage the changes in their respective fields, but adding in the world of nutrition makes an already time-pressed existence even more hectic and inefficient. With such challenges and barriers, how can the healthcare team begin to impact the billion dollar problem of our country’s obesity epidemic? It starts with using appropriate resources, every day, and with every medically appropriate patient. 

 Photo by Trang Doan from Pexels

Photo by Trang Doan from Pexels

Working as a dietitian for 10 years in various health care settings has provided me with opportunity to experience the power of a team-based approach. I have seen where the synergy of physicians, dietitians, nurses, physician assistants, health coaches, physical therapists, personal trainers, pharmacists, and licensed clinical social workers working together can yield much success when treating obesity, diabetes, and other nutritionally-focused chronic diseases. Obesity and diabetes lead as one of the most costly issues in our healthcare landscape and 75 percent of the United States population is categorized as overweight or obese. Addressing this issue head on should be a priority in any primary care practice. 

Regularly making referrals to dietitians for overweight or obese patients is only the first step toward addressing the problem of obesity. The need for multidisciplinary metabolic centers is much needed. While these centers exist in some parts of our country, comprehensive obesity care centers are lacking in the areas of the country that need it the most such as Louisiana and Mississippi.

As I experience what it is like to be a medical student, I see how little nutrition education is given in preclinical years to future physicians. While there are progressive schools that offer more nutritional education for their medical students, the vast majority of healthcare schools just do not have enough room in the curriculum to train their students as dietitians as well. They should not need to. The resources are out there and we just have to know how to use them. 

The first step is to reach out to the state and local dietetic associations to see what resources are available for dietitians interested in working in obesity. Visiting local chapter meetings to network with dietitians is also a way to build resources. Speaking from experience, physicians do not often reach out to find dietitians are not receptive or available to have the much needed discussions. These lines of communication must be initiated by healthcare leaders, because it is the leaders who are shaping the healthcare landscape. 

After seeking out qualified dietitians who are willing to design customized weight loss programs for patients, there should be support staff and health coaches to handle the weekly follow ups. After working with bariatric patients for 4 years and owning my own weight loss clinic, I have seen the best success in treating obesity comes with establishing non-judgmental rapport with patients and offering frequent follow ups to help patients stay on track. This does not have to be with a dietitian or a physician; a certified health coach is often all that is needed to remind patients of their goals for success.

For any healthcare professional, learning advanced motivational interviewing techniques and using them daily is the best approach to helping noncompliant patients. Simply referring out is not enough. The healthcare system must have open communication with all parties involved in the treatment of obese patients to ensure accountability and progress. These simple strategies are just the beginning of what needs to be done to effectively treat obesity, and are strategies that can begin to be implemented today. 

 Rebecca Markway Lee, RDN, CSOWM, LDN

Rebecca Markway Lee, RDN, CSOWM, LDN

 

Rebecca Markway Lee, RDN, CSOWM, LDN completed her dietetic internship at North Oaks Health System in Hammond, LA, and obtained her registration and license as a RDN, LDN in 2008. She became a Board Certified Specialist in Obesity and Weight Management by the Commission on Dietetic Registration (CDR) and received a Certificate of Training in Adult Weight Management in 2010, as well a Certificate of Training in Childhood and Adolescent Weight Management in 2017. Rebecca worked for East Jefferson General Hospital in the inpatient clinical and outpatient settings, including the EJGH Wellness Center and Corporate Wellness Department. In 2012, she began working with the bariatric population and Ideal Protein Weight Loss Method at Northlake Surgical Associates. She opened her private practice, True Body Nutrition LLC in 2016. With her business partner, Katherine Bridges, she then opened a business geared toward providing childhood obesity prevention programs to preschools, True Body Kids LLC. Rebecca is current a second year medical student at William Carey University College of Osteopathic Medicine, where she is currently enrolled as a second year medical student. Just this year, Rebecca received approval to undergo a longitudinal research study aimed at discovering interventions to prevent the rise of obesity.

Don't Leave Depression To The Psychiatrists

The depression epidemic is a pervasive health crisis that has yet to receive the full attention it deserves. Healthcare professionals can take measures during the patients’ earlier stages of depression that can help provide a more effective form of diagnosis and care. Patient treatment of depression is usually only initiated after a particularly troublesome episode such as an instance of self-harm or attempted suicide. This is also the very worst stage of depression, and we can do better to start treatment earlier. By the time the patient has attempted self-harm, it might already be too late. Therefore, effective treatment of depression relies on a consistent method of early detection in patients who are prone to depression.


Traditional screening for depression involves the use of two standardized questionnaires: PHQ-2 and PHQ-9. It might seem that questionnaires are a convenient and timely way to screen for depression; after all, a questionnaire can be filled out with a pen and paper and doesn't require a physician to administer. However, here is where a breakdown between healthcare provider and patient occurs. From a diagnostic standpoint, many signs which might indicate a patient in need of help are taken away when the questionnaire is the main method of screening. For one, the physician does not see the patient face-to-face when the patient is answering these questions. This could lead to the physician missing many non-verbal cues or mannerisms exhibited by the patient that might be indicative of an imminent depressive crisis. Furthermore, patients might be more inclined to open up to a physician if he/she knows that the doctor is actively listening and paying attention to the patient’s answers. In other words, including depression screening in the medical interview would lead to more successful and effective screenings of mental health inadequacies.

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“… own ignorance and the negative stigma I had associated with depression delayed my diagnosis for years…”


Many students in high school, college, undergraduate education, post-baccalaureate studies, professional school, and residents experience a common onset of depression. My personal experience with depression is not representative of every patient’s struggle; each patient deals with depression in his or her own way, hopefully with the aid of a healthcare professional who is trained to handle such cases. However, I do think that my case could have been managed better on multiple fronts.


My experience with depression started long before my diagnosis, which seems to be the case more often than not in patients today. After all, one of the screening criteria is a formal suicide plan or attempt. This poses a problem in that many patients between the area of mental wellness and depression are missed, just because they haven’t experienced or are afraid to admit that they have suicidal ideations.


As for me, every doctor visit consisted staring at the floor, waiting for the history and physical exam to be finished. When asked questions designed to screen for positive depression, I would generally mumble the answers I thought were unremarkable without much thought to the questions. Furthermore, it was always either a paper questionnaire I ended up filling out or a tech conducting the interview without an upwards glance towards the patient as he or she filled in the answers for the doctor to glance at. I am quite confident that any competent health care professional, if told to specifically look for signs of depression, would have noticed something off in my wellness during any number of doctor visits I had during my college education. During that time, I remember being morose, stressed, lethargic, unmotivated, and complaining of sleeplessness. However, my own ignorance and the negative stigma I had associated with depression delayed my diagnosis for years. These years could have been spent as time taken for understanding my illness as well as possible therapy. I wish a single healthcare worker I interacted with would speak up. 


Depression is a huge problem in that it is more common than the average practitioners believes. Screening procedures are designed for time-based efficiency rather than efficacy. As a healthcare worker, we all know this, but we push off our responsibility to others. 


“Maybe a psychiatrist could deal with this better.” 
“Maybe the attending physician will say something.”
“Maybe they are just having a bad day.”
Maybe it is time to listen to our patients. 

 Anthony Silvestre, MS-2, Ross University School of Medicine

Anthony Silvestre, MS-2, Ross University School of Medicine