The Big D Awards! (Friday Links)

So last post Doctor D examined the ways The Man is always trying to hold us decent bloggers down. With all the great blogs by medical students and nurses they got no love from The Man over at Medgadget.

With all the thankless hard work med students and nurses do the least we could do is recognize their blogs! So Doctor D decided to stick it to The Man, and declare his own Medblog Awards!

So one lucky Nurse Blogger and Med Student Blogger shall be declared "the most awesomest medblog in existence" and receive the coveted Big D Award:

The Big D Award

The nominees for The Big D in NurseBlogging:

• Call Bells Make Me Nervous
  
• New Nurse Insanity, Fundus Chop!
  
• Life In The ER
• Nurse Me
  
• At Your Cervix
  
• Those Emergency Blues
  
• Weird Nursing Tales
  

The nominees for The Big D in Med Student Blogging:

• Journey To MD
  
• Indifferential Diagnosis
  
• Asystole Is The Most Stable Rhythm
  
• Old MD Girl
• Doc 2 Be
  
• The Life & Times of J. O. Morris
• Med Student 101
• Medically Mind Numbing
• The Dragonfly Initiative

Enjoy discovering the odd worlds of nursing and medical school! Bloggers, rally your readers and send them to vote you to victory!

The winner in each category gets the honor of a Big D Award and a free Supratentorial Mug direct from Doctor D.

Doctor D nominated the good nurse and med student blogs he knows, but the blogsphere is a big place there are probably other frickin' awesome nurse and med student bloggers out there. Nominate your favorite nurse or med student blog that Doctor D missed in the nominees. Shameless self-promotion is allowed! (as long as it isn't spam)

D's favorite new blog will get a link, and the reader who nominated it will also get a Supratentorial Mug!

The winners will be announced next Friday. Have Fun!

It Was Fun While It Lasted

Today is a sad day here at AskAnMD.

Doctor D was really excited about this new blog getting nominated for "Best Medical Weblog of 2009." Doctor D was doing his victory dance and playing "Eye of the Tiger" so loud the neighbors complained because he was totally gonna win that sucka.

Alas The Man over at Medgadget didn't think Doctor D's blog should be in the finals, thus all the AskAnMD fans that couldn't wait to vote it to victory were disenfranchised. Doctor D suspects The Man is dabbling in politics again since a lot of the finalist blogs in this category look like they were written by corporations or medical schools and are about as interesting as watching paint dry.

But never fear! The Man didn't totally succeed in exterminating personality in medblogging. Our dear friend Doctor Rob from Distractable Mind slipped into the finals!

So mosey on over there and vote for Dr. Rob early and often!

Is Doctor D encouraging you to vote more than once? Naw, you must have misunderstood that.

While you are over there be sure to support the beautiful work being done by WordDoc at Medical Moments in 55 Words for Best Literary Medical Weblog.

The real competition this year comes in Best Patient's Blog. Three of Doctor D's total favorites made the list: Queen of Optimism, ∞ itis, and RheumaBlog. Doctor D is so torn, because all those blogs are excellent! I might just have to vote for all of them.

Would Doctor D vote more than once? Of course not! You guys are totally misunderstanding me.

Have fun voting!

By the way, did you notice that Medgadged totally ignored medblogging nurses? WTF? Why is The Man always trying to hold the RNs down? Medical students too!

That's it! Doctor D has to set this right:

Tune in to this week's Friday Links to Vote for Doctor D's totally unofficial NurseBlog of the Year and MedStudentBlog of the Year awards!

Feel free to say sweet and comforting things in the comments to console Doctor D in his time of sorrow. Or you can just tell him to get over it and be a man, because its just some stupid contest and he isn't 8 years old!

Mystery Diseases (Diagnosing the Undiagnosable)

Lots of emails to Doctor D ask:

Why hasn't anyone figured out what's wrong with me?

This a common sentiment of patients whose doctors have yet to find a reason why they feel miserable. Patients with mystery symptoms tend to get lots of tests and shuffled to lots of specialists. More people than you might think are in this limbo of an illness without a diagnosis.

This is frustrating for everyone. Patients get irritated with their doctors: "If I just had a smart doctor like the ones on TV I would have been diagnosed by now." Doctors, who like having answers and hate looking foolish, get frustrated with patients and wonder if the weird symptoms are all in your head. We need to all take a collective deep breath.

We all want uncover the mystery diagnosis, but we have to acknowledge an unfortunate possibility:

We sometimes won't find a diagnosis.

There are diseases that are very common and ones that are very uncommon. It also stands to reason that there are diseases that may be so uncommon as to not yet be discovered. Some diseases may be so uncommon as to affect only one human being, which could be you. If this is the case you could never find a “diagnosis” per say, because a diagnosis groups you with other people with the same disease.

There is a point at which we say, "We've done a thorough work-up and found nothing. You may have to live with this." Doctor D hates saying this as much as any doctor, but at sometimes it needs to be said.

What is a disease?

Literally disease means dis-(without) ease. If you are visiting doctors because you have miserable symptoms you already know your body is without ease. You don’t need a multi-sylable medical term attached to your suffering to know that you suffer.

When doctors diagnose diseases, we look for particular patterns of symptoms and physical findings that are specific to known illnesses. It feels great for everyone when Doctor D can say with confidence, "You have _____."

But naming your disease doesn't cure anything. Having a diagnosis is useful because we can look at research from others who have had the same disease to know what treatments work and how we can expect the illness to progress. The rarer the disease the less other patients we have to get useful info from. We can just name your disease symptoms after you (John Doe Syndrome). It might feel satisfying to give it a name but it really doesn't help us make you feel better.

The Good News About Mystery Illnesses

People with mysterious symptoms get a lot of tests. A competent work-up has likely proven you don't have certain dangerous diseases. Doctor D has yet to see a patient with a mystery illness after a good work-up die. (I'm not saying it never happens, but it is exceedingly rare.)

Why? Even though the number of conditions that can cause discomfort are limitless, the mechanisms that can cause your heart to stop are fewer and generally well-known. Your large work-up has probably excluded most of the mechanisms that lead to premature death. A negative work-up can be a good thing.

Doctor D has often reassured frustrated patients about negative studies, "Trust me, you don't want the disease I was looking for."

The other good news: We don't always need a diagnosis to treat your symptoms.

Treatments do two things: postpone death and/or decrease suffering. A thorough work-up makes impending death unlikely, so we are left with easing the suffering. Doctors often treat symptoms even without knowing the underlying disease process. Whatever helps your symptoms and isn’t dangerous is a good treatment—whether it be Tylenol, or nice sunset, or an off-label use of a medicine.

Shifting Perspective

It can be liberating to realize that finding a diagnosis is not the be all end all. Lots of patients with mysterious symptoms get run through a gauntlet of tests and doctors and often feel pressure to advance to more uncomfortable and even dangerous testing to find an answer. Doctor D has actually found that patients often find it comforting to not to "have to find an answer."

Sifting the aim of care from finding a diagnosis to learning how to treat and live with your symptoms doesn't mean that we've given up. It just acknowledges that the ultimate goal is not diagnosing diseases, but helping you find ease and comfort.

What do you think? Do you have a mystery illness? Are you a doctor who works up patients with mystery illnesses? What do you think about acknowledging not all diseases will be diagnosed? As always Doctor D loves to hear your stories and perspectives.

Click here to read follow up post: What Is A Proper Work-up?

Don't Forget Yet! (Friday Links)

In the comments on the last post Old MD Girl rightly pointed out: It is our job to care.

She's right.

Last week's Friday Links was dedicated to the humanitarian response after the earthquake in Haiti. That disaster awakened the sympathy and generosity of the world, but the news cycle moves on. Each day the updates on Port-au-Prince get shorter and shorter until in a week or two you won't hear any more at all. We might just assume everything is better. The fact is that our neighbor Haiti was a humanitarian disaster even before quake. "Port-au-Prince, on a good day, looks semi-destroyed."

It is our job to care, but we often forget.

So for this week's Friday Links I give you: Doctor John Carroll and his wife Maria.

Doctor Carroll is twice the physician I am. He is an ER doctor in Illinois who has been going to Haiti for 15 years and finding children with life threatening congenital heart conditions that he brings to the US for surgery. Johh and Maria have an organization named Haitian Hearts that it appears they run completely by themselves. They have saved thousands of lives. They were in Haiti before the quake and will be there after.

Doctor D once met John Carroll, long ago when D was a college student. John Carroll sat down with young D and spoke to him about caring for patients. He was the first doctor that D ever met that he wanted to be like. After meeting John Carroll, D went home and signed up for the MCAT.

Well, I'm a doctor now, but unfortunately I'm still nowhere near the kind of person that John Carroll is.

Finding John's blog Dying in Haiti and Maria's blog Live from Haiti has been a breath of fresh air for Doctor D. Sometimes I forget why I chose this profession. My caring gets worn out and jaded. The Carrolls are a constant reminder of medicine at it's best. The Carrolls' stories of their work and their patients are inspiring. John's bravery and his uncompromising stand for his patients just might be infectious.

Seriously, you should subscribe to these blogs. Don't forget those who are suffering, and for those of us that work in healthcare don't forget why we do this.

John Carroll is a real hero for Doctor D. I might not be an MD if it weren't for him. Do any of you other healthcare worker have heroes like this? I would love to hear about them in the comments.

Teaching Empathy (Fit Doctors and Sick Patients)

A reader asks:

My doctors are all very fit. It would seem that being a doctor is so demanding that it requires good health. Can doctors ever really understand what it's like to be ill?

Of course, doctors understand illness! We spend our whole lives studying it! ...but if you mean personal understanding of what it is like to feel your body betraying you, or the dread of approaching death, or the strained relationships created by severe illness—actually, most of us have never been there.

With a few notable exceptions, most people able to dedicate a dozen years of their prime to the punishing ordeal of becoming a doctor have always been pretty healthy in body and mind.

The worst Doctor D ever felt was a moderate case of sinusitis. I have no idea what how it feels to be in daily pain, to be unable to walk, to face death.

The Need For Empathy

So how do doctors, who are rarely sick, relate to ill patients?

Often poorly ...but if we do relate well it is through empathy: the emotional intelligence that allows us to experience the feelings of others. Doctors must learn the true experience of illness from our patients. Doctors may teach patients the science of disease, but in the experience of illness patients are the teachers and doctors are the learners.

Unfortunately, life in the medical business strains one's empathy. The sheer volume of suffering we see can make us numb. There is also the professional objectivity that we fear will be compromised if we care about your pain too much. Empathy may atrophy till a fit physician can diagnose and treat all day long without connecting with a single ill person in a humane, healing way.

Teaching Empathy

You—the patient—must teach the doctor. Empathy is a lesson physicians desperately need to learn. But how can you teach your MD?

The Direct Approach: Speak directly to your doctor about how uncomfortable your symptoms are and how miserable your illness makes your life. Remind your doctor about how horrible it is regularly, just to make sure they don't forget.

Hate to break it to you, but the direct approach doesn't work. In fact, it has the opposite effect. The more someone talks about their suffering the less we identify with it. Yes it's cruel, but it's human nature.

Remember when you were a kid and that elderly relative complained incessantly about their horrible bowels or joints? Chances are your grandmother really was miserable with those symptoms, but how much did you really empathize with her? Not much right? You just wanted her to stop complaining. It's called “compassion fatigue” and it has infected every doctor by about the 2nd year of medical school.

(By the way, I'm not saying you shouldn't tell your doctor your symptoms and how they affect you. Just don't expect compassion as the natural response to your discomfort.)

The Indirect Approach: Tell the doctors your symptoms and cooperate with them to diagnose and manage your disease. Only mention your miserable experience in passing. Instead, ask about how your physician is managing the stress of his or her life. Your doctor likely has a lot of frustrations despite their healthy body. Even if the doctor's problems seem petty compared with yours try to act like you care that it sucks to miss sleep or leave family dinner to care for a patient.

Believe it or not, this is the best way to teach empathy to doctors. The doctor will empathize with you instinctively.

We all naturally focus on our own sorrows and minimize the suffering of others. We awaken to empathy when we see that others care for us.

Doctors are educated in a system that only cares about how much they know and how hard they work. Few of their teachers care how they handle our rigorous training or the suffering they see. Doctors learn that feelings don't matter.

A caring patient's interest in a physician can teach more empathy than watching a whole world of suffering.

Doctor D has been told by patients that he is a caring physician. If so, it isn't because he has ever been ill himself, or any illness he's seen. It was because my first year of residency a patient with a miserable disease actually made an effort to find out about young D and encourage him. With an education like that how could I not want to understand the experience of every patient I met from then on?

What do you think? Is Doctor D too cynical about human nature? Have any patients out there had success with the “indirect approach” for teaching doctors to empathize? Healthcare people: Has a patient ever taught you empathy? Doctor D always loves to hear your thoughts and stories!

Compassion in Emergencies (Friday Links)

I realize that Friday isn't until tomorrow, but some links are too urgent to wait:

As you probably know a massive earthquake recently struck Port-au-Prince, Haiti. The destruction and loss of life was catastrophic. The people are in dire need right now.

What you may not know is that Doctor D decided to become an MD while working in Haiti. As a college student young D volunteered at a hospital in Port-au-Prince. Even though Haitians are some of the poorest people on earth many of them brought me into their homes as a guest and treated me with a kindness I will never forget. Caring for ill Haitians made young D certain that the practice of medicine was the right life for him.

Now many of the homes, buildings, and hospitals in which D was once a guest lie in ruins. Thousands are dead and many survivors are in grave danger from disease and starvation. Doctor D considered going to Haiti to help, but they only currently want doctors and nurses with experience in disaster response.

But what we can all do is give. Many of us are blessed with jobs and resources that give us the ability to share with those in need. Those of us who chose medicine as a career usually did so because of our compassion for our fellow human beings.

Now is a time to put that compassion in action! These are two emergency aid organizations that Doctor D chose to use:

• The Red Cross -Usually the first on the ground with the most experience in responding to disasters.

• World Vision -Does wonderful work getting food, water, and medicine to people in desperate situations. Doctor D chose World Vision because he already sponsors several kids through that organization.
  

I'm sure there are other excellent organizations coming to the aid of Haiti. Give what you are able.

Thank you so much for caring.

Extending Doctors: Physican Assistants and Nurse Practioners

Question from a reader:

How do you feel about PAs and NPs?

So Physician Assistants and Nurse Practitioners are medical providers who are not doctors, but do doctor-like care for patients with basic problems. NPs and PAs are often called "physician extenders" or "mid-level providers." PAs and NPs don't go to medical school—therefore the care they provide has to be supervised by a physician.

How does Doctor D feel about them?

The Good, the Bad, and the Ugly:

Just like doctors, physician extenders are individuals with different styles of care. Similarly, there are good ones and bad ones. Doctor D is in favor of the good ones.

I have met some excellent physician extenders who work wonderfully with both patients and MDs to provide superb care. My own son, Little D, was delivered by a Nurse Midwife who is like a physician extender for obstetric care. It was an uncomplicated pregnancy, and I was totally comfortable with the midwife caring for my wife and son. It was one of the best deliveries I have ever seen.

Bad PAs and NPs can be trouble. Just like doctors, they can fall prey to the God-complex, which can be even more dangerous when arrogance is coupled with less medical education. D once worked with a NP who was doing some bad care. When Doctor D brought it up he said, "Who the hell are you to tell me how to practice!" And D was like, "Well actually, I'm the doctor assigned to supervise you, dude. It's kind of my job to tell you how to practice."

Just like bad doctors, bad physician extenders are the minority, but they can give all the good ones a bad name. Generally speaking, PAs and NPs are an important part of the healthcare system. Mid-level schooling is shorter which allows excellent people who just don't have the time for medical school to become medical providers.

NPs and PAs in Primary Care:

One place that you will see a lot of mid-level providers is in Primary Care. Since Primary Care is high stress with less pay a lot of medical students just aren't choosing that field. PAs and NPs are helping fill the gaps.

Something that concerns Doctor D is the idea being forwarded by some that all Primary Care can be done solely by physician extenders. The theory is mostly forwarded by politicians eager to save money and Specialist MDs who have no idea how complex Primary Care medicine can be. While there is need for PAs and NPs in Primary Care, physicians must remain intimately involved in this essential part of healthcare.

The Importance of Teamwork:

Patients who see a PA or NP are usually in good hands, but you should be aware that you are being cared for by a team.

Your mid-level provider is working with a physician even if you don't directly see that physician. This team approach has some obvious strengths: you get two providers involved in your care. Two minds can be better than one at spotting problems or unusual diagnoses. You always have the physician as a back-up if the mid-level provider feels your situation needs more advanced attention.

Of course, the flip side of this is that if either the MD or the mid-level are bad, irresponsible, or just don't communicate well your chance of problems increases significantly. Sometimes a really good mid-level provider is stuck with a bad physician. You may not even know you have a bad doctor on your team who is detrimental to your health.

If you are seeing a PA or NP you should understand how the system works, and particularly know about their relationship with the physician that supervises them. If your mid-level provider appears to be competent and has a good working relationship with mutual respect with their physician you can usually rest assured that your care will be done well.

So what do you think? Do you see an NP or a PA? What is your experience with mid-level providers? Any PAs or NPs out there who can tell us more? As always, Doctor D loves to hear your thoughts.

The Medical Life (Friday Links)

The blogs of health workers can be a fascinating peak into the minds and motivations of those of us in medical life. I enjoy the funny or amazing true stories on blogs as much as the next guy, but what's really interesting to me are the lives of people who choose to work with sickness and suffering every day.

Judging by the number of TV shows on us it appears that the public at large is fascinated with medical students, nurses, and doctors too. Truth be told, we aren't as good looking, dramatic, or perfect as our TV counterparts. We are normal people, but personally I prefer real people over stock characters with stethoscopes.

One of my favorite nurse bloggers, Maha, used the turn of the decade to tell the fascinating and personal story of her life over the last 10 years. Her personal growth during her journey to become an ER nurse is very interesting reading. Behind the sharp wit and toughness there is a humanity and sensitivity that makes her blog one of the best out there.

I found another glimpse into the personal motivations for a medical life over at Asystole Is The Most Stable Rhythm. Besides having the coolest blog name ever AlbinoBlackBear has some great stories. Her encounter with a dying child years ago as a nurse left her wondering if healthcare was a good choice for her. The answer was yes and now she is in medical school. Asystole is a wonderful med student blog and I can't believe it took me this long to find it.

So what leads people to choose a medical life?

Ella the med student and Old Girl both followed Maha's lead and posted their own biographies of 2000 to 2010. Doctor D shall follow in the footsteps of these great bloggers and give you a brief picture of how he has transformed over the last decade:

At the dawn of 2000 young D was a college senior applying for medical school. He was a bold, iconoclastic idealist who was certain he would save the world. Young D wore a long beard with long hair and was certain that human suffering was a puzzle that could be fixed if people just cared enough to help others. He figured that medicine was the highest and purest calling a person could choose for their life.

Then came reality: years of medical school, followed by years of residency, followed by the ultimate goal—being a "real doctor."

After a decade of ceaseless work I no longer think I am going to save the world. I have saved a few lives, but it was by doing my job not through any heroism. Jesus may save the world, but doctors and nurses certainly won't. We simply do our jobs day in and day out.

In the end, the medical life is a life like any other. It isn't always fun or sexy. We are not so brilliant or so heroic. We are humans who take care of humans, so our work is fraught all those troublesome human complications. Some days we love our vocation and some days we want to quit, but we do our best because we care about our patients.

In 2010 Doctor D is more tired and less idealistic. These days D is more more proud to be Ms. D's husband and Little D's dad than he is about that MD he spent so many years dreaming about.

What do you think? Did you imagine doctor's lives to be more heroic and dramatic? Do you work in healthcare and have a story about your own medical life to share? Doctor D always enjoys the perspectives and stories you tell in the comments.

Pills and Suspicions (Controlled Drugs)

A question Doctor D gets asked a lot:

Why are doctors so stingy with medicines that make me feel better?

Yeah, I have to admit doctors are totally difficult when it comes to certain pain and anxiety medicines. You show up in a doctor's office and request a medicine that has worked for you in the past and suddenly you get read the riot act and treated like a criminal. Weird isn't it?

Doctor D admits that he does this too. It's not because he doesn't care. D went into medicine because he cares. He has just learned to be cautious over the years.

These medicines are very powerful. Some people really do require them when other meds just won't work, but they can also get you high or even make you stop breathing. Every MD has seen these medicines destroy people's lives.

Heath Ledger and Michael Jackson kicked the bucket because of medicines like this, and Doctor D can guess what's probably gonna show up in Brittney Murphy's toxicology report.

But forget about celebrities, these medicines harm regular folks every day. There was the young mother that broke down in Doctor D's office saying she can't make it though a day without buying pills off the street, and the high school freshman that died of an overdose after spending her birthday money on pills to party with her friends. You don't forget patients like those.

It's one thing to see somebody hopelessly addicted to alcohol or die of a cocaine overdose. It is really sad.

But with prescription drugs it's different. I'm the supplier of drugs that are killing local kids and ruining families. You can see why I get nervous about every prescription for a controlled substance I write.

I totally want to help people in pain. Unfortunately that compassion makes me a sucker for manipulative people. I wish that I could believe what every patient says they need, but if I gave everything that was requested of me I would most certainly end up killing someone. Therefore Doctor D uses very conservative prescribing practices to make sure he has obvious medical reasons for every prescription he writes.

This sucks for patients with legitimate needs who use these medicines responsibly. The behavior of the bad apples causes good people with real needs to be treated like criminals.

Sorry! Doctors hate to act like cops, too, but the very serious drug problem puts us all in positions we don't like.

Please be patient with us. Doctors really want to help people, so if you are honest, patient, straightforward, and work with the system you will usually be taken care of. But doctors are edgy about these meds so please don't react with anger or game the system. I understand your frustration, but acting out won't help you. It will send up red flags that may get you banned from every getting strong medicines.

What do you think? Are doctors too hard on patients who need controlled drugs, or do you find the restrictions reasonable? Have you ever been mistreated when you asked for medicines? ...or known someone who was addicted to pills? Doctor D would love to hear your thoughts in the comments!

The Year In Review (Friday Links)

Doctor D will take this first day of 2010 to reflect on this last year...

In May of 2009 a young physician decided to name his alter ego "Doctor D" and become a medblogger.

He hadn't even read medbloggers before, but he really wanted to frankly discuss health and medicine so he opened a blog and put up some random post asking people to send in questions to some anonymous MD who was willing to spill the beans.

Doctor D just ignored the blog for 3 months, expecting a readerless blog to magically generate interesting questions his email box.

In August Doctor D finally decided he really wanted to do this, so he started posting answers to random questions that popped into his head.

Thankfully, a blogger named Magda stumbled across Ask An MD and asked the first question: about finding a new doctor. D was so thrilled he answered it in a 4-part series.

Since then the questions have been rolling in!

Along the way Doctor D has met some really amazing people on the web. The first person to show D the medblogging ropes was WarmSocks. She blogs about her experience as a patient and she explained to Doctor D how to make a blog like this helpful to people navagating the healthcare system. Later D met other cool patient-bloggers like Neo-Conduit, Queen, Wren, Helen, who really are must-reads for medical folk who want to understand the suffering and strength of a lot of the patients we care for every day.

Doctor D also wants to thank the inspiring patients he has met over email. Many readers don't have blogs, but have shared their experiences with him. D wishes the whole world could hear your stories.

Nurse K was the first and still the awesomest medical-worker blogger to welcome Doctor D to the net! Even though her ER blog is now on hiatus K has always been D's webcrush and he still reads her twitter religiously. Ask An MD has also been visited by such great medical bloggers as Nurse Maha, Nurse Lee, Doctor Rob, Ell the med student, and the hilarious Dr. Grumpy.

So Doctor D has met some very cool people, answered a lot of questions, and had a lot of fun. Ask An MD is getting hundreds of visitors each day and it's really only a few months old. Keep those questions coming!

Thank you all for a great 2009!

So what do you think? What have you liked and disliked about the blog this year? What direction do you think Doctor D should take the blog in 2010? What sorts of questions do you think Doctor D should be selecting from the mail bag in 2010?