Medical School 2020, Year 3, Week 29 (family medicine, week 5)

We start at 7:45 am to read up on the ten patients we’ll see this morning at the clinic. 

The 37-year-old nurse (from week 25) with a large MCA stroke and amputation after subacute bacterial endocarditis (presumably from a dental procedure) is the first to arrive. Two days ago, she presented to the ED as a stroke alert. “We were driving back from physical therapy,” said her husband, “and she just seemed confused. She would ask me something that I had just answered a few minutes ago. I was frustrated and annoyed until I realized that something was amiss. I turned the car around and we headed for the emergency room.” The community hospital ED physician called a stroke alert, which initiated her ambulance transfer to the stroke center and the ensuing work-up: CT head non-contrast, CT head angiogram, CT perfusion study, MRI brain, and transesophageal echo. The headline bill could easily exceed $50,000. After six hours, she’d gotten through the first CT scans and her symptoms had resolved. I look at the imaging studies from the Epic web-link to the picture archiving and communication system (PACS, made by Sectra, a Swedish company ). The patient has no memory of the incident prior to reaching the second hospital. Great anatomy for me to go over, especially with her prior MCA infarct, but nothing acute.

The husband repeats the story when Doctor Dunker arrives. “Did she ever slur her words?” asks Dunker. “No, she just kept asking the same questions.” Doctor Dunker: “And she never had any weakness or sensory deficit on her notes. I don’t think she had a transient ischemic attack [TIA, a “mini” stroke that resolves within 24 hours]. This sounds like transient global amnesia where you are unable to remember new events [anterograde amnesia].”

If she was an “observation patient,” their private insurance might have paid only 80 percent of the hospital bills. Between the previous physical therapy bills and the new flood of charges they’re nervous. I ask if they might qualify for Medicaid. The nurse: “We would have to spin down all our assets, we’ve worked too hard. My husband worked two jobs to pay off the mortgage.” The husband: “It’s demoralizing though, we don’t know what to do.” Dunker: “I am so sorry to hear this. First, if she has another episode like this you don’t have to go to the emergency room. Call here. Of course, if she has slurred speech or weakness in the face or arm, head straight to the ED, but what she had is not a stroke.” He also informs the family about our health system’s charity programs.

After the visit, he explains to me: “I don’t understand some of these ED providers. Why did they order a full stroke work up? She didn’t have any focal neurologic deficits. I can understand getting an MRI to rule out a small infarct, but why does she need a $10,000 CT perfusion study? She is not a candidate for endovascular treatment, and is way outside the window for tPA [tissue plasminogen]. These patients break your heart.”

My next patient: A 61-year-old presents for a two-day history of pain and swelling in his left big toe that started two days ago after his daughter’s wedding. I ask how much he drank? “You know, a couple beers. I was celebrating!” What was served? “A bit of everything, fish, steak, chicken.” My diagnosis: “It looks like a gout flare to me” and explain that we will get some lab work and probably start him on high dose NSAIDs for the pain.” Doctor Dunker agrees that this is his first gout flare and we ordered a uric acid level and started him on ibuprofen. 

Our clinic holds a party to celebrate one of the doctors becoming a citizen. He went to medical school in his native Philippines and then did a U.S. residency. He explains, “There are two options for a foreign medical resident. You can go back to your home country for two years and reapply to work in the US, or you can work two years in an underserved area.”

The area continues to be “underserved” for the afternoon because I have to leave to attend a required “Bystander Awareness and Responsibility” seminar. This is organized by our university’s dean and head of the Office of Inclusion and Diversity and subtitled “A sexual and relationship violence prevention workshop for establishing a community of responsibility.”

The first activity involves the lecturer and her two full-time coordinators asking students to shout out examples of inappropriate conduct. Each is placed on an axis of socially recognized “inappropriateness”. Rape and murder are on the far right; “a bystander would recognize someone being raped is bad and act on seeing this.” We learn that a man yelling at a significant other rates lower on the agreed-inappropriate scale than rape and murder. (Every example of inappropriate conduct featured a male perpetrator.)

Next is a PowerPoint on the Pyramid of Oppression. The small sliver at the top is labeled “core offender” and is supposed by “facilitators” and “apathetic bystanders”. The foundation of the pyramid is labeled “sexism, transgenderism, strict gender roles”. “By changing these stereotypes we can stop the cycle of violence,” explains the dean. “The power dynamics in society camouflage and empower perpetrators.”

She then asks the audience to read out loud in unison statistics from the powerpoint slide:

1 in 4 women will be a victim of assault

30 percent of college couples report at least one incidence of physical aggression.

90 percent of college couples report at least one incidence of psychosocial aggression.

(No sources for these statistics were provided on the slide or elsewhere in the presentation.)

The Dean of Inclusion and Diversity adds “The vast majority of women tell the truth about rape. Only two percent are considered false stories, but this is probably an overestimate because many of those ‘false’ statistics are because of recantation. We can speculate that many of those recanted accounts were withdrawn because of fear and embarrassment.”

We then discussed several cases in groups of 8. “How does the power hierarchy impact the way you as a bystander would behave?”

Case 1: As a bystander, you walk by the surgeon lounge and notice a resident is making two medical students watch pornographic content on his phone.

Reponses:

• Pinterest Penelope: “I would never question the resident, we’d get bad evaluations!”
• Straight-Shooter Sally: “I’d provide feedback on the anonymous evaluation form.”
• Lanky Luke: “I felt that residents were just as afraid of medical students as vice versa because we write evals about them as well.”

Case 2: Several students are having a discussion in a hallway. A male patient comes out looking for ice chips. He asks for assistance from one of the students, referring to her as “honey” and slaps her backside before walking away.

Suggestions from the handout: “I never thought something like this would happen – it’s 2019!… No one is reacting… maybe it’s not that big a deal?… That student looks mortified… I’m uncomfortable with what just happened… does this have to do with gender?… This is a patient, though. Can we say anything?… What if we say something and the patient gets mad?… Should we just let this go?… If we do, will this patient continue to treat all of us and the other staff this way?… What should I do?”

Case 3: A student is asleep in a call room. Someone else (another student) goes into the room even though they know it is occupied. They don’t come out right away, and you aren’t sure that anyone else has noticed.

On Facebook, Type-A Anita comments on Joe Biden’s remarks about asking permission before hugging onstage at a campaign event: “If you think it’s appropriate to joke about making a woman uncomfortable by touching her without her permission, you’re not only out of touch, you’re also an asshole. Boy, bye.” [reference to Beyonce’s song “Sorry”]

Statistics for the week… Study: 6 hours. Sleep: 6 hours/night; Fun: 1 night. Example fun: Grilling with Lanky Luke and Sarcastic Samantha.

The rest of the book: http://fifthchance.com/MedicalSchool2020