ACP Internist Blog

Monday, September 16, 2019

Joining a clinical trial helps others



Here's what an investigator might say to a patient: “I thought you would be interested in a new clinical trial testing a new medicine for your disease. Preliminary data show promising results.”

If you were a patient, wouldn't you infer that the drug might help you?


Clinical trials are not designed to benefit the participants. They are performed to generate new knowledge that may help future patients. This is the key point that so many study participants are not fully aware of, and they should be. The investigators do not know important data about safety, efficacy and dosing. These are among the fundamental data that the study and future studies will determine. If medical investigators knew that the drug actually worked, then there would be no need for a clinical trial. There's a reason behind the term experimental treatment.


Thursday, September 12, 2019

For those who want socialized health care, be careful what you wish for

Admittedly, my views on funding health care have done a 180 since I left medical school. I grew up and went to university in the United Kingdom, which famously has one of the most heavily centralized socialized systems anywhere in the world. Born out of the ruins of World War II, the core concept of the National Health Service (NHS) is to provide equitable care to the entire population which is free at the point of use. It's a wonderful and noble concept. Most people who grow up in the UK see health care as a fundamental right and view any notion of making a profit out of illness, as not only strangely foreign, but also to be honest, a bit sick.

Fast forward to coming to America to do residency training, and there were a lot of things I had to get used to seeing and hearing about for the first time. Uninsured patients who were struggling with getting any follow-up, elderly patients cutting pills in half because they couldn't afford them, and heartbreaking stories of medical bankruptcy. Yet the UK is not without its share of concerning stories too—such as excessive waits, significant rationing, and hospital patients lined up in multi-bed and multi-sex wards. Talk to most people over there, and they won't always give you particularly glowing accounts of their NHS experiences (the private sector over there is extremely small compared to almost all other Western countries). However, no patient will ever say they can't afford their treatment or fail to get any urgent care they need.

From the physician perspective, it's no secret there's a job dissatisfaction and burnout crisis that's escalated in the U.S. over the last 20 years. Large numbers of practicing physicians are not happy. As for the UK, speaking as someone who still has friends and former colleagues in the NHS, I honestly believe that staff morale is actually far worse over there—for a number of reasons including the government having total control over working conditions and the NHS being the sole employer for almost all doctors (it would be like all doctors in America receiving a direct deposit each month from Medicare for their entire salary). In America, if a doctor (or any health care professional) isn't happy with one particular organization, they can quit and go to a neighboring facility— which could be completely different and give them a better deal. That option doesn't really exist for British doctors working in a monolithic system.

My own opinion is that the ideal health care system rests somewhere between the two extremes of private insurance-based coverage and an entirely government-controlled system. The U.S. health care system is fraught with issues and so is the UK. In my final year of medical school I worked in Australia, which came as close as I've seen to having an ideal middle-of-the-road system, with solid public health care for those who need it, running parallel to an insurance-based system, with tax incentives for those who buy their own coverage. But with the current political debate, I would implore those in America who are blankly advocating for “centrally socialized medicine eliminating private insurance” to be very careful what they wish for. I don't think it would work for either patients, physicians, or the country.

Wednesday, September 4, 2019

'Am I the only thing standing between you and the weekend?'

I was recently working in clinic on a Friday afternoon. I was on my last patient of the day, and it had been a particularly long clinic. I had big plans for the weekend and should have already finished. The gentleman entered the room, sat down, and we began the consultation. Because I was so behind, I went through everything a little quicker than I usually would, but still covering everything required. He answered all my questions and told me what he needed to. His problems did not seem overly serious and he was otherwise quite healthy.

We got to the examination and I led him to sit over on the exam table. As I turned around to wash my hands, he said to me: “So Dr. Dhand, am I the only thing standing between you and the weekend?!” He said this in a somewhat jovial and friendly tone, definitely not in a derogatory way. However, he was an intelligent man and must have known he was my last patient of the day. As he asked me that, it made me stop in my tracks and wonder whether he had sensed that I was rushing through things to get him out of the room as soon as possible (which to be honest, I knew I was a little bit). I answered something along the lines of: “Oh, ha, yes my weekend is going to begin very soon!”

Anyway, him saying that really made me think that I was perhaps dropping my professional guard in how I was handling him. After all, he had been waiting for a very long time to see me and it wasn't this patient's fault that he had fallen last thing on a Friday. I decided that I would take a couple of deep breaths, slow down, and give him the full attention he deserved (and that I had given my first patient of the day). I deliberately went through the rest of the examination very slowly and then sat down with him again and made a conscious effort to address all concerns and answer any questions. I ended up spending a significantly extra amount of time with him, actually more than I usually would! Who cares if my weekend started 20 minutes later?

That interaction made me reflect on a couple of things. All doctors, including myself, are human. We need to get the job done and have lives outside of work. Me just as much as anyone else. Ask any physician, and they will tell you that the practice of medicine is full of moments like the above. Where we know we can do better, take just a little bit extra time, and give someone a few minutes more attention. It's so important to keep on remembering that every patient is unique and deserves our fullest consideration and very best care.

Most doctors already hold themselves to very high professional standards (and sometimes that can be our downfall). We want to do well and have strong ethical and professional standards. So much is expected of us. Every interaction and all our words (not just with patients, but other staff around us) carry immense weight—even though we may not always realize it. I'm sure no doctor ever wants their patient to palpably feel like they are in a hurry or their mind is somewhere else. And yes, maintaining that level of engagement and performance often involves personal sacrifices. In our unpredictable field there's really no way around that. No matter what hospital, clinic, health care system, or even country, we are in. You may be tired, hungry, worn down, or ready for a big weekend—but can never let your patients know it.

Tuesday, September 3, 2019

The danger of assuming

Recently I have spent much time listening to linguistic podcasts. They have triggered many thoughts about how we take histories from patients. Linguistics represents a very complex science of language.

One concept that has intrigued me involves the meaning of words. When we hear words or read words, we automatically assign a meaning to those words. Too often, especially when we are students and residents, we make assumptions about meaning. However, with experience we learn that words mean different things to different persons.

Experience teaches us that certain words have different meanings amongst patients. Thus, we have to practice our questioning skills to determine the story with precision. Some examples that come to mind include: diarrhea, pain, weakness, shortness of breath and dizziness. Patients often use these words to describe their symptoms, but further questions reveal a wide variance in their meaning of the words.

For example, when a patient claims diarrhea, we should not start ordering tests without further characterizing the symptoms.

Learn to not make assumptions from the words patients use without spending the time to further specify the symptoms. Assuming definitions without clarification will often lead to over-testing or misdiagnoses. While it takes precious time, we have a responsibility to understand what is bothering the patient. We should not assume that we know just from single word complaints.
