Interesting Case of "Co-rumination"

I haven't written much about actual medical cases I see here at my hospital but this one intrigued me. Some details have been altered of course.

A 30ish female showed up in our emergency department complaining of a sharp, stabbing pain in her left neck (10 out of 10 in intensity) for several days along with a palpable mass over the area. The pain had been present for two to three months but not nearly this intense nor had the mass been as large. She also complained of fatigue, shortness of breath, tactile fevers (felt hot but hadn't actually checked her temperature), and a range of other symptoms. The intern who presented this case to me found absolutely nothing on physical exam: normal vital signs, no mass, lungs clear, etc.

My impression just from the presentation was that this was unadulterated BS (medicalese for "move along, nothing to see here"). How wrong I was.

When I walked into the exam room there were two healthy-appearing women sitting, both with the same look of overwhelming dread. Usually I'm fairly insightful but in this case, it took several seconds to determine which one was the patient. Seeing an "older" attending, the patient's friend whom I'll call "Patient #2" immediately unloaded Patient #1's symptoms upon me.

Patient #2 related in great detail every ache, every sensation, every pain, every bowel movement, indeed every agonized breath of her friends over the past three months. Certainly, it is not unusual for a patient's friend or family to function as an advocate and relate observations about the patient that may be helpful to clinicians.

It's rare however for such advocates to give detailed subjective descriptions of how the patient is actually feeling (at least when the patient herself is articulate, not shy or embarrassed, and for whom English is her native language). Between Patient #1 and Patient #2, I was barraged with with a torrent of imagined symptoms.

In examining Patient #1, I agreed with my intern that there was no mass, nor any other physical findings of note. In my most professorial and reassuring manner and despite the fact that my skin was crawling in much the same way as when I walk into a room with a patient believed to have scabies, I told her her symptoms were nothing to worry about, that medical science can't always explain what patients are feeling, that her problems would undoubtedly resolve shortly, and that we were always here in case she didn't get better...

Our patients were greatly reassured and they both thanked me profusely. I walked out of the room feeling I'd done some good.

The diagnosis? This woman (and her friend) turned out to have a severe case of co-rumination, a topic I've written about before. The problem was that, like many females, they tend to "share" far too much. By doing so, their anxieties spiral upwards out of control as happened here. Men seem much less likely to engage in this maladaptive behavior. Certainly, we'll see more of this with men as society continues to encourage us to explore our "feminine side".

Perhaps if I had been more upfront with my convictions, I would have also recommended they stop co-ruminating regarding each other's maladies.

But that might not have been cool.

From Dr. Jill Bolte Taylor: The Most Electrifying Lecture You'll Ever Hear

I've heard a lot of lectures in my life but never one like this. This is neuroanatomist Dr. Jill Bolte Taylor giving a talk on the functional differences between the right and left hemispheres of the brain. She's passionate about her subject as she actually suffered a massive intracranial hemorrhage that trashed her left brain. Dr. Taylor brilliantly describes the experience and sensations both as a stroke victim and as a scientist.

Not that I want to replicate her experience but man do I wish I could teach like her! Check it out and prepare to be riveted by the most amazing 20 minute talk you've ever heard.

It makes me never want to step up to a podium again.

Gonzo Medical Blogging

Periodically, I will add a new blog to my "blogroll". Unlike many bloggers that maintain such lists, I try to post only the ones I like to read frequently. Some bloggers maintain huge alphabetized lists of blogs, a practice I've never really understood. Perhaps these lists grow because of quid pro quo (you link to me and I'll link to you, a practice I hate) or perhaps some people just like the look of really unwieldy, completely unfiltered lists.

Personally, when I look at someone else's blog, I enjoy looking through their blogrolls to see just what they like to read. Being an avid reader, I'm always curious about such things. When my patients or their families have books with them in the hospital or exam room, I invariably ask what they're reading. Huge blogrolls don't really give me that kind of insight into the compiler's tastes.

At any rate, this post is to announce an addition to my blogroll. That we are judged by the company we keep concerns me as I add a link to Panda Bear MD but what can I say? The guy is hysterically funny and says things that many of us think but are unwilling to express in polite company. Panda is a resident in emergency medicine. I'm sure he is a bit older than his fellow residents as he's described a wide variety of prior life experiences.

This added age undoubtedly gives his writing a level of sophistication extremely unusual in someone the age of a typical resident. If I had to pigeonhole him, I guess I'd call him the Hunter S. Thompson of medical writing, an appellation I'm sure he'd understand as a compliment.

I enjoy his observations, his insights, and his style very much and have pointed colleagues, nurses, and residents towards selected posts to much hilarity.

Truthfully, I sometimes worry about Panda. My hope is that his posts are put-ons and that the darkness, even bitterness, imbued in his writing is more for shock value than anything else, sort of like Ann Coulter's subtle style. But I have my doubts. His writing is too authentic and fluid.

I think that while most of us will occasionally laugh at the peccadilloes of our patients and their families, most of us don't define such people by them. I hope he is happy in what he does and that if so, medicine continues to sustain him. Unfortunately, my suspicion is that his cynicism has been acquired at far too early a stage in his career. He has all the markings of someone headed for premature burn-out. Hopefully by turning others' attention to his writing, I'm not reaffirming his world view and somehow facilitating such burn-out.

One last point Panda, if you're reading this. You should give some serious thought to posting your name and your institution. Not because I want to know who you are but instead, to protect yourself. While I don't recall reading anything you've written that's frankly libelous or in violation of HIPAA or terribly likely to get you into trouble, some of your posts definitely push the envelope. I think that writing without the imagined security of anonymity helps ensure just enough caution to prevent saying things that can have tremendous legal or professional repercussions. Internet anonymity is fleeting. Just ask the Flea.

My two cents.

Patient Privacy, Gratuitous Nastiness, and the Ubiquitous Tort Lawyers

KevinMD has posted about a news article dealing with a privacy issue that doesn't come up too often. A chief resident of general surgery took a picture of a patient's penis while he was under general anesthesia.

There were three problems with this incident:

• The patient did not consent to or know about the photograph (he was unconscious).
  


• The photograph was not used for the purposes of medical education but rather for its "check this out!" factor.

Federal privacy regulations (the Health Insurance Portability and Accountability Act or HIPAA) have surely been violated. It is acceptable to disclose a patient's medical data (including photographs) if the patient's data is "de-identified" or the patient's consent is obtained; and the information is used for academic purposes.

De-identified means that the information is stripped of 18 parameters defined by HIPAA such as name, address, etc. The 18th is, "Any other unique identifying number, characteristic, or code..." (emphasis mine). The man had a tattoo on his penis that said "Hot Rod" and unless I'm seriously unhip, it's fair to say that his tattoo would be considered uniquely characteristic.

In addition, the photograph was not taken for medical education or research but rather to be passed around the campfire for its "entertainment" value.

This resident is in a LOT of trouble. He violated federal law and surely his hospital's formal bylaws. More importantly, he violated standards of basic human decency. Apparently however, he did try to make amends. He apologized to the patient and also appeared to form a close bond with him. The patient in fact "had been terrified about the impending surgery and said he had formed a 'bond' with Hansen (the resident), who helped him stay calm."

The resident's institution suffered a public relations nightmare and an expensive one. HIPAA violation fines can be quite expensive. I also assume there'll be a major lawsuit or a large settlement. The victim has obviously been coached by an attorney and is using the "correct" language with the press:

"But now I feel violated, betrayed and disgusted. I've never been in a hospital and (my) first experience is the worst thing ever."

There was once a time when such a act would have been handled with an apology and some form of disciplinary action, possibly getting fired. Such times now seem a quaint anachronism. Frankly, I hope his young physician has learned a serious lesson. To be honest though, I hope this example of emotionally retarded behavior doesn't end his career.

Update: The Blog That Ate Manhattan has a more insightful post than mine. Of course the "whistle blower" committed a more egregious HIPAA violation than the resident by going directly to the press (HT Kevin MD)

Medical Schools Struggle to Integrate "Integrative Medicine"

Medscape posted a thought-provoking essay on how medical schools are integrating "integrative medicine" into their curriculae. Its take home message: bad idea.

I agree. Find our why here.Medscape posted a thought-provoking essay on how medical schools are integrating "integrative medicine" into their curriculae. Its take home message: bad idea.

I agree.

The article discusses the Flexner Report which was indeed a remarkable document in its day. The authors make the point that it is no less relevant now. The original report published in 1910 covered a lot of ground but a central point was that medical education needed to be based on data-driven scientific knowledge. Flexner eschewed hokey, unproven, unquestioned dogma and established that modern medical education needed to do better than that.

While I have not studied the extent to which medical schools of today are getting away from that paradigm, it seems that we are to some degree. Integrative medicine is the new big thing. Traditional western medicine is increasingly being viewed as dogmatic, uncreative, and narrow-minded. Alternative modes of healing are seen as more holistic and somehow more natural.

I don't object to anyone following the call of their own belief system. But it is becoming less politically correct to argue against the incorporation of nonwestern therapies in modern medical practice.

Don't get me wrong. I would whole-heartedly embrace the most bizarre witchcraft imaginable...if it made people better and alleviated suffering. I wouldn't even demand that such therapies actually cured anyone. Unfortunately, so many of these treatments (herbology, accupuncture, magnets, crystals, magical incantations, channeling through my neighbor's beagle, etc.) have not been proven effective.

So why give these treatments the prestige that explicit support by allopathic medical schools engenders? It would be one thing if the principles of integrative medicine were being presented simply as information med students need to be aware of. It can be argued that such knowledge will facilitate communication with their patients (many of whom are using or considering such therapies). But that's only part of it. As the article discusses, fewer and fewer judgments are being made as to their validity and they're being presented as legitimate alternatives to standard treatments.

I remember a committee meeting of one of the two major private hospitals in a community where I used to practice (a highly regarded institution with a solid medical staff). A family practitioner on staff outlined a marketing push to promote our institution's support of alternative medicine (it wasn't called integrative medicine at the time). Some of us on staff were stunned that this hospital would risk its reputation on something so obviously non-evidence-based.

When she was asked about this, her response was simply, "Well, everyone is doing it and if we don't get on the train now, we'll be left behind." What an inadequate, wishy-washy excuse. Ultimately, the hospital caved. It's disturbing to read that (as documented in the article) these same changes are happening in our nation's medical schools as well.

And now, a personal anecdote. I once tried to learn accupuncture. I signed up for a very sophisticated, very rigorous course (that involved many hours of training). I read the textbooks, memorized the meridians and the accupuncture points (it was harder than gross anatomy). I learned the different diagnostic protocols, the personality types, etc. I practiced "feeling the Qi" when placing the needles in my classmates.

I failed miserably. I simply couldn't do it. I've asked myself many times why this discipline so thoroughly eluded me. The bottom line was that I just couldn't "let go". I just couldn't get away from the ludicrous silliness. It was like watching a movie where the characters were so poorly drawn, the storyline so utterly absurd that I couldn't achieve the suspension of belief needed to enjoy it.

I am an integrative medicine failure. I am a philistine.

Update: Read this post by Orac.

The ultimate medical mnemonic

I have been deliberate in my attempt to keep this blog somewhat "general interest". I hope it is accessible to healthcare professionals and lay people alike. Today however, I've decided to post my contribution to the ongoing heritage of medical education. This, in the form of the greatest mnemonic of all time. Sometimes I just can't resist withdrawing back "inside the fraternity".

As every doc, nurse, med tech, etc. who's ever faced the daunting task of learning the cranial nerves can attest, there are countless aids to memory or mnemonics to assist. The best ones (i.e. the most evocative) are of course x-rated. Here is one that is not:

Frank Sinatra Takes Four Fifths Seagram’s Seven Each Night To Ease Tension.

This of course stands for the First, Second, Third, Fourth, Fifth, Sixth, Seventh, Eighth, Ninth, Tenth, Eleventh and Twelfth. As the astute reader might realize, this mnemonic has wider applications eg. as an aid to memorizing the names of the thoracic vertebrae.

Let me know if this is helpful.