Semana numero tres...

Week #3 Assessment: Newbies, Dr. Stevens, and Advocacy.

This week gets a 3. The workload is building up, but slowing down simultaneously. On Thursday, the department welcomed a new batch of PCAs who shadowed for the remainder of the week and practiced doing intakes, too. Basically, Priya and I were sometimes left with almost no intakes (except for the wee hours from 5-7 on Thursday, when a lot of them left), which made me feel like my presence was superfluous.

On a lighter note, I did tons of translations this week, including processing pre-op paperwork for an elderly woman, and helping an uninsured male patient apply for emergency Medicaid before his surgery so he won’t have to be burdened with astronomical medical bills. Dr. Stevens is somewhat suspicious of my Mandarin, though. I can hear and speak it, but I guess I’m not fully confident enough to utilize my skill. With the male patient, he was accompanied by his friend who can speak a little Cantonese, so I was constantly looking at him to make sure they both understood me. I did the same thing in the financial office when he was trying to apply for Medicaid and the process went well. In the end, I was somewhat embarrassed at myself, but I absolutely love challenges like this.

By the way, I learned how to do a breast exam and how to find someone’s liver by scratching their abdomen and hearing for sounds. Dr. Stevens wouldn’t let me see a rectal exam done on one of his patients, though.

Community Project: Studying potential case studies.

I decided to take advantage of my schedule’s flexibility (the people there really don’t care about where I go, as long as it’s appropriate for my project) and went hunting for literature and annual reports. We struck gold in several places:

• The public relations department. The director gave us a whole program guide with the history and overview of Gouverneur.

• The financial and administration offices which were right across the hall from me the entire time. I got some financial spreadsheets on payor coverage in the department.

• Google. I found one of NYU Department of Asian Studies’ working papers on redistributing NYC demographics, which included a 100-page case study of Gouverneur in one of its appendices.

Basically, we have sufficient data, resources, and countless brochures (times 3, because they’re multi-lingual) for our ethnography. Personally, I didn’t see walking around the hospital, asking certain professionals about where to find info, and smiling a lot in front of receptionists as much of a challenge.

For the whole week, the pilot surveys were sitting in a corner while we proceeded to finish up ethnography and began searching for potential patients/families for our case studies. Before Wednesday’s seminar, I began to personally put more emphasis on observing patients in terms of their feelings and reactions to hospital stimuli, as opposed to clinical characteristics, which a lot of the information could be found on their charts. At the same time, I want to see if individual patients and families are any different when interacting with physicians and hospital staff. One of my most memorable cases occurred on Tuesday, when I was shadowing Dr. Liu. A family of 3 – a 77 y/o Hispanic female with her 82 y/o husband and middle-aged daughter – visited their doctor for a checkup. All 3 were using walkers to assist with mobility, and the mother was also in a wheelchair. The daughter, who had trouble walking herself – had to manage medication for her parents (I counted a total of 23 prescriptions filed for both of them on that day), who had a plethora of problems (depression, asthma, DM, HTN, COPD, hyperlipidemia, aplastic anemia, etc.). While talking to them, I learned that the daughter’s husband is also sick with hypertension. The daughter is obviously under a lot of pressure from managing so many people, but the way she neatly organized her parents’ blood sugar, blood pressure, and medication schedules is incredible. I can’t help but wonder how many doctor’s visits and meetings with financial counselors, pharmacies, medical equipment companies, and health aides was required to train her like that. Most importantly, it would be great to find out how Gouverneur is helping the family; it’s remarkable how many services this hospital provides, regardless of their disorganization and sometimes chaotic processes.

Our first week dealing with case studies is disappointing. When we inquired about it with Dr. Hanley on Thursday, she questioned why we didn’t just interview the patients she had that day. Then on Friday, I was working with Dr. Stevens’ team with Priya and he gave me permission to observe some of his patients for the case study. He warned me that they speak Spanish, but I was willing to give it a shot. Then while we were in the office seeing his patient, he caught me by complete surprise. Here is how it went:

Stevens: [While doing a physical exam] when would you like to speak with my patient?

Me: I will after you’re done.

A few minutes after he finished the physical exam…

Stevens: You can talk to my patient now.

Me: [awkward silence, trying to regain my composure and mobilize myself into Spanish-mode] So…how long…

Stevens: “Cuánto tiempo....”

Me: [thinking] Damn it.

More silence.

In the end, I managed to learn that the patient had chronic asthma for over a decade, finds it really easy to take his medication, lives in Brooklyn, has no trouble commuting to Gouverneur because his appointments are quarterly, and that he enjoys his job as a delivery man. After this patient, I decided to challenge myself again with another patient, but I ended up saying nothing but “Cuidate.” Next week, I am definitely doing my case study on the Chinese population. And I definitely need to tell myself to stop being so pensive towards these patients, especially those who speak Spanish.

Subjective: Culture, EBM, and a cute kid.

My highlight of the week was shadowing Dr. Coun on Thursday morning. He was a very pleasant physician: walks into his office relaxed and sings songs while he’s running errands, very nice, speaks fluent Spanish, and has pictures of his cute 2 year-old son plastered all over the walls of his office. More interestingly, he’s very much into Pharm-free attitudes: he puts white labels over boxes of tissues and alcohol prep pads with drug brands printed on them.

Dr. Coun is also a resident preceptor, so he’s very used to students observing his practice and is very knowledgeable about just about every clinical subject I brought up, even mentioning that he’ll note any clinical pearls he might encounter that day.

Before his patients visited, he mentioned how home health aides (HHA) have made a big difference in the quality of patient care, as he explained to me that one of his patients was spared from a time-consuming doctor’s visit; she only needed medication refills, so Dr. Coun could simply file the orders over MISYS and have the patient’s HHA pick it up. Dr. Coun also mentioned that most HHA are immigrants, and that particularly gained my attention because many NYC immigrants’ home countries place a big emphasis on family values, just as my Chinese culture does. It might be possible that some patients prefer HHA over visiting nurses; based on Dr. Coun’s remarks, many HHA are very caring and sometimes treat the patients as if s/he is family.

While going over some chart reviews, Dr. Coun emphasized the importance of EBM. After seeing a patient, diagnosed with prostate cancer, with fluctuating PSA levels, Dr. Coun expressed his contempt for the inaccuracies of PSA testing, how false negatives may happen and how difficult it is to explain to a patient about this possibility. I also learned that although prostate cancer is often chronic and so passive to a point where it frequently goes away on its own, many doctors opt for aggressive treatment that are sometimes unnecessary. We then went into physicians’ tendency to order expensive CT scans at the onset of a “My (insert name of body part here) hurts” complaint. Personally, I feel that physicians doing such things are being ignorant about the intricacy of the decision-making process required for a diagnosis, and instead they are taking the easy way out by diagnosing using brute force: similar to someone trying to open by lock by using every possible numerical combination, or a desperate student solving a difficult math equation on an exam by substituting x with the entire number system. Even worse, my insecurities with this issue leads me to thinking that some doctors are able to get away with malpractice because apparently, results from fancy exams are very, very persuasive; if doctors couldn’t find anything with an MRI, then “they’ve done everything they could.” With that, Dr. Coun advised me to avoid practicing “bad medicine” in the future, an advice I am more than happy to follow.

With that said, I feel that I should be more wary with my cholesterol literature. This is why even with the NCEP guidelines (which I believe is a good source because the NIH is pretty reliable), I always back-reference, hopefully to find the original studies so that I don’t fall into the diaspora of “bad medicine” traps which I feel are extremely deceptive. But more importantly, responsible physicians should always keep themselves updated, as they are ultimately being held accountable for every decision they make.

Overall…

I need to improve my relationship with my preceptor, and to also establish better rapport not only to individual patients, but the entire hospital population that includes patients, nurses, and PCAs (one of them thinks I’m very type-A, aggressive, and hyper; but everybody has their own working pace…). As always, I need to practice Spanish and Mandarin. My Spanish got better with the immersion, but Mandarin…eh.