When the best medicine means asking parents to leave the room

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I struggled to get the burly 20-year-old construction worker to talk about his fatigue.

Was he sleeping okay? “Yep.”

How was his mood? “Fine.”

At this point the patient’s mother, sitting in the chair beside him, broke in. “What he’s trying to say,” the mother said, giving the patient a playful punch to the deltoid, “is that he …”

After that, the patient’s mother talked more than he did. She provided articulate descriptions of her son’s symptoms, occasionally interrupting him to do so.

“He hasn’t told you this,” the mother said at one point, “but on weekends he drinks a lot with his friends and … well … I wonder if that relates to what’s going on?”

I had wondered the same thing. Also, I needed to get the patient’s mother out of the room.

For more on how to support young adult autonomy and self-advocacy, check out my new article at the Washington Post.

Posted on September 17, 2019 .

Did you know hospitals hire "secret shoppers" to understand the patient experience of care?

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A nurse walked in with a loaded syringe. “Can you lift your gown?” she asked.

The woman on the gurney held the scratchy emergency room blanket closer to her chin. “What’s in the syringe?” she asked.

The nurse frowned. “Don’t you want the medicine your doctor ordered?”

The woman took a deep breath and kept asking questions. She had more than just self-interest on the line.

She was a “secret shopper,” a consultant pretending to be a patient in order to evaluate the quality and culture of care in a hospital.

TO learn more, check out my article at The New York Times.

Posted on August 2, 2019 .

How professionalism grades hurt medical student professionalism

I love the profusion of new ways to teach and assess professionalism in medical school. It’s a huge advance from the days when people like me could still get in.

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Yet, there are sharks in those waters. My friend and med ed collaborator Dr. Roshini Pinto-Powell of Dartmouth’s Geisel School of Medicine and I describe one of those sharks: numerical professionalism grades.

It starts with good intentions: we create a grading rubric on the thought that we should take professionalism AT LEAST as seriously as other topics in medical school. And the easiest way to grade is on a Likert scale.

Yet, we argue, boiling down something as complicated as professionalism into a simple, arguably meaningless professionalism grade is perilous. One reason why is that it imposes external incentives on a complex task, a combination known to sap students’ internal motivation.

That means we might begin with the intention of highlighting the importance of medical student professionalism, and end by undermining it.

Fortunately, there are better ways forward.

To read more, check out our full text publication at the Journal of General Internal Medicine, here.

How we honor a new organ donor

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The double doors of the surgical intensive care unit opened into a hallway crowded with dozens of hospital employees. A hospital bed emerged, and we all fell silent.

Most beds roll out of the I.C.U. briskly, en route to radiology or an operating room, whirring with the beeps and blinks of monitors and the quick conversation of busy nurses.

This bed was different. It moved at a stately pace, and the team that accompanied it was changed as well. Nurses steered, but there was no chitchat this time. A tall anesthesiologist learned over the head of the bed to squeeze a bag valve oxygen mask with clocklike regularity.

People in street clothes trailed close behind the bed, unsure of where to look. These were the parents of the young woman in the bed, the one we had all come to honor.

This was an “honor walk” for a dying patient about to donate her organs to others.

To learn more, check out my new article at The New York Times.

Why volunteer for a vaccine study?

Despite a legacy of scientific misconduct,and the usual complexities of conducting science across cultural differences, people in countries across the world volunteer for vaccine studies. 

Why? What motivates them? What are their fears?

Medical anthropologist Sienna Craig, I and our esteemed colleagues recently investigated. Check out our new paper, here in BMC Public Health.

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Posted on April 24, 2018 .

A harder death for people with intellectual disabilities

Several weeks after my patient was admitted to the intensive care unit for pneumonia and other problems, a clear plastic tube sprouted up from the mechanical ventilator, onto his pillow and down into his trachea. He showed few signs of improvement. In fact, the weeks on his back in an I.C.U. bed were making my 59-year-old patient more and more debilitated.

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Still worse, a law meant to protect him was probably making him suffer more.

When the prognosis looks this bad, clinicians typically ask the patient what kind of care they want. Should we push for a miracle or focus on comfort? When patients cannot speak for themselves, we ask the same questions of a loved one or a legal guardian. This helps us avoid giving unwanted care that isn’t likely to heal the patient.

This patient was different. Because he was born with a severe intellectual disability, the law made it much harder for him to avoid unwanted care.

To learn more, including what happened, read my new post here at The New York Times.

Will New Hampshire open safe sites for people who inject drugs?

New Hampshire is still in the throes of one of the worst opioid epidemics in the country. Deaths are mounting, and mostly in young people.

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As hospitals around the nation and our fair state scale up to provide medication assisted therapy and other evidence-based ways to help, safe injection sites remain controversial.

Based on data from Vancouver's Insite program showing lower public drug use, less needle sharing, and prevention of infectious diseases like HIV, I think it's time for us to get over our hangups and act to save lives.

It was fun and illuminating to talk with Laura Knoy's and guests on NHPR's Exchange. For a stream of the hour-long show, click here

Did I make a professionalism mountain out of a medical education molehill?

Every March I run the last required course at Dartmouth's Geisel School of Medicine. It’s a three-week-long, 47-hour sprint – a sort of boot camp for professional formation. Midway through the usual mechanics of instruction, I got an email that felt routine at first - but then it felt like an opportunity to talk with a student about professionalism.

Click here to read it, over at Reflective MedEd. What do you think? Did I make a professionalism mountain out of a logistical molehill? How do you try to support your students’ professional formation?

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Posted on March 28, 2018 .

Go ahead, hit "record" in the doctor's office

The elderly woman’s right knee was bright red and twice its normal size. Her doctor explained that her prosthetic knee joint was infected and would have to be removed — antibiotics alone couldn’t cure her.

Her doctor (T.L.) began discussing treatment options, but the patient stopped him. “Do you mind if I record you?” she said, picking up her cellphone.

Surprised, the doctor leaned back in his chair.

This simple request can elicit starkly different reactions from patients and clinicians.

To learn more, check out my new article (with co-author Glyn Elwyn) at STAT.

Posted on July 12, 2017 .

How (and why) academics can (should!) write for the popular press

It has been wonderful to publish in The New York Times, The Atlantic's health section, and other popular outlets. 

Writing for the popular press has felt like learning in a whole new language. The rules of academic writing do not apply. 

Through luck, the smoking hot wisdom of a nationally prominent education writer, and invaluable training as part of Dartmouth's chapter of the Op-Ed Project, I've been able to write about what moves me.

For tips on how (and why) academics can (should!) write for the popular press, check out this interview on episode #61 of the popular podcast #AmWriting hosted by Jessica Lahey and her former New York Times editor KJ Dell'Antonia.

Posted on July 4, 2017 .