Jul 22, 2010

Dr. D's Guide to Killing Your Loved Ones

A very different question this week:

"What can I put in someone's IV that will kill them fast?"
Now don't start judging yet...

This person was writing out of compassion not hate. Someone they love has a terminal illness and asked them to do this if the pain got too bad. (Think: Clint Eastwood in Million Dollar Baby)

It is a hard question. I feel for the person who wrote because I have been in this situation many times.

The Moment of Truth
There is the moment when doctors say, "I'm sorry, but there is nothing we have that will stop your illness. The disease will win shortly and you will die."

We are all going to die one day—many of us from illnesses that are long and painful. Everyone mentally acknowledges this as a concept, but when you are on the receiving end of such news it still hits you like a ton of bricks.

It is not uncommon for people to get in a very dark place after this news. Despair, fear, and hopelessness are understandable emotions given the circumstances.
Doctor D is by no means the final word on such a heavy topic, but perhaps I can offer some perspective from a doctor who has accompanied many patients on that difficult final path...
A Cry for Help
Depression is miserable. Anyone who has depression can attest that the mental anguish of hopelessness can be just as terrible as the worst physical pain. Often depression is triggered by traumatic life events.

The good news is that depression is not the end. Most people recover from depression, especially depression that is due to horrible news.

We all work very hard to convince a suicidal but otherwise healthy 20 year old that life can be better and their depression can be treated. Why should we not similarly address the depression of terminally ill patients? Whether someone's life will be decades or days they can live to the fullest when supported by people who love them.
Often when a dying person asks someone to kill them it is a cry for help. In their despair they are asking, "Am I worth anything anymore?"

The answer they need to hear is, "Yes, you are still worth everything to me! I may not be able to save your life, but I will cherish and honor you to the very end."
Every terminal patient that ever asked me to die, they later expressed to me their joy in life and how much they value their time once they had made peace with what was happening. Depression can be treated allowing people to pass with a peaceful heart.

Do not doubt the value of a human spirit, even during the final hours! Doctor D once watched a dying woman do more good during her last day of life in a hospital bed than he has done in all his years of practice.

Fear of Pain
Hurting sucks. We all hate pain and want to avoid it. The thought of dying in pain is intolerable even to consider. And a lot of fatal conditions are also very painful. Many people who otherwise are at peace with dying might contemplate suicide to avoid the pain at the end.

I believe that the field of Hospice is perhaps the finest breakthrough medicine has made in recent decades. Hospice is care for those with terminal illnesses.

Hospice is the art and science of comfort, and as a discipline they have made amazing discoveries in the treatment of people in the dying process.
There is no reason that anyone with terminal illness needs to die alone and in pain these days.
It is sad, but many people still don't know about Hospice. (I guess it's because they don't have their own TV dramas like every other field of medicine. I suppose the ratings wouldn't be good for a medical drama when the patient dies every episode.) Many patients seem shocked when I tell them there are teams of medical professionals that are skilled at managing every aspect of care at the end of life.

Not only do they insure you don't physically suffer, but they address the emotional and spiritual pain of facing death as well. Hospice patients are able to pass in peaceful environments or even in their home. There is support for the family as well. And yes, insurance does cover it.

Many patients are skeptical if Hospice can really deliver.
People figure that if fighting an illness was miserable, then loosing to it must be torture. Back in the old days that may have been the case, however, hospice has an advantage: they aren't trying to cure you. The very thing that seems like the problem they use to create solutions. Without needing to cure anything they can avoid any procedure that causes pain, and they don't have to avoid treatments that might not be good for your illness because fixing your illness is no longer the goal. Your comfort becomes the ultimate goal.

I have never seen a hospice patient die in pain.

Some patients wonder if they can trust the doctors and nurses involved with Hospice to really care about their pain. "Aren't a lot of doctors jerks who enjoy hurting patients who complain too much?" I admit, there are some callous doctors, but I have yet to see a single one involved in the hospice system that wasn't about as kind as a human can be.
Please don't touch the IV!
So in response to the question: Your loved one is asking for your help, but it is important to recognize help they need. Putting down your loved one like a dog is not the solutiondespite what Clint Eastwood says.

Love, support, respect, and connecting them to resources that can help them through this difficult time is the right and humane approach.

Doctor D always loves to hear your thoughts. Have you ever had someone you care about feel this way? Have medical professionals ever wanted to help someone die?

Anyone have any experiences with Hospice?

I realize that suicide is a difficult topic with lots of emotion on all sides. Please share opinions and discuss with respect.

Jul 13, 2010

Should Fear of Patients Keep You From Medicine?

The first of the series: Should I Become A Doctor?

A confused premed writes Doctor D for advice:

"I really want to be a doctor, but I have a fear of sick people. I don't mind needles or blood and guts, it's just people being physically sick that I am horrified by. It's the only thing holding me back from applying to Medical School. Is this something you think I can overcome?"

Excellent question my young friend!

The good news is that you aren't the only person who feels discomfort in the company of ill people. Many people feel this way to some extent or another. Ask any chronically ill person and they'll tell you how often people squirm in their presence. If you want to be a doctor you will eventually need to work comfortably around sick folks, but first lets examine why people feel this unease...

Why would you be horrified by sick people?

1) You're afraid you will catch their disease.

I suppose this is an understandable concern. But many illnesses aren't contagious and most of the others can be easily prevented with proper hand washing and immunizations. Doctor D has caught more things from his preschooler than he ever caught from patients!

But... I suppose there is always a small chance you will catch a bad illness from practicing medicine. If you aren't willing to take this risk then you should probably stay away from medical school.

2) Ill people remind you of your own frailty and mortality.

If you want to blissfully imagine you will live forever in perfect health the existence of illness in others is a painful reminder of reality. If fear of sick people is an extension of your personal dread of death then by all means stay away from medicine because every day at work will terrify you.

Believe it or not, a lot of narcissists with the this issue are drawn to medicine because they want the MD as a status symbol. They leave medical practice when they realize that the presence of suffering kills their hedonistic buzz. Good riddance!

3) Ill people make you uncomfortable because you feel their discomfort.

Human beings are social creatures. We all to some extent experience the world through the experiences of others. When we are around people who suffer—if we are at all feeling persons—we tend to feel a small amount of their pain.

This is Empathy, and empathy has motivated some truly amazing people to choose medicine as a career. Rather than avoiding the ill because of the sympathetic pain they feel, many empathic people want to help those who suffer.

If you are disturbed by ill people because you feel their pain, then you can become an understanding doctor goes the extra mile to help. We need more doctors like this.

If this is you, then you could have the makings of an excellent physician!

"Trust me kid, I'm more scared of you than you are of me!"

Disclaimer: Empathy Can Be Handicap Too!

If you feel so strongly for ill people that you turn into a puddle of ineffective mush when confronted with the suffering of another person then you aren't much use. Sick people come to doctors for help, and sympathy is an extra—a good extra, but only if it comes with professional help and skill.

Can you calm your emotions enough to think clearly and help people who are suffering greatly?

Also, empathetic doctors tend to get burned out. It's wonderful that you feel for your patients, but you have to realize that disease always wins in the end. You will lose a lot of patients. You will be unable to cure a lot of diseases. If your motivation for being in medicine is helping people's suffering you will have a lot of days you want to just give up. This is called compassion fatigue and it is the bane of kind doctors everywhere.

Can you keep doing your work with sick people and still care even when you lose again and again?

If you can maintain your empathy despite these obstacles you may just find that your initial anxiety around sick people made you into an even better doctor!

What do you think?

Patients: Would you be comfortable seeing a doctor who still sometimes feels uncomfortable around sick people? Would you go see our young premed once she graduates from medical school?

Med Students and Doctors: Have you ever overcome a dread of ill people?

PreMeds: Dr. D loves bringing premeds to the hospital and answering their questions about medicine. He always gives it to them straight about what it is really like to go through the training and then practice. So send him more questions!

Jul 6, 2010

32 Years

Drumroll please...


She correctly nailed it on the head at 32 years old. Although she loses points for suggesting that Mrs. D is a "teenyboppper" [D married a woman his own age, thank you!] she still wins the coveted Medical Mafia Mug!

Congrats to Old MD Girl for finishing as runner up with a guess of 31!

But apparently Doctor D doesn't look 32.
While looking younger than one's actual age may be the goal of maturing women, it doesn't always bode well for an MD.

Patients who don't know D usually refer to him as "that young doctor."

Often in the middle of an examination patients will stop and ask, "Doctor D, how old are you?" The don't care much about the age I tell them. The real question is, "Do you have enough experience to be taking care of me?"

"Hi, I'm your new doctor. No, really I am! Wait, where are you going?"
Actually D has had an MD at the end of his name for half a dozen years and knows his shit, but it doesn't matter when the babyface stirs up immediate distrust.

D would grow a long beard to radiate age and wisdom if Mrs. D could stand kissing it, but since she dislikes beards, Doctor D has to wear his face stubbly to keep the old ladies from asking if he would like to meet their granddaughter who is still in highschool.
Admit it. This is the doctor you hoped for, isn't it?
The fact is that everyone expects a really good doctor should be old.

Now D isn't hating on old doctors, since he plans to be one eventually, but it gets frustrating when patients give him that "Oh shit, a young doctor. I'm gonna die!" look when they first lay eyes on him.
What do you think? Does a doctor's age change your expectations about his or her competence? Do you prefer younger or older MD's to care for you?

D always loves to hear your thoughts!

PS: Linda, email me so I can send you your award!

Jul 2, 2010

The Doctors In The Ivory Tower

After spending the last month on sex, drugs, and rock-n-roll Doctor D is back to discussing hardcore medical issues:

Sick Momma asks,
"Everyone tells me I should go to Mayo Clinic or Johns Hopkins. Are the doctors there so much better?"
If you travel to Hopkins or Mayo you are basically paying extra for "name brand" medical care.

Is the name brand better than the regular stuff? Sometimes, but often it's just more costly for the exact same thing. The docs in those places have all published a lot of studies or are recognized names in their field.
"I am the chairman of Medical Expertology at Ivory Tower University, and I am never wrong about anything."

The Academic Brand
Doctor D's time in the ivory tower of medical training revealed to him that the biggest brains in medicine aren't always the best at caring for patients.
Some super-experts will be good at the bedside, but quite a few of them suck at actual doctoring.
Occasionally the super sub-sub specialist expert will know something useful to you that your regular working doc didn't know, but this is more rare than you think. Academic abstraction can also prove a distraction from the simple problem-solving that is often needed. If your car isn't acting right a regular mechanic is usually a better choice than the mechanical engineer at a big name university.

The SuperClinics
The Mayo Clinic is a bit different from academia. They are more hands-on than academic. Superclinics like Mayo pride themselves on being a Mecca for VIP patients.

From anecdotal stories from patients I know who went to Mayo my impression is that they do a lot more tests than most doctors. More tests can be a double edged sword. If you've been reading AskAnMD you know that more care isn't always better. Doctor D has a relative who had a very bad outcome at Mayo after what sounds to have been excessive, unnecessary testing.

In the end, big brand name hospitals and clinics will often do the same tests or treatments your local doctor would do, but the diagnosis or cure is considered more "brilliant" or "amazing" just because it happened Mayo or Hopkins.
A lot of people go thousands of miles to get the exact same care they could have gotten down the street.
Generally speaking I would advise people to work with local resources first.

Only if you are told by the you local docs that you are beyond their abilities would I suggest you look into the big names.
Often the primary doctors and specialists in your own area are more convenient and just as good for your needs.
What do you think? Do any readers have first-hand stories from the "Ivory Towers" of medicine? Did you go for a rare disease or a common problem?

Do you think that the care there was superior to the care you could have gotten in your own city?