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Tuesday, June 17, 2014

Doctor Who?

I'll be the first to admit it - doctors are terrible at introductions.  If you go to any major hospital that trains young doctors or works with a medical school, known as a "teaching hospital," you will likely be taken care of by a boatload of twenty-somethings who all look very similar and introduce themselves once and assume you will instantly remember their names and jobs.  

Please do not feel bad asking someone to introduce themselves again or simply saying, "Remind me who you are again?"  or "What was your name again?"  Believe me, I do this every day with nurses, other doctors I don't work with often, as well as patients and their families.  The hospital is a much safer place when you know who your team is!  

If you are in the hospital and on a "teaching service" you are being taken care of by young doctors in training and medical students.  Here's a breakdown of your very large team:

Intern - this is the title given to a doctor (MD or DO), who just graduated from medical school and is in her first year of training (called residency).  Often, this is your primary doctor in the hospital.  This is usually the doctor talking to you and about you the most and who also knows many intimate details like if you had a fever overnight and how many times you peed.  This person also comes to your room very early in the morning and examines you, and hopefully talks to you.  The intern also changes your medications and orders tests for you in the computer system.  
NOTE: intern is easily confused with internist - who is a doctor for adults.  They are usually not the same thing, unless you are in a hospital for adults and being taken care of by a first-year doctor.  

Resident - A resident is any doctor in a training program; so an intern is a resident.  However, this title is usually given to a doctor who has finished his first year of training and is now helping the intern out or working on a team with other 2nd and 3rd year doctors-in-training taking care of sicker patients.  
NOTE: Senior Resident - This is the doctor who usually comes to see you if your intern is worried about you and is also there when the big team comes to see you in the morning.  This person is responsible for knowing the major details and plan for all the patients the team takes care of (which can be over 10 people) so this doctor does NOT know all the little details about you and needs to work with the intern and nurse (and may ask you questions you already told your intern) to help with your care.  This doctor usually has more experience with patients who are very sick than the intern.

Fellow - A fellow is a doctor who has finished her general training and could take care of adults or children in the community, but has decided to focus on a specific disease (like kidney disease or cancer) and is doing some extra training.  This person has completed his residency and has at least 3 years of doctor training already.  Most fellows you will see in the hospital are in their fourth year of training (unless it is a surgeon) and that is usually the first and only year she will be in the hospital.  A fellow usually spends the other 2 years doing research or a project and is not often in the hospital.  This person, like the supervising resident, knows a lot of the big picture and some important details about you, but still not the same details as your intern.  

Attending physician - sometimes just called "the attending" this is the doctor who has completed his training and is in charge of the team.  On a general team, this person has at least 3 years of experience (and may still look pretty young), on a more specialized team (like the liver team), this person has at least 6 years of training (and again, may look young).  This person has a lot of experience, but manages the whole team, and needs to work with the doctors in training to help take care of you.  

Medical students - medical students are people in school to become doctors.  Most of the students you see in the hospital are in their 3rd and 4th years of school and deciding what kind of doctor they want to be.  This person should always introduce herself as a "medical student" or "student doctor".  Written out, this person may have MS3 or MS4 behind his name, instead of MD or DO.  The medical student may see you and talk about you to the doctors on the team, but cannot order medicines or tests.  The medical student is always working with an intern or resident to learn how to care for you.  This person also has the most time to spend with you and does a great job presenting lots of details about you.  

Consultant - A consultant doctor is usually with extra training is a specific body part (like a infectious disease doctor), who does not run her own team.  She gives your doctor team advice, usually about a specific question (like which antibiotics are best for you) - often a fellow is part of a consultant service.  This may also be a surgeon or interventional radiologist, who will do a procedure that your regular team does not do.  This doctor usually makes suggestions to you team, but does not order tests or medicines for you.  

There are lots of other wonderful people who are part of your care team including your nurse, maybe a respiratory therapist, social worker, or chaplain.  They are very important and hopefully working well with your doctor team.  Sometimes its hard to remember who is who - so don't hesitate to ask!

Monday, June 16, 2014

Informed Consent - The Treachery of Images

Rene Magritte's painting, "This is not a pipe"
Some things are not what they seem.  Take one of my favorite paintings for example.  If I asked you what you see, most people would say a pipe.  But, written in French underneath, it states, "This is not a pipe."  Well then, what is it?  It is just an image, a picture of a pipe - you can't actually use this pipe!

Why the art history lesson?  Because it is the best way I can explain to you what is and is NOT informed consent in medicine.  Most people, when they think of informed consent, think of a piece of paper they are asked to sign shortly before some  procedure or event occurs.  Its usually a highly scientific paper with tiny print that most people don't even read before signing.  Just like the image of the pipe, it looks like something useful and meaningful, but in reality its not, it's just a piece of paper.


Informed Consent is the meaningful discussion of the good and bad things that could happen to you if you agree to what your doctor is asking you to do or offering to do for you.

As a patient, you need to insist on this conversation - it is your body, and you will live with the outcome of whatever happens.  So, how do you have this conversation with your doctor?  Here are some tips:

1) Start off by asking who will do the procedure - are you actually talking to the person who will be doing or assisting in the procedure?  Does this person know enough about the procedure to answer all your questions?

2) Ask why this procedure is necessary and what all your other options are.  What happens if you choose to do nothing?  What other types of surgery or procedures are similar to the one being offered and why is your doctor recommending this one?

3) Do not be afraid to get a second opinion.  Medicine changes quickly and there is also a big difference in how surgeons or other doctors who do procedures learn what they do.  If something doesn't feel right, ask for an opinion from one of their colleagues or a different group.  A doctor who gets upset and angry at this request is NOT someone you want to work with.

4) Ask for time.  If a situation is truly a life-threatening emergency, a doctor technically does not need to tell you the risks and benefits because she assumes you want everything done to save your life.  You're in pretty bad shape and usually not with it at this point.  If that is not your situation, you have time.  It may mean rescheduling your surgery, it might mean making someone cranky, but at the end of the day, you need to feel ready for this.

5) Think of whatever procedure you're having as an investment in yourself.  You want to feel good about this and know this will help you somehow.  It might mean less pain, a longer life, getting around easier - decide what it means for you to get this done!  Now also think of ALL the bad things that could happen - not just death, but infections, pain, not being able to eat, drink, go to the bathroom, talk, walk by yourself, and anything else that matters to you.  Find out how often these occur and then decide.  Ask your family and friends for their opinions too - but ultimately, its your decision and your body!

Friday, June 13, 2014

What is a hospital docent?

Docent - (noun) a person who serve as a guide and educator for the institution she serves, usually on a voluntary basis.  

My mother is an amazing person.  As a breast cancer survivor, she has had many encounters with the medical system and would often call me in frustration, saying, "I never know what's going on!"  I imagine many of you are, or know someone, in the same boat.  

I am a pediatrician and mother.  I work at a major children's hospital and I will be your tour guide.  Thought I cannot give you specific advice, I am here to make the process of working with your health care team easier, safer, and patient-centered.