Author: Angela Gupta

Angela Gupta is a member of the Saint Louis University School of Medicine Class of 2018. She graduated from Saint Louis University in 2014 with a B.S. in Public Health. Angela is particularly interested in the prevention of chronic disease and the eradication of food desserts—she wants to help those in underserved communities gain access to fresh fruits and vegetables. In her spare time, she enjoys reading historical fiction, watching psychological thrillers, and running outside (and to the kitchen).

Categories
Clinical Lifestyle Patient-Centered Care

Running Low and No Longer Running

I recently completed a rotation in endocrinology, and I learned valuable lessons about diabetes management in both the inpatient and outpatient setting. Today, I wanted to share a clinical pearl generally not discussed in lectures: Diabetic patients often gain weight because of the fear of hypoglycemia.

That’s right. The fear of hypoglycemia drives patients to eat a little more at meals. Let’s backtrack. Patients who have persistently elevated sugars are often started on insulin in addition to oral agents. Depending on their insulin regimen, patients may not eat enough after an insulin dose to prevent a drop in blood sugar. Patients who experience a hypoglycemic event try their best to prevent it from occurring again. This is understandable—fainting is scary and should not be taken lightly (pun intended).

The problem is that patients counteract this fear of hypoglycemia by either eating more after an insulin injection, or by exercising less. This impedes diabetes management. In addition to advising our diabetic patients to monitor their carbohydrate intake, we urge them to start some form of physical activity. Physical activity enhances the body’s insulin sensitivity—it gets to the core of the problem (insulin resistance) and improves overall cardiovascular health as well. But how can we encourage these lifestyle modifications if our patients are getting lightheaded after injections?

The answer: carbohydrate counting and education.

Not the answer: increasing insulin.

My attending explained that “increasing insulin” is actually what happens in some cases. For example, let’s say a patient named Sara comes in for her follow-up appointment and unknown to us, has “fear of hypoglycemia.” Sara brings her glucose meter, and the sugars are poorly controlled. Part of the reason for this poor control is secondary to a) eating more after an injection to prevent fainting and b) decreased physical activity to prevent fainting. Now, if we just treat her numbers, we would increase her insulin.

The lesson here is that one can’t just treat the number in medicine. Talking to the patient, even for a few minutes, will provide the story. Increasing the insulin perpetuates a viscous cycle, and breaking the cycle comes from better regimen management. Validating patient concerns about hypoglycemia and educating them on injecting based on carbohydrate intake is invaluable.

Photo Credit: Melissa Johnson

Categories
Clinical Emotion Empathy General Patient-Centered Care

Opinions Aren’t Facts

I wanted to discuss an experience I had in the newborn nursery. I was assigned to Baby K—a small baby girl who was delivered by emergent cesarean section because her mother abused cocaine during her pregnancy. Looking through Baby K’s chart, an unsettling feeling came over me. This was one of the first times I directly saw how a mother’s behavior impacted her child. Before this, all my clerkships had dealt with adults who were responsible for their own health. Seeing an innocent newborn enter this world with a disadvantage because of her mother’s actions was disheartening.

With this in mind, I went to talk to Mother K the next morning. The chart stated Baby K was going to be given to her great-grandmother, and I needed to confirm this information. I could immediately tell that Mother K was upset when I asked her to confirm. She said, “Yes, she’s going to her great-grandma, but I’m still going be involved! I’m NOT giving up on her!” I realized that just asking the question caused her emotional pain. Especially since the social worker, the nurse, and probably several others, had also asked this question. She again assured me that she loved Baby K, but that she just needed to get her life together before she could care of her. After talking more to Mother K, I realized she was trying her best.

This experience opened my eyes to my perception of patients. After browsing Mother K’s chart and reading that she continued to abuse cocaine while pregnant and was planning on giving Baby K to another caretaker, I may have made the assumption that she didn’t want anything to do with Baby K at all. This assumption may have been reflected in the way I asked her questions, leading her to become distraught. Many patients, especially those who suffer from substance abuse, have lost complete control over their actions. Their mind is controlled by an addiction, and they need help before they can take care of others. After talking more with her, I learned that Mother K actually planned to enroll herself in a treatment center that has housing. After getting better, she yearned to resume care of Baby K. These are details that were never mentioned in any notes, but if they had been mentioned, may have altered my first impression of Mother K before I met her. I also learned that Mother K continued to use cocaine during her pregnancy because she didn’t realize its impact on Baby K. She used cocaine during her prior pregnancy with her older son, and he remained “normal and healthy.” Even though we, as medical professionals, can understand how abusing cocaine during pregnancy is directly detrimental to the fetus, many individuals may not understand this basic concept of maternal-fetal physiology. We thought Mother K’s use of cocaine was due to her lack of care for Baby K, when in reality it was fueled by her lack of knowledge.

The most important lesson I learned was not to judge patients based on chart review alone. I know this seems like “common sense,” but it can be easy to jump to certain perceptions after reading the tone of some of the notes in a patient’s chart. My goal in the future is to enter every patient’s room with a blank slate. Our duty has always been to provide the same quality of care for all patients, regardless of their actions or beliefs, but sometimes we let our feelings get in the way of this duty. I have struggled with this in pediatrics more than I have in any other specialty. When I talk to parents who are willing to move mountains for the health of their children, I feel endearment towards them. There is nothing stronger or more special than a parent’s love. In contrast, with parents like Mother K, it is easy to become frustrated. After examining Baby K, I kept thinking about her fragile little arms and small shrunken head. Baby K may grow up to have health consequences that could have easily been prevented. All I can do is allow this experience to shape future patient encounters. I’m going to try to place myself in each parent’s situation and ask myself: what information or advice would I find the most helpful right now? At the end of my time with Mother K, I gave her a tight hug—I’m rooting for her. I hope she is able to complete her treatment and be reunited with Baby K soon.

 

Photo credit: Weird Beard

Categories
General Narrative Patient-Centered Care

Lunch Chats

It’s 6:30 AM. I have one hour to see four patients before morning rounds. This seems like ample time, and it is—it just isn’t the best time. My patients are still sleepy. They aren’t in the mood to listen to me talk about meal planning or exercise regimens (at the crack of dawn, I wouldn’t be either). Each morning, I wake my patients up, ask them pertinent questions, and perform a focused physical exam. Then, I let them get back to sleep. Yes, I would see them again during morning rounds, but no, seeing them twice is not enough. I realized early in my clinical education that if I really want to make a difference, I need to visit my patients after lunch.

I was motivated to visit my patients in the afternoon after hearing the following wise words from one of my attendings: “the patient you see at 7:00 AM is very different from the one you see at noon.”

In the morning, sometimes as early as 6:00 AM, patients are sleepy. It’s much harder to engage them in conversation. In the middle of the day, after they’ve eaten lunch, they are often looking for an engaging visitor.

When I started third year, I wanted to heal every issue on my patients’ problem lists. Inpatient medicine is driven by a patient’s “chief complaint,” and the management of long-term health issues is left for follow-up with a primary care provider. This is a practical system, but it is still unsettling. I was never convinced that Ms. B, who came in with a toe ulcer, would continue to manage her diabetes with a “low carbohydrate diet” and regular glucose checks.

When Ms. B was on my team’s service a few months ago, our daily visits to her room generally entailed checking the status of her toe. She received accuchecks every four hours, and her blood sugars were generally well-controlled, but would she really continue to eat this healthy at home? I wanted to find out. After I started visiting Ms. B multiple times a day, I learned so much more about her health obstacles. I learned that she often starved herself the entire day and binged on one “feast” at night. She thought she was being healthy by only eating one meal! I explained that her eating pattern was messing with her body’s metabolism, and I gave her a presentation I had made a few years ago about affordable healthy food choices available at the local supermarket.

Attendings and residents work extremely hard, and they don’t often have enough time to sit with every patient and discuss life choices. As a medical student, I have this time. I’ll never know if Ms. B implemented my suggestions, but I do know she left the hospital with more than a healed toe. Since then, I’ve been visiting my patients after lunch…I’m always surprised by how much I learn.

 

Photo courtesy of Am Kaiser

Categories
Lifestyle

Just Give Me Ten Minutes

As medical students, we are undoubtedly busy. Between studying and trying to maintain some semblance of a normal life, we don’t pause. Sometimes the only quiet we get is the car ride to class, or the few minutes before we fall asleep. A recent experience showed me that we might need a little more of this “quiet.”

When I was volunteering at Hope Lodge, a place for cancer patients and their families, I led a few short segments on meditation. Each segment was only ten minutes, but its benefits lasted much longer. After only ten minutes of focusing on my breathing and my body, I felt rejuvenated. We are often told that thirty minutes of moderate exercise, five times a week, will help us feel awake and alive. While this is correct, it’s still hard to find time to go to the gym regularly (especially during exam week). For meditation, you don’t have to get sweaty, leave your room, or change your clothes. Don’t get me wrong—I still love and encourage regular exercise. Yet if you feel too overwhelmed, stressed, or tired to exercise at the gym, give yourself ten minutes of meditation. These ten minutes will give you the clarity your body is craving.

So, what exactly do you do?

You can go about meditating in three ways:

  1. Complete silence
  2. Soothing music or sounds (such as a steady waterfall, a running stream, or nature’s lovely birds)
  3. Guided mediation with a voice accompaniment
    Both (1) and (2) can be found on YouTube. One of my favorites for (c) is this 15 minute video.

Once you have made your choice, give yourself at least five minutes to reap the benefits. You’ll find that even five minutes of focused breathing can do wonders for your mind and body.

Sit down in a comfortable position, close your eyes, and start breathing. Breathe in through your nose and exhale through your mouth.

When you are done, get up, and enjoy your renewed alertness!

There is no right or wrong way to meditate, and I am far from an expert. I only ask that you try it.

Further strengthening the therapeutic value of meditation, an article by the Huffington Post discusses the role of meditation in cancer patients. We all know about telomeres—telomeres shorten as we age, and shortened telomeres increase one’s risk for cancer. This article discusses a study where patients who participated in a mindfulness intervention had longer telomeres.

So give yourself ten minutes. You won’t regret it.

 

Featured image:
Meditation Transcendence by Hartwig HTG

Categories
Emotion Reflection

The Power Of Crying

Last week, we started a class called “Death and Dying” (doesn’t it sound fun?).  Jokes aside, this class is a valuable component of the medical school curriculum. Physicians deal with death on a regular basis—some every day, and others every hour. During one of our discussions about a patient, a small tear rolled down my cheek. I quickly wiped it away in embarrassment, pinched myself to “get my act together,” and hoped no one had seen. Later that day, I wondered what would have happened if another student had seen me almost cry? Would their opinion of me change?

I am a “crier.” Not when I am faced with my own struggles, but when those I love go through happy or sad times, that’s when the waterworks kick in. This has me worried. I know that crying is seen as a sign of weakness. Some would even call it unprofessional, and I can’t blame them. Our profession teaches us to set personal and emotional problems aside. But what happens when our profession is the cause of these emotions?

A recent discussion we had in class answered my questions. It turns out that crying is okay. Of course, this does not mean we should break down every time a patient has to spend an extra day in the ED, but it does mean we can be vulnerable in a highly professional setting. One of the pediatric oncologists shared a special patient experience with us. She had always shied away from crying in front of her patients. However, one day after a family had received especially disheartening news, she unintentionally teared up in the clinic room. This was well received by the patient’s family—the patient’s mother told her, “It let me know you cared.” From that point on, the physician’s relationship with the family was altered—an unbreakable, unspeakable bond was formed.

This alleviated a few of my fears concerning the display of raw emotion. We are in a profession where humans care for other humans. It is natural to cry. In fact, we become physicians because we deeply care and love others. Showing this empathy is not a sign of weakness—it is a sign of power.

Yet, there are some important points to remember about crying. Though releasing a few tears is okay, you cannot become a mascara-stained mess.

  1. Your tears have to come naturally. These tears are symbols of your love and devotion. They signify your raw, genuine emotion. Don’t cry to make yourself closer to a family.
  2. You still need to be strong for your patients and their families. You want to be able to process and deliver information to them in a calm, collected way.
  3. You do not want to cry and then have your patients feel they have to comfort you. You are their robust pillar of support! They should be leaning on you for guidance and comfort—not the other way around.
All in all, I am happy to have realized that watery eyes in the clinic will not make me a pariah. Crying, like all aspects of medicine, has to be motivated by your candid empathy. Only then can it be powerful.
Featured image:
A Single Tear by Lauren C
Categories
Lifestyle Reflection

The Hypocritical Oath

Taking the Hippocratic Oath is a rite of passage. Before any physician enters Exam Room 1, he recites these words, written by Hippocrates centuries ago. These words are powerful; so powerful that they are treated as more than just words. These words represent a physician’s love and devotion to his patients.

No matter how stressful this field can be, I have always seen physicians set these words—the oath—as their standard. As physicians (or budding physicians, in our case), we tell others to fill their bodies with nourishment and to practice a variety of healthy habits. But, the question remains: do we treat our own bodies the same way?

As a public health major, I’m all about “prevention.” My special interest is the prevention of chronic disease. Whenever I go home, I am the first to scrutinize my parents’ pantry—making sure their ketchup is devoid of high fructose corn syrup and that their fridge is filled with raw food. When I talk to my friends or relatives, I push them to exercise because “it really only takes thirty minutes of your day, and you’ll feel amazing afterwards!”

Basically, I play the pushy health coach. But is this health coach all talk and no walk?

Sadly, I don’t always abide by the values I preach. Even though I know I should be drinking water equivalent to half my body weight in ounces, I generally don’t. Well, why not? Sometimes I don’t make it a priority, and other times I forget. Many patients probably experience a similar scenario. Likewise, I often see my fellow classmates put academics above their health at school. I can be guilty of this too.

When I started thinking about our habits, I was hard on myself and my peers. As healthcare practitioners, our own health should never be placed on the backburner. More importantly, I don’t like the idea of telling my patients to do A, B, and C if I can’t do A or B or C myself. It just doesn’t seem very reasonable. I’ve come to the conclusion that there are two ways I can approach this in the future:

  1. Practice what I preach
    OR
  2. Preach with empathy

I’ve realized it’s okay to push those I love to be better, even if I’m far from that point myself. But this conversation should be accompanied by a discussion on health barriers. It’s hard to get your limp legs out of a warm bed in the morning, but what will help you rip off the covers and jump on the treadmill? Sleeping with your sports bra on? Placing your alarm farther away from the nightstand? We all know what “healthy” looks like; what we don’t always know is how to achieve it. I want to share my own obstacles with patients while also discussing theirs.

Bottom line: I don’t have to be perfect to offer health advice…I just need to be compassionate.

Featured image:
The road to health by Sarah Joy