Mea sententia...

Trust but verify

Trust but verify (Doveryai no Proveryai) is a Russian proverb that underlies an important principle in medicine. We need to trust our patients, our tests and our knowledge - but must also always remember to check and verify.

The panic attack

One has to ask the right question in order to get the answer.

The chief complaint on the encounter form said ‘panic attack’ and a quick review of the chart before I entered the room showed a healthy 28 year old woman with no health or emotional issues who came in every year for a routine birth control visit. She told me she had had a ‘panic attack’ the day before and was sure there was nothing serious wrong, but came in at the insistence of a colleague. “It’s probably a waste of time, but Seeley made me promise to come.”

The delusional pursuit of metrics

Two points:

  1. Measuring something is not the same as improving it. 
  2. Improving something requires thinking of quality as a process rather than a product.

Before we think about how these two principles apply to medicine, let’s consider two approaches to coaching basketball: one using incentives tied to outcome metrics, and one using interventions designed to identify and address process problems.

Things are seldom what they seem

W.S. Gilbert might have been writing about patients when he penned this lyric:

Things are seldom what they seem; 
Skim milk masquerades as cream.

What I learned from a garbage can

My parents never yelled, let alone spanked. We always understood what was expected of us and feared failure rather than punishment. They expressed disappointment far more often than they showed anger. They often asked us to devise our own punishments. And, perhaps above all, they were masters of the object lesson.

Sampling error

I recently received an email from my employer, with a link and a request to fill out a short survey evaluating a new service available to our patients. I had a brief gap between patients, so I clicked and did the six questions. As I hit submit, it occurred to me that the survey seemed familiar. Hmmm. Looking back in my older emails, I found that I had received a similar request from the same group about 2 weeks earlier, with the same link. I contacted the person who had sent the second email.

Insomnia snark

It was about 2:30 am when the phone rang, waking me from the deepest and best part of sleep. It was the answering service, and they patched my patient through.  

Me: (Still groggy, trying to wake up.) “Dr Elias here, on call for Family Health. What’s the problem and how can I help?”

Female voice: “I can’t sleep.”

pause…

On listening to the patient

Osler, often referred to as the Father of Modern Medicine famously said: "If you listen carefully to the patient, they will tell you the diagnosis.” He emphasized both the value of a careful history in medical diagnosis and the value of learning from one’s patients. Ask any practicing clinician and they will have anecdotes that illustrate how right he was. One stands out for me.

Put on your shoes

It was January and there were several inches of fresh snow on the ground and no shoveled path to the car. The temperature in the teens. I had an errand to run with a child who INSISTED on going barefoot.  The following brief conversation between a seriously sleep deprived post-call parent and an articulate three year old. 

“Do you want to put your shoes on yourself, or do you want help?”

"I don't NEED to wear shoes. My feet aren't cold."

"They will be. It's cold out."

"My feet aren't cold."

"Put your shoes on."

"No."

"Fine."

Surrogate markers

A recent conversation about an institution’s use of the A1c (a measurement of average blood glucose levels over the preceding 100 days) to grade clinician performance and adjust compensation frustrated me. The issue was the misunderstanding and misuse of surrogate markers, those things we measure when we can’t measure what we really want to know.

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