Friday, December 21, 2012

Patient Education: It Can Make All The Difference

I volunteered this week at the free clinic where I am a Spanish medical interpreter. I was reminded of a very important lesson: the need for patient education.

As I have mentioned previously, I am very interested in endocrinology and diabetes (both the research and clinical aspects). The Latino population in general is at a higher-than-average risk for diabetes, so a large proportion of the patients with whom I work have this disease.

A diabetic patient came in with high daily blood sugars as well as a high HbA1c (the test that monitors blood glucose over a 3-month period). The physician who patient saw was somewhat frustrated at the fact that his diabetes was uncontrolled, because the patient was on a high dose of NPH insulin.

So the doctor probed the patient. Did he ever skip doses of his meds (including the insulin)? Was he taking his insulin twice a day as prescribed, X units in the morning and Y units in the evening?

Turns out that the answer to the second question was "no." And not because the patient was trying to be noncompliant. He was taking all (X +Y) units of insulin once a day, because he had previously been on Lantus. He didn't understand that Lantus is a long-acting insulin, which means you can take it only once a day, while NPH is intermediate acting, which means you have to take it twice a day to appropriately control your sugar. (The reason he had been switched from Lantus to NPH was that the clinic pharmacy had run out of Lantus, an unfortunate occurrence which sometimes happens given that all the medications at this free clinic are donated.)

When the doctor explained this clearly, it was like a light bulb went off for the patient. He said he just didn't know, and thought that it was OK to keep taking the insulin the same way he had been taking it before. He agreed to make the change right away.

It is true that sometimes patients are just noncompliant, and that leads to uncontrolled conditions. But other times, they simply don't understand the (often very complicated) instructions they receive. Language and education barriers make this all the more difficult. And so it is the responsibility of the physician to make sure the patient does understand, so that he/she has the tools to control the disease, whatever it might be. A good lesson to remember as I make my way toward a career in medicine.

Sunday, December 16, 2012

Death In The Line of Duty: The Ultimate Sacrifice

The Friday, Dec. 14 shooting at Sandy Hook Elementary School has citizens across the United States, and the globe, mourning. And thinking. In part, about ways (such as more stringent gun control) to try and prevent such tragedies. It has the Newtown, Conn. town thinking about how to move forward amid the grief and shock. According to a Chicago Tribune article I read this morning, people across the town are taking down Christmas decorations, saying that celebrating a festive holiday during a time like this is unthinkable.

This tragedy, a massacre of 20 young students and 6 school staff members, got one of my friends, who is an education major, thinking about something else. Something more personal. I spoke with her yesterday on the phone, and the shooting came up (as I know it has among so many conversations in the last couple of days). She just finished a semester of class observation at a local middle school. Over the course of the past semester, she has told me multiple times how much the students meant to her, how much - even though they were not her own students - she cared for them and appreciated them. And yesterday, she told me all she wanted to do was go to the school and give each and every one of them a big hug, even though they would likely not understand why. She had thought long and hard about what it would mean to lose a student, and how that would affect her. And she could not even imagine what those community members, including those teachers, are going through right now.

But she also got to thinking about the school staff who literally gave their lives for their students. In that same Chicago Tribune article, I read about principal Dawn Hochsprung, in an attempt to overtake the gunman, paid with her life. And about 27-year-old teacher Victoria Soto, who tried to use her body as a human shield to protect her first-grade students, was also killed. One of Soto's friends, Andrea Crowell, was quoted in that Chicago Tribune story as saying: "She put those children first. That's all she ever talked about. She wanted to do her best for them, to teach them something new every day." That day, Soto taught her students about the ultimate sacrifice: death in the line of duty.

Which got my friend thinking: Would she, as a teacher, be willing to die for her students in the same way Hochspring and Soto did? Would she feel OK about giving her life in exchange for her students' lives? "And I decided that yes, I would," she told me. I felt shivers go down my back, and tears well up in my eyes. I told her that this was a profound moment for her. Then she told me that she had begun thinking of herself more as a teacher than as a college student. This realization, I told her, was evidence of that newfound association.

And in the course of that conversation, my dear friend got me thinking (as good friends do). Would I, as a physician, be willing to give my life for my patients' lives?

Granted, there are very few instances where teachers, or doctors, are called to do that. But I believe that  it is something that people who enter service professions such as medicine and education need to consider. As a teacher, you put your students first. As a physician, you put your patients first. Above yourself. Always.

People don't normally think of medicine as a "risky" or "dangerous" profession. They often think of it as a posh one, at least financially. But there are risks involved. When a you makes a treatment decision, for example, you risk angering a patient (or a relative) and having them come after you. While I didn't find a lot of examples of this on the Internet, I did find a few:
- 2007: a Chicago dermatologist was allegedly killed by a patient who (according the Daily Mail article I read) thought the acne medication he was given made him impotent
- 2009: a Las Vegas internal medicine physician was allegedly killed by a patient, possibly because he was in intense pain from prostate cancer and might have blamed the doctor (according to the Asian Journal article I read)
- 2009: a Kentucky physician was allegedly killed by a man whose motive may have been that the doctor denied him narcotics after the patient refused to give a urine sample (according to the Associated Press article I read)

Another risk to physicians is that of contracting a contagious disease during the course of treatment. In an American College of Physicians article posted on the AMA Web site, called "The Physician and the Patient," there is a section on the "Medical risk to physician and patient." The article clearly states that doctors must put their own health second to that of their patients', and that refusing treatment to patients with potentially dangerous conditions is out of the question, ethically. Here is what the article had to say on the subject:

"Traditionally, the ethical imperative for physicians to provide care has overridden the risk to the treating physician, even during epidemics. In recent decades, with better control of such risks, physicians have practiced medicine in the absence of risk as a prominent concern. However, potential occupational exposures such as HIV, multidrug-resistant tuberculosis, and viral hepatitis necessitate reaffirmation of the ethical imperative ... Because the diseases mentioned above may be transmitted from patient to physician and because they pose significant risks to physicians' health and are difficult to treat or cure, some physicians may be tempted to avoid the care of infected patients. Physicians and health care organizations are obligated to provide competent and humane care to all patients, regardless of their disease state. Physicians can and should expect their workplace to provide appropriate means to limit occupational exposure through rigorous application of infection control methods. The denial of appropriate care to a class of patients for any reason is unethical."

Whether a teacher, physician, police officer, firefighter, or other service professional will, indeed, give up their life in an emergency situation may be difficult to predict until the situation presents itself. But it is definitely something to consider.

For myself, and for those of my readers wanting to practice medicine someday, let us ask ourselves: What would we risk for our patients?