Patient Autonomy

When I was in clinic today, my preceptor (Dr. M) told me about a patient he saw last week. An 86 year old man came into the office with his son and daughter because of altered mental status. His children reported he has been getting progressively more confused and the patient could barely stay alert during the office visit. At one point, they had given him coffee to try and help him stay awake, and he felt asleep holding the coffee, ending up spilling it on himself.

Altered mental status in an older patient is never a good sign, so Dr. M discussed going to the emergency room with the family. The patient was insistent that he didn't want anything done to him and he certainly didn't want to go to the emergency room. Dr. M and the family compromised and decided to do blood work in the office that day and set up an appointment to get a CT scan the next morning (to rule out stroke, etc...)

The blood work came back the next morning with HUGELY elevated liver enzymes and some other minor elevated electrolytes. Dr. M immediately called the daughter to advise them once again to go the hospital. He even arranged for a hospitalist to admit them directly, so they wouldn't have to wait in the ER. The daughter said the previous night had not gone well, so she would discuss it with her brother and father. She later called Dr. M back that day to tell him her father had passed away, not wanting to go to the hospital.

This story bothered me. At the core of it, lies the issue of medical ethics. One of the four pillars of medical ethics is patient autonomy -- you can't make a patient do something they don't want to do, but as their doctor, you feel a certain level of responsibility for their well being. So what do you do? Can you force someone to go the ER? If someone has resigned themselves to death, but you know there is an easy way to save them, do you just let them die? I think it's one of the bigger lessons in medicine that I'll have to learn -- to accept that you can't control everything, sometimes it's the disease and other times it's the patient's will.

Becoming comfortable with the uncomfortable

Today we learned/performed the male GU exam. An important exam, no doubt, but an uncomfortable one for the patient as well as the doctor sometimes. The male GU exam involves examining the genitals, feeling for hernias, and doing a digital rectal exam to check the prostate.

It was a lot easier/less awkward than expected.

First of all, our standardized patient was fantastic. He was completely comfortable teaching us how to do a proper exam, and I think his comfort level put us all at ease. Any man that is willing to go through 8 consecutive prostate exams by first year medical students is someone who really cares about us learning for sure. It was really helpful to have instantaneous feedback regarding our exam technique (too much pressure, too little pressure, try a different angle, etc...)

Afterward, we had a "debriefing" session with the urologist where we discussed how to handle different patient reactions during the exam (he's had people get so nervous that they faint), which is also a really important aspect to think about.

I have to say, it is SO nice to have the first male GU exam out of the way-- probably one of the most awkward experiences is past.

P.S. Heading out to Haiti in 4 days -- so crazy!

Firsts

Today was...exciting.

I did my first pap smear.

I drew my first blood sample.

I did my first IV line (ok, so that one was on a simulation mannequin)


I volunteer at the low-income health clinic fairly regularly, but I never have the confidence/comfort level to volunteer to do any of the more procedural based activities (pap smears, blood draws, etc.). I don't really know what was different today, but I said yes whenever someone asked me if I wanted to try something new -- and it was awesome!