You report that the IBM supercomputer Watson is aiding medical diagnoses (25 August, p 19). Why is anyone in the least bit surprised that it is useful?
Many people long to be assessed by a computer that will set aside human preconceptions and listen to a full range of symptoms. After the 30 years it took me to get a diagnosis of coeliac disease, I believe I would have done better if handed a questionnaire to be run through a computer of this sort.
Linking together all of the various hospital services to present an integrated database sounds fine, but personal experience has shown a severe downside to that approach (14 June, p 21).
Three years ago my wife was taken ill and was referred to a specialist who was part of a network of hospitals using linked databases. The first specialist misdiagnosed her condition and entered this into the database. From that point on it became impossible to obtain an unbiased second opinion. Everywhere we went, the first thing the new specialist did was log on to the network, access my wife's records and then close their mind to any other possibilities.
After three years, we finally managed to find a specialist outside of the database network who made an accurate diagnosis of my wife's problem.
Implementing these large databases presents the danger of one doctor recording erroneous data which is then locked to the patient for all time.
ASK a medical patient how he feels about the internet and he may well wax lyrical. The web offers copious information about symptoms, diagnoses and treatments - empowering the individual to understand and discuss their illness.
Ask a physician, however, and you may well be met with a resigned roll of the eyes. Even if a patient has tapped into a reliable source of information, their understanding of how it applies to them may be way off-base.
One can easily imagine this divide widening thanks to the "self-tracking" movement, which stands to revolutionise doctor-patient relationships (see "Quantify thyself: Tracking your life from food to mood"). Monitoring your own vital signs promises significant benefits: continual health checks, advance warning of illness and personalised medicine.
But here's the rub. How should a doctor react to someone with no symptoms anxiously brandishing their own analysis of data from a consumer gadget? Equally, will patients eventually be compelled to understand or even conduct such analyses to secure proper treatment? Taking our health into our own hands is about to get a lot more complicated.
In your special issue on thought, you list Occam's razor as a tool for easier thinking, as follows: "Don't invent a complicated explanation for something if a simpler one will do" (21 September, p 38). It is also useful in medicine: do not make two or more diagnoses when one will explain the symptoms.
But, in or out of medicine, the razor may sometimes fail. We should recall Hickam's dictum: "A patient can have as many diseases as they damn well please." This is the same as saying it is often more likely that a patient has several common diseases than a single, rarer one that explains their multiple symptoms.
Medical professionals of Reddit, what mistake have you made in your medical career that, because of the outcome, you've never forgotten?
I work in Palliative Care, and in the fall I sent a patient home to see if he could die there instead of in hospital. We weren't very hopeful, but thought it would be worth a try. To no one's great surprise (even his and his wife's), he ended up coming back a couple of days later for whatever reason.
I re-admitted him, since I knew him. I knew he wanted to be a DNR (do not resuscitate). I wrote it on my note. But I didn't re-fill out the hospital paperwork. The next day, I got to work to discover he'd been coded and was on a ventilator in the ICU. Instead of passing peacefully, his wife had to make the decision to turn off life support. My entire job at the end of life is to ensure as good a death as I can. And in one simple omission, I f---ed that up royally.
I do HIV testing and once I showed up to work super tired because I couldn't sleep the night before. This guy comes in for a test, we go through the pre-counseling and then I tell him to step out for a few minutes while the results come up. Once he comes back to get his results, I tell him to take a sit and the first thing that came out of my mouth was "Your results are positive" and then I saw the look on his face and that's when I realized I fucked up. I then said" Oh no no no, I meant to say negative." I almost gave the guy a heart attack :/
I'm a Registered Nurse. When I had just graduated,I was the charge nurse working a night shift, and the only Rn working on my floor that night. A Licensed Practical Nurse asked me to help her draw up Methadone that we were giving a patient for pain management. The medication came in liquid form and we would mix it in juice for them to drink. They were due 70mg, so,assuming she had read the label, I poured up 70mls of liquid. I then noticed that we wouldn't have enough medication to last the weekend at this rate, so I rechecked the label and discovered the concentration was 10mg/ml. If I had not picked up on that, the patient would have received 700mg of the medication. When I realized what could have happened, I got so sick. I have never ever ever made that same mistake. ALWAYS always triple check your medications. There is a reason they teach you that in nursing school.
As an anaesthetist (anaesthesiologist) I'm constantly drawing up drugs and administering them both solo and without writing them up yet. Because of this I'm obviously at high risk of making errors, so I've got into the habit of reading every bit of information out loud, its seems to help.
I've twice had incorrect dose, and once incorrect medicine given to me at a pharmacy. PSA: Always double check, and ask the pharmacist if you feel like something could be wrong. They might get mad for you questioning them, they most likely will tell you you're getting a different brand of the same pill, but once in a blue moon they'll get a "holy shit please don't report me" look on their face.
I'm a lab tech and used to work in Histology when I was new. I got a skin biopsy specimen and that day I was embedding , basically putting the fixed tissue into wax so it could be mounted on a cutting block to slice 3 micrometer sections for staining. It's very important what side you place "down", based on how it was cut out of the body. Well I messed up and placed it sideways instead of down. The person cutting the tissue couldn't tell and ended I'll cutting through the tissue. This was a problem because the patient had skin cancer and they were looking at how far it had spread. Since it was cut too deep they couldn't see the edges anymore. This means the doctor had to cut a bigger piece of skin off to be sure they got it all. That's when I found out it was a skin biopsy from the patient's nose. This patient had to have a bigger, potentially unnecessary, piece of skin from his face cut off because of me. I was horrified and learned my lesson that day on how important it is to be certain of embedding technique.
Our histology department processes tissue from kidney biopsies, taken with a large needle "gun". They can be very painful and are not something to take lightly, especially in children. Unfortunately the nurses and ward doctors don't get nearly enough training in tissue processing after collecting the sample, meaning many samples are unusable. We had a child last week who required two additional kidney biopsies after samples were left sitting around.
Once as a tired medical resident I was called to the ER to admit someone at like 3am. This bonehead had gall bladder removal a week ago and now had a surgical-site wound infection. I asked if they'd taken their post-op antibiotics they were prescribed, and they weren't sure. I was getting more and more frustrated with this dumbass preventing my sleep when I decided to use a "pregnant pause" interview technique, and just shut up. This usually results in either awkward silence and the patient saying "uhh WTF doc" or awkward silence followed by some useful deep revelation.
In this case the guy hung his head low, looked at his feet through unfocused eyes, started to sniffle while his halting voice cracked "I can't read. Never could. Didn't know the instructions they wrote down for me and didn't know I had medicine to buy. I didn't ask them because I was embarrassed."
Illiteracy haunts rural and urban places in most countries. Those folks aren't reading this, and they depend on our patience and understanding, and acceptance, to detect and bridge that vast communication gap. That's what stuck with me.
That's interesting. I worked with a doctor who was pioneering giving discharge instructions as a video. It turns out that the same poor people that are illiterate also tend to have smartphones (but no internet at their house). The chances of a poor person having someone in their inner circle with a smartphone is like 90%. So they get the cell phone # and they text links to videos with the discharge instructions. Amazing program.
I may start giving my patients the option to record me giving them instructions. It would also keep me on my toes to be super-accurate haha.
Now I feel like an ass. Every time doctors or pharmacists go over meds with me I have this "WTF am I retarded" look on my face. I mean helllooooo I can read! Apparently they're just being good people and covering their bases.
I sort of wish pharmacists would say why not to eat/drink certain things with meds. They make everything sound like it will kill you, which, for me, would cause undo stress. I have the advantage of being in med school, so I actually know what the interaction is. For example, I went to pick up some Cipro the other day, and the lady behind the counter was like "DON'T take this with milk, yogurt, any dairy, anything fortified with calcium, zinc..." so on and so forth. It came across as super scary and dangerous. The interaction of Cipro (or fluoroquinolones in general) and calcium (really, divalent cations in general) is decreased absorption. Just tell the people, "Hey, don't take this with dairy or zinc products because then it won't work." Don't make it sound like I'm about to die from it.
I once was the interpreter for a 14-week ultrasound for a young Brazilian couple (first boo-boo, somebody by default put Spanish as the patient's preferred language instead of Portuguese, of which I didn't speak a lick at the time). The ultrasound tech wasn't talking nearly as much as she usually did for these things, and the happy couple were just gazing at the screen with pure joy.
The tech soon left to talk with her doctor, and the doctor's first words upon taking a quick look at the unsound, without even greeting the patient or her partner, were "it definitely stopped growing. I'd say it died at around 10 weeks." Well, the couple didn't speak great English but the poor woman literally jumped off of the bed and asked me what she said. Ethically, I have to speak exactly as the providers, so I had to give the same news on the same blunt tone. It only got worse as the doctor showed little sympathy and basically continued to explain that these things happen, blah blah, while the couple were in tears.
I still think about that couple three years later, and they're part of the reason I study Portuguese now. I've had to tell couples about miscarriages other times since, but I've never had a provider that seemed so indifferent or even annoyed by such a reaction.
My girlfriend (now wife) had a miscarriage awhile back. The doctor told us it was probably a good thing because she was too young and overweight to have a child anyway. Cunt.
It's very common for UK trainee pharmacists in hospitals to carry out "medicines reconciliations" under supervision, where you try and establish what medicines patients take at home. We do this because clerking doctors try their best but often have to work with limited information. You see what the patient's brought in to hospital, get a fax of regular meds from the GP/care home/etc, ask the patient how they take their meds, etc, then advise the medical team about differences in doses, missing medications, things that the GP has recently stopped, etc. You can do it with family/friends present but it's best to get the patient's permission first. Sometimes this is better, because often the patient will tell you their spouse does all their meds and they have no idea what they're on.
So the trainee pharmacist goes to see a patient, who is there with the patient's partner. The trainee gets the meds out and starts showing them to the patient, and says "these are your HIV meds, how do you take them?" The patient hadn't told their partner that they were HIV-positive.
Do you have a legal requirement to disclose a positive HIV status in the UK? I know we do in Australia, and I'm fairly sure it's the same in the US, but I'm not sure about the UK.
It's also against the law (except under very specific circumstances) for physicians to disclose HIV status to a patient's partners without patient consent. I'm not defending people who fail to disclose their HIV status, but there are very, very significant repercussions for that kind of information being disclosed.
A screwup perhaps, but that's better than the partner never finding about about the HIV until it was too late.
In the US at least, this would be a HUGE deal. It's a huge HIPAA violation.
There's also a lot of laws in the U.S. concerning withholding HIV status from your partner, so I'm not sure if this guy would have a case. They differ state to state, but some individuals have been tried for attempted murder.
The patient might have a valid HIPAA complaint. That isn't affected by the fact that the patient's partner might have a valid suit for nondisclosure.
True, but I don't think one cancels out the other. Both parties fucked up pretty hard in this scenario.
Learning the hard way why patient confidentiality is sacrosanct. I remember back in the early 00s (before everyone had the Internet) a parent coming up and asking what a medicine was for: it was Yasmin, and the daughter's prescription. Fortunately stopped the staff member saying.
Under 18? Parent can ask and be told. But here is how I handle the situation. "What is this pack of 28 pills used for" "Well, it's depends. They are hormones so used for a lot of things. Usually birth control, but is this person going through mood swings, or does she have painful cramping, or have acne, irregular menstruation, or do they ever complain of heavy bleeding during menstration? How old is this person?" Honestly most parents know it's bc, but want plausible deniability in their head. If they are teenagers one or more will apply .Once you get to menstration, the dads usually are like fuck it, I dont want to know. Moms will usually say to regulate the periods. and a lot of the time the question are on the phone and they dont give patient specific info. One time it was for a 12 year old. Her mom quickly pointed out she didn't want her kid to get preggers from the 20 year old she was dating after mom caught them having sex. There was a lot of counseling on that one.
In the UK parents of a teenager have no right to be told. The original case centred around a mother who thought that parents should be consulted about the prescription of contraception for minors, but the court found against her. The principle doesn't state a minimum age, just that a child has the right to make their own decisions as soon as they are capable of understanding those decisions.
That includes the same right to confidentiality as an adult. It's a challenging decision for a lot of HCPs to make, deciding whether a kid is competent or not.
So the decision to have sex at 15 can get her partner thrown in jail, but magically the same girl is responsible enough to make medical decisions without parental knowledge? And she's responsible enough to make medical decisions, but if she chooses to have a baby, society has to pay for it? It's amazing how these one-way streets work.
Just because someone is able to understand the consequences of medical decisions, doesn't mean they are ready to deal with the emotional consequences of a sexual relationship. They're very different. But despite that, the age of consent is set where it is to protect children from predatory adults; the outlawing of consensual relationships between say a 15 & 16 year old is almost a side effect. I haven't seen any evidence that partners in such relationships are routinely prosecuted, either. Perhaps laws similar to some parts of the US, where sex is only illegal at certain ages if one partner is more than 2 years older, would be more sensible.
... good thing about military medicine. Unless they're a dependent, they're used to masochistic humour and in all likelihood use it as a coping mechanism when being shit on. Whenever I take a patient back, my go-to icebreaker to keep them calm and get their vitals normalised is something along the lines of "So apart from your appendix exploding, your morning going pretty good?"
It's got to be said just the right way and in the context of the really informal relationship that corpsmen have with their patients, but apart from getting to the part of the check in interview about bowel preps and getting to ask a guy with a broken arm "Did they give you an enema during pre-op screening? ...Would you like one?" it's the highlight of that case and one of the few things that gets a smile out of them.
'End of life goals' talk is so important. My dad died after going into emergency gall bladder surgery. He had a DNR. His surgeon, I think, tried to express the seriousness of the situation (dad was on blood thinners, and already septic from gall bladder failure, and old, and bad heart) but he kept giving me options I didn't know I had. If he codes on the table do you want to try once, or try twice, or not at all. If he stops breathing do you want to intubate? I didn't understand why I suddenly had a say in what moment he could die. I, of course, should have just said, if he's out, he's out, but he'd always been so plucky, surviving stuff he should have never survived. ugh. He ended up coding in the elevator, they intubated and he was unconscious in ICU for a week before they suggested hospice. The worst part is that my dad was a surgeon and he knew he never wanted to die with a bunch of tubes in him keeping his body working after he'd long left the room. I always felt I let him down there.
True but not too serious. I was a medical student looking after a boy of about 8 years who had broken his arm. He needed an IV but was terrified of needles. I was trying to calm him when he asked "will it be like what they did in the movie Elf?". I had not seen Elf and I figured it must have been a pretty benign scene with that title. I said "Yes" and the kid went into hysterics. I saw the movie later and understood why the poor kid got so upset. I became an expert in Barney, Dora, Bob and Blue to try and prevent future misunderstandings. I watched some Teletubbies too, but it kind of freaked me out.
I gave a patient suppositories that he tried to take as pills bc he assumed I was giving him pills.
I was a third year medical student on my surgery rotation at Cook County Hospital back in the mid-1990s when it was still in the old building. It was a chaotic mess. I was post-call and in clinic and saw a patient who had some type of intra-abdominal procedure and was in for follow-up. He lived in a trailer park on the far south side of the city, was poor as dirt, and clearly wasn't thriving post-op. He was dehydrated and we were concerned that he had a ileus (bowels weren't moving). I was told to admit him. I told the transporter to take him over to the surgical ward, but somehow forgot to write admission orders, so he went over with no paperwork.
He ended up getting put in a bed, and stayed there. For 3 days. With no paperwork. He got IV fluids and bed rest for 3 days, but because no admission orders went over, he never got entered into the computer system. He never showed up on our list of patients. The nurses just kept changing his IV fluids. He had no vitals, no nothing. Well, 3 days later we were on rounds, and walked past his cube (it was an open wall with cubicles at the time) and my senior resident stopped and said, "Who the hell is this guy?" The patient poked his head out, pointed at me and said, "Hi Doc! When can I go home. I feel great." He was completely better (probably because we did nothing to him). My junior resident whispered to me that I should just quickly (and quietly) write up admitting orders and discharge orders.
I worked in pathology for several years as a histotech. Once I had two breast biopsies for two different patients waiting to find out if they had breast cancer. The pathologist ordered additional testing in which I had to cut additional sections of the biopsy to stain for specific qualities in the tissue (immunohistochemistry). Turns out I mixed up the two biopsies because the two patients had the same first name. I put tissue sections from one patient onto a slide labeled for the other patient. The other histotechs missed it when they double checked my work, even the pathologist missed it when he diagnosed the patient. Amazingly (luckily?), these two patients ended up having the same type of cancer, and the mistake wasn't even caught until a week later.
I've never felt so sick to my stomach. If these two patients didn't have the same type of cancer, they would've received the wrong treatment, maybe even told they had cancer when they actually didnt, and vice versa. All because I didn't pay close enough attention. I will never forget that moment as long as I live.
fresh out of residency and working in a remote location outside North America (location held for privacy). Being so far out there was not a lot of sophisticated help (or any for that matter). His first procedure he needed to perform was very minor but he needed to sedate the patient. Again he was by himself. He hooks up the patient who goes under fine. Shortly during the procedure the patient's vitals begin to drop dramatically. Frantically he looks to find the problem.....sedation method and amounts appear fine so he is confused and the guy is almost coding! Finally he stands up and races for the defibrillator and all of a sudden they patient starts to get better and goes back to normal. Turns our he was stepping on the oxygen tube! He vowed always have another person administer the sedation after that! He felt terrible btw.
Nothing life altering for a patient...but. When I worked OB I had co worker give birth who was expecting a girl, it turned out to be a boy.......with downs and a cleft palate. I was only aware of the sex not the other issues. First words out of my mouth when I came on shift " Congratulations , I bet that was a big surprise !". I'm a fairly blunt asshole most of the time, jaws dropped.
This one happened just last week, but I will never forget it. We accidentally CT scanned a lady's abdomen against doctor's orders and found a HUGE post-op abscess the size of a baseball. Doctor thought she just had a bladder infection and was planning on sending her home. If he had, she would have come back very, very sick, or maybe even dead. Accidentally scanning her saved her a hospital admission likely measuring weeks in length, and IF she survived, she would have faced a six-figure bill as her reward. Sometimes our mistakes can end up being to a patient's benefit rather than to their harm.
This is a mistake that happened to one doctor I know. A patient was pregnant and was about to deliver via c section. Unfortunately the doctor on call forgot to measure the blood pressure before the surgery and apparently the patient had pre- eclampsia. The patient ended up in a coma and eventually died at a young age of 27. Her child survived but without a mother to care .
Work Hours in Britain's NHS
For background, it is important to note that the British Medical Association (BMA) continues to assert publicly that the overriding reason for striking is concern for patient safety, on the grounds that the health secretary’s proposal for a “seven-day NHS” — in which junior doctors will see their hours unchanged but spread more evenly over the week as a whole — will in some way endanger patients.
Yet almost all the junior doctors who sent me critical emails were most exercised by the fact that — if Jeremy Hunt’s contract went through — they would be rostered more over weekends (and less on weekdays) without a system of pay that would compensate them properly for working at “unsocial times”.
One of many such emails was from a Dr B, who wrote: “Dominic, would you work over weekends for the same pay as weekdays with no choice for you to choose between weekday and weekend?” I wrote back: “As a matter of fact I do work throughout the weekend and for the same pay as I would if I were required to do the same job only on weekdays. I work on my Sunday Times column on Saturdays — as you would imagine — and I spend every Sunday writing a column for a newspaper which comes out on Monday. Neither employer gives me a choice about this. I have no intention, however, of withdrawing my labour in protest.”
A Dr O, with whom I had an almost identical correspondence, quite properly shot back: “With all respect, running around A&E departments seeing people who are acutely ill, telling people they are dying or their loved one has died, isn’t quite the same as [someone] who has to meet writing deadlines . . .” Absolutely right, Dr O: but that valid point doesn’t deal with my argument that this is a dispute about remuneration and working practices, rather than defence of patients — whose mortality rates are undeniably higher at weekends, when many fewer NHS staff are on duty.
A number of doctors wrote to me in similar terms about feeling underappreciated and indeed under-rewarded by their employer, and said that they were considering emigrating to countries such as Australia and Canada, where (they claimed) they could do much better for themselves with the skills they possessed. That is their right; perhaps it was tactless of me to point out that, in terms of the high moral ground, this argument is indistinguishable in principle from a businessman who declares that the British state penalises him too much by way of taxes and he is considering emigrating to a country where his hard work is treated more sympathetically by the authorities. It is doubtless a frustration to the doctors making this argument — treat us better or we will leave — that, because of freedom of movement in the EU, the NHS will have no trouble finding qualified doctors from countries such as Spain or Greece who can earn much more here than at home. In other words, the emigration argument cuts both ways.
So, as Dr A — an ex-practitioner with family members in the profession — wrote to me: “Doctors have experienced real wage suppression in recent years. I find it difficult to be neutral about this, as my son and daughter-in-law are greatly exercised about it. But from a business point of view what Hunt is doing makes sense, trying to make the service more responsive while keeping labour costs fixed. He is doing the right thing by taxpayers and voters. Doctors want very high job security, moral kudos and wages unaffected by market conditions. That is now unreasonable, although in better times they have achieved it. And both sides are shroud-waving, when this is a bog-standard industrial dispute about money.”