December, 2017 | The Pillbox

If you don’t ask, you’ll never know

On the first day of my first rotation as a medical student, my preceptor shared this bit of wisdom: if you don’t ask, you’ll never know. In the nearly 18 months that have followed, I think about those words on a daily basis. To my mind, asking questions does more than just help us gather data. Asking questions establishes the type of relationship we are going to have with our patients. There are so many questions I wish I would never have to ask, whose affirmative answers are often indicative of the cruelty of this world. But when I ask about things like whether a patient has been the victim of abuse, I hope it sends the message that the relationship we are about to embark upon is one that can withstand such unpleasantness.

Not only can it be excruciatingly frustrating when other practitioners don’t share this point of view, it potentially has grave consequences. Unfortunately, patients with mental illness often seem to be the victims of physician “brush-off.” As someone who plans to devote her life to working with the mentally ill, I can only hypothesize as to why the same patients I find so much joy in working with are often given sub-par medical care as compared to their non-mentally ill peers. Perhaps physicians feel uncomfortable providing care for patients who come across as different than the norm, or perhaps their medical problems are too frequently attributed to psychiatric causes.

I recently cared for a patient who was two weeks post-partum from the birth of her first child. Though she was being seen for psychiatric admission, multiple aspects of her health were addressed during our initial evaluation. When asked about her post-partum health, she denied having been scheduled for a post-partum visit with her obstetrician. Casually, she mentioned that she was having some malodorous green discharge since giving birth. It doesn’t take a medical degree to know that green, foul-smelling discharge is not a good sign, let alone when it occurs in the immediate post-partum time period. We were able to secure a next-day appointment with our hospital’s obstetrical practice, and with the patient’s permission, called ahead to the clinic to alert them of her complaints.

The next day, the care team gathered around to read the note from the obstetrician who had seen our patient. The note comprised all of five lines. There were no pending labs. There was no mention of a physical exam.

There was no mention of the discharge at all.

The American Congress of Obstetricians and Gynecologists (ACOG) states, “It is recommended that all women undergo a comprehensive postpartum visit within the first 6 weeks after birth. This visit should include a full assessment of physical, social, and psychological well-being.”[1] The issue here, though, isn’t really about post-partum care. The issue here is about how we as health care providers need to provide equal care for unequal bodies and minds, and how we need to protect and advocate for our patients.

Patients with mental illness undeniably have poorer overall health. The average lifespan for an American adult with mental illness is a striking 30% shorter than for a non-mentally ill individual.[2] While it is known that mental illness itself creates difficulty in accessing the healthcare system, for mentally-ill patients who do access healthcare, their quality of care is demonstrably lower than it is for those without mental illness. Literature consistently demonstrates that patients with psychiatric diagnoses receive fewer preventative health measures and have overall poorer quality healthcare than patients without psychiatric diagnoses.[3]^,[4] No matter what field of medicine you are in, you will see patients with mental illness. For these patients who sometimes cannot speak for themselves, the role of the physician in patient advocacy becomes even more crucial.

I will never know exactly what transpired during that appointment between my patient and the obstetrician, but I do know that obstetrician did not ask the questions that needed to be asked, and therefore did not ascertain the information necessary to appropriately care for the patient. At our request, a different practitioner saw the patient again. This time, the appropriate questions were asked, the appropriate testing was completed, and ultimately the patient was diagnosed with a sexually transmitted infection. Left untreated by the first obstetrician, this infection could have caused my patient systemic symptoms and permanent infertility.

As future physicians, it’s important for us to keep asking questions. So often, I have been surprised by the information I find when I ask a question about which I almost kept silent. Equally as important as asking the questions, however, is doing something with the information that you receive. The good doctor isn’t necessarily the one that stops the green discharge; they’re the one the identifies the problem in the first place and advocates on behalf of the patient to get the best people for the job.

[1] https://www.acog.org/Resources-And-Publications/Committee-Opinions/Committee-on-Obstetric-Practice/Optimizing-Postpartum-Care

[2] http://europepmc.org/abstract/med/19570498

[3] http://journals.lww.com/lww-medicalcare/Abstract/2002/02000/Quality_of_Preventive_Medical_Care_for_Patients.7.aspx

[4] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2951586/

Photo credit: airpix

A Budding Clinician-Scientist

Before I embarked on my second year of medical school, I wanted to try something different — an experience I probably wouldn’t attain during the medical school curriculum.

I have always had an inquisitive mind, hence research held a natural appeal. Research, at least to me, can be broadly categorized into two groups: dry lab and wet lab. I was already involved in the former, but was keen to give the latter a shot. An oncologist took me under his wing, and I was soon introduced to the world of lab-based, experimental research.

Coming from a background with literally no lab experience, it was undoubtedly a steep learning curve at inception. There was an avalanche of lab-based skills I needed to learn and understand. I was tasked to perform lymphoma research, but it wasn’t until a month later that I actually got to perform experimental work on lymphoma cells. The first month was humdrum but necessary. I had to complete multiple safety courses, practice micro-pipetting, and learn about the entire range of complex lab equipment and procedures such as the centrifuge, film development for western blots, and flow cytometry machine.

After one month, I was given my topic and tasked to draft the experimental protocol. In brief, I was investigating complement-mediated cytotoxicity of rituximab (anti CD20 monoclonal antibody) on lymphoma cell lines. Even though I had some prior knowledge about the cytotoxic mechanism, I had to perform an in-depth literature search to augment my understanding and look for existing experimental protocols that I could potentially adapt.

With a protocol in my armament, I thought I was confident and equipped enough to perform the experiment, until I realized that multiple roadblocks lay ahead of me. An initial protocol with six simple steps turned out to be twice as long after adding several intermediate steps that I had missed. There were other reagents that I had to add. For instance, staining the cells involved identifying the appropriate stain color, optimizing the concentration of the stain solution, incubating it for a period of time; it was not as simple as adding a reagent to a test tube of cells. Hence, it often took longer than expected to complete a single step, which resulted in me being late for the equipment bookings. Time management was the first lesson for me. It was quintessential for me to plan, in detail, the total amount of time I actually needed per step, with some degree of overestimation.

The road ahead was filled with pockets of ups and downs, albeit often the latter. There were many occasions on which experimental results contradicted my hypothesis – cells died when they were not supposed to; cells didn’t die when they were supposed to. When occasions like these arose, I went back to scrutinize every step in the protocol, to make sense of what could have possibly went wrong. But I soon realized that the things that seemed insignificant to me were the sources of the experimental failures. For instance, I had initially assumed that all serum types were similar in composition and purpose. However, the serum I had used was not viable for cell survival. Hence, I switched from commercial serum to human serum in subsequent experiments. The next road block came when my cells became unresponsive to rituximab. It was only much later on that I accidentally happened upon a paper, which stated that the particular cell line in my experiment was intrinsically resistant to the drug. These experimental failures served to teach me one very important lesson — to scrutinize the fine details and consider every possibility that could account for failures.

Lastly, I would like to underscore the significance of perseverance. I consider it to be the cornerstone of being a good scientist and researcher. Amidst the myriad of failures, I would have given up on continuing my experiments if I was devoid of it. Research can be a plodding process with multiple failures; but if you believe in your purpose and persevere, you will eventually reap the fruits of your labor.

I have always had an ardor for research, and I intend to pursue the Clinician-Scientist pathway. I am thankful for this lab experience, for it has opened my eyes to the unappealing — at least to most medical students —world of research. As mundane as it can be, I find both the process and end product meaningful to fellow scientists, doctors, and the society at large. This experience has not stifled my interest and passion for research and science; it has taught me instead the values that are essential for a scientist.

If you’re thinking of doing research or being a clinician-scientist, this is just my two-cents worth of lessons that I’ve personally picked up in my short five month stint thus far in the lab. Be humble. Be hungry to learn. Be careful to look out for details. And, most importantly, persevere despite how monotonous research can be.

Photo Credit: United Soybean Board