Prescription Medicine

Danny Green, a star basketball player for the University of North Carolina, had a tough week in the middle of March this year just as March Madness was getting started.  He's known for his exceptional shooting skill yet Green was 3 for 25 in two games and even missed three layups. I mean, come on, I can make a lay up. The media was all over him.

It would be easy to slip into a serious funk. It would be easy for his coach, Roy Williams, to tell him to shape up, pay attention, be a stud, whatever. It would easy for Green to think it's over. He's finished. He's lost his mojo.

Instead, what was did Roy Williams tell Green?

Keep shooting.

Green took his advice and within a couple of games, found his mojo and UNC won the National Championship.

You can think things are too hard, or why bother, or it's not worth it. You can quit. You can go hide somewhere and sulk. Injuries tend to do that to you.

Or, you can keep shooting.

DK

From About.com:

"A home exercise program is essential to doing well in your rehabilitation program. If your physical therapist has not reviewed several exercises for you to do at home, you should ask to do so. A home exercise regimen should be performed two to three times per day. Being active in your own rehab will greatly pay off!"

Ok, so this pushes a button. I admit it. Global, one-size fits all, you-should statements are useless.

I agree with the first sentence - sort of. I think a better word is "independent" or "unsupervised". You may not be doing the exercises at home. The term is a hold over from a hospital based practice environment. The patient is about to be discharged and they need "home instruction" which turned into "home program". It's not in sync with reality. It is essential, at some point, for you, as the client, to be able to execute a plan on your own that will maintain your improvements. Agreed.

The second sentence seems reasonable. Any client would likely want to know the answer to, "What can I do at home or on my own?" Now, depending on the case, all that the person might really be able to do is to change sitting positions, sleeping positions, duration of sitting, etc., to relieve symptoms, for example, of back pain. None of these things are "exercises" but all of them are part of an overall plan. And, why is it so important that you, the patient or client, get "several" exercises? What's wrong with one or maybe two that really work?

Third sentence. Wait a minute. Just exactly what should you be doing two to three times per day? Quad sets? Ok. I'll buy that. Jogging intervals? Don't think so.

Exercise is controlled trauma. Used wisely, exercise can heal injured tendons, ligaments, and bones; strengthen muscle; improve posture. In fact, mechanical load via exercise is the most important thing in your life. Without it, you die. Through exercise, you stress tissue. Through rest and recovery, that tissue adapts; grows stronger. Too much exercise with too little recovery leads to progressive weakness.

Part of the problem is that some clinicians use passive techniques (massage, mobilization, physical agents like ultrasound, etc) as their primary intervention and leave the "exercise" up to the patient or client to do on their own. So, if the patient has not been instructed in a "home program", then, well no exercise happens. The decision to use manual therapy or a physical agent or exercise is a clinical decision making issue and one that cannot be solved by a blanket statement that everyone should be on a "home program" and should be doing that program two or three times per day. That's just stupid.

To suggest that somehow a physical therapist has missed something because he or she did not prescribe an exercise to be performed two to three times a day is like saying a physician goofed by suggesting you should take a medication only once a day. It depends on the problem and the "medicine" you've chosen.

"Being active in your rehab will greatly payoff!" Only if you're doing the right things the right way.

More is not always better. And more at home could be a disaster.
DK

52

Do you know me now?

What does “age” tell us?

What if my blood pressure is too high, my cholesterol is out of control, I can do 2 push ups, cannot stand on one leg for more than 2 seconds, cannot walk around the block or up a flight of stairs without being winded?

And what if now I told you I was 32?

Age is not a number. Age is a collection of numbers.

Focus on the collection.

I’ve said a lot of goodbyes over the past few weeks–classmates, old friends, family, exes, and now you, my dear readers. (Yes, yes, say it ain’t so!)

I started this blog almost 5 years ago (wow) to document the process of becoming a doctor, write about health policy, explain medicine, and provide an outlet to process and reflect on the things that I experienced. By all possible measures, I’d say it was a success.

The further I got into medical school, the harder it was to remember or understand what it’s like to be a patient–in terms of the knowledge and the experience. It’s hard to remember what it’s like not to know what a drug does, or the pathophysiology of CHF, or when a patient is ready for discharge. I think this is one of the biggest challenges we have to overcome–becoming doctors by definition requires us to enter a different space than our patients, yet we still must communicate and explain without trying to over- or under-simplify.

And along the way, I guess another goal was to show people that doctors are simply fallible humans that are, in the vast majority, trying their best, but are prone to the same flaws and errors and mistakes that all of us are. It just sucks that our mistakes have much bigger consequences. I will always strive for perfection in my practice of medicine, but know I will never achieve it. I wish more patients would realize this.

Thanks for all the comments, support, criticism, and linkage over the past 5 years. This book of my life is over, but who knows, you may see me again. My goals right now are to hit residency with a running start, learn New York, meet friends, find some love along the way, and if I find that I still have time to blog, perhaps I’ll be back. It’s been a great 5 years!

(I’ll be moving the archives over to http://www.grahamazon.com/over/ in the next week or so.)

And the text:

Good Afternoon Dean Pizzo, family and friends, colleagues, The Guy Who’s Totally Uploading This To YouTube Right Now, The Undergrads Who Heard There’s Free Alcohol Afterwards, and of course, my fellow classmates, the Graduating Class of 2008,

Britney Spears once famously said, “Hit me baby—.” That was my ORIGINAL version of the speech. You weren’t supposed to hear that. Awk! Ward! Blarg. Wow. Uhm, okay. Let’s just pretend that didn’t happen.

Hannah Montana once famously said, “We. Need. Single-payer national health insuran—.” Okay fine, she didn’t. But, I’m kind of known for ranting about health care reform, so everyone probably thinks that’s what I’ll talk about today. But don’t worry. I won’t. Today, I would like to talk about something that’s been bothering me: name-calling.

During medical school (and my entire life) I’ve answered to just about any variation on the theme: Graham, Graham Cracker, Grahamazon, Grahambo, Grahamakin Skywalker, “Hey you,” Kilo, Graham Stain, Graham Positive, Graham Negative, and even, as one attending who didn’t care to learn the names of her students called me, “a medical student,” with the same tone one might use to ask, “Could you hand me a pen?” Man, I’m really going to miss medical school!

But lately, most people have been calling me doctor, and I’m not sure if I like it. Sure, people have said it all throughout medical school, but I always had sufficient grounds to correct them: “No no, not yet, I’ve still got 6 more months to go,” or “Gosh, I wish, but I still have to pass my boards!” But lately, I haven’t had a leg to stand on.

It’s almost as if I don’t want Graduation Day to be here. But too late now. Change happens. Today, we’re becoming doctors.

I remember at orientation an upper-classman saying that we probably thought becoming a doctor was a noble, selfless act—but any of you in the audience can easily vouch for how selfish it can be. We have demanded your patience, love, understanding, compromises, and support for all these years. So up front, I want to say to each of you, from all of us up here, I am sorry. But I promise to do better next time. Not to forget slash have to reschedule: your birthday, our anniversary, the dinner reservations we had, or that trip to Mexico.

But truly, we could not have made it this far without you. Not to get all Mr. Rogers on you, but to us, you are special. You are why we are dedicated to this: because our patients have their own families and friends like you. You are the selfless ones…not us. So from the deepest reaches of our hearts and souls, thank you so very, very much. Today, we celebrate becoming doctors as much as we celebrate you.

I guess I really worry about how the title of Doctor defines you. How it changes you. That I’m becoming a little bit more Doctor Walker, and a little bit less Graham. Sure, the title affords me some prestige and privilege—for example, complete strangers will now feel totally comfortable whipping out their strange moles at dinner parties—but at the same time, it makes people see me as primarily—or only—a doctor, not as a son, brother, partner, computer nerd, or Trader Joe’s enthusiast.

Maybe this is how it’s supposed to be. Maybe that’s the purpose of the title. To remind us and others of the Oath we take, or that patients’ needs are to come before our own.

But if becoming a doctor will change how people view me, there are several values I’ve learned here at Stanford that should get to represent me, too. And I have numbered these values, as I am going into Emergency Medicine, and have a short attention span. Oh, and just a sidebar: The next time you want to complain about your hospital’s Emergency Department, please remember that we’re probably getting distracted by… oh, I don’t know, coding patients, big traumas, (mumbling) bodily fluids being flung… at… us, or… … shiny… things.

Sorry. Back to my values:

Number one: I will continue to use objectivity, without forgetting the subjective.

Medicine is an art grounded in science. I’ll do my best to know the studies, the data, and the pathophysiology, and try to apply them objectively.
But I won’t forget the patient. I’ll listen. I’ll be compassionate. I’ll try to keep social context, “chief concern,” and patient perspective in mind.

And number two: I promise to ask questions, and on occasion dare to admit: “I don’t know.” And thank you to Stanford for encouraging this—in Gil Chu’s class, where we weren’t allowed to leave until we had collectively asked him 10 questions; with Dr. Wolfe, who teaches students to admit their own “Areas of Ignorance.” We are a generation of physicians who are unfortunately (or fortunately) still human. We are not gods. We still make mistakes, and we still don’t have all the answers. But, hopefully, we’ll know where to find them.

Number three: Don’t mess with the pancreas. Or, in the famous words of master pancreatic surgeon Dr. Norton, “I’m tellin’ you, don’t mess with the pancreas! You gotta believe me!”

And number four: I promise to be involved. Whether it’s researching, teaching, advocating, or volunteering, I will remember that health and medicine are often advanced and affected more by time spent outside a hospital than within one.

While passing clerkships and boards and memorizing facts may make us doctors today, it’s our values that will drive us to become great doctors, like the many we have met here at Stanford. Because the great physician is dedicated to the truth, but also to patient. She is a scientist, but also a healer. He tempers prognosis with hope. I think Kurt Vonnegut sums up medicine’s curiosity and compassion better than I ever could: “We are here to help each other get through this thing, whatever it is.”

So, today, fellow classmates, this is it, for better or worse. When our patients call us doctor, they’ll finally be right. (How scary is that?) While our profession may change how we see the world, or even how the world sees us, we must keep a part of ourselves the same. That part—our goals and our values—is what has gotten us to this point, up on this stage. You can call me Dr. Walker now, but I promise to remain just Graham. I’m too proud of each title to be dropping either anytime soon. Thank you.