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

 

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