Saturday, December 20, 2008

"Studied calm"

I'm still reading Jerome Groopman's book "How Doctors Think", and I still highly recommend it to you. Not only does he illuminate the processes--some good, some ill-considered--that doctors use to arrive at clinical decisions, he recommends various participation strategies to patients that they should use to keep their doctor on an objective path to a diagnosis.

Dr. Harrison Alter is an ER physician that Groopman interviewed for this book. Alter notes that the emergency room atmosphere can be hectic and chaotic, and he personally works on fostering "studied calm, consciously slowing his thinking and his actions with each patient in order not to be distracted or pressed [into a hasty decision]. "

Well, you don't have to practice in an ER these days to feel pressed for time. I too have to make a conscious decision to slow down and forget the schedule, settling into my chair and focusing on the patient and what she's saying. Sometimes, this take-a-deep-breath-and-listen attitude pays off big-time.

I was running nearly 15 minutes late when I called Ms. V in from the waiting room. She's a 70-something dynamo, raising her teen-aged granddaughter and taking care of her ailing spouse. The previous morning, she'd had nothing to eat in preparation for a glucose tolerance test. After two hours at the lab where she drank the hyper-sugary Glucola and had hourly blood draws, she headed home, lightheaded and nauseous. Once there, she proceeded to begin cleaning the kitchen, leaning into those counters with her usual elbow grease. Moments later, she dropped to the floor, hitting her head and not really coming to until the paramedics arrived. While she was cleared for home at the ER, the doc there urged her to follow-up with me.

Ah, that is so you, I said to Mrs. V, cleaning up in lieu of relaxing over a late breakfast. On the other hand, I thought, it is so not you to faint. Groopman warns against making clinical judgments based on what we know or expect about a patient. I checked her goose egg of a lump on her head, took her blood pressure, then asked "So anything else going on?"

Well, she said, she'd been having episodic shoulder pain, did I think perhaps she had strained a muscle? And she'd nearly fainted in the Sears parking lot the week before. Ms. V has hypertension, high cholesterol, pre-diabetes, and her EKG at my office looked vaguely abnormal. I sent her directly to the hospital for admission to the cardiology service, and the following morning they put a stent into her nearly obstructed main coronary.

Here's to studied calm.


Cilicious said...

Good thing you asked her what else is going had your thinking cap on correctly that day. :)

Midlife Midwife said...

Wow, great catch Denver Doc! I will have to work on that "studied calm". I have the book...just trying to find time to read it.

Mauigirl said...

Wow, you are good. I'm glad you dug into it deeply enough to realize what was going on.