Personal experience is one of the best teachers--for physicians as well as patients.
Personal experience is one of the best teachersfor physicians as well as patients.
The older I get, the more enlightening medical experiences I havenot so much as a physician, but as a parent, a spouse, and a patient.
I was reminded of this recently when I countersigned a first-year family practice resident's prescription. "That's not enough antibiotic to give this 18-month-old," I told her.
"Yes it is," she replied. "One teaspoon is 5 milliliters given three times a day equals 15 milliliters a day for 10 days150 milliliters."
"Ever give liquid antibiotics to an 18-month-old?"
"It doesn't always go smoothly. When my daughters were that age, I had to hold their heads between my thighs and squirt one milliliter at a time into their cheeks from a syringe." I remember watching the pink liquid bubble out of their mouths and onto my pants as they screamed. Before my baptism by antibiotics, I assumed children took medication without problems. Now I give a little extra for spillage.
One mother asked me for a referral to a psychologist because she was worried about her son's temper tantrums. "I spend an hour telling him a bedtime story, then I sit with him until his eyes close. But as soon as I leave, he starts crying and comes downstairs. I don't know what to do."
Pre-kids, I would have echoed the advice I learned as a resident: "Whenever he comes downstairs, pick him up and put him back in his room." Yeah, right.
These days, I start my advice with a little vignette. "That's nothing," I say. "My daughter pulled the screws out of the doorjamb after I held the door shut against her." Then I tell the parents that strong-willed children can tolerate such firmness, as long as their parents reassure them that they're still safe and loved. I now realize there's a vast difference between giving textbook advice and having to follow that advice with your own children.
My daughter also serves as an example to parents worried about their child's high fever. "Rachel had a 106-degree fever when she had chicken pox," I tell them, "and she managed to get accepted to Columbia and Berkeley. So I don't think it caused any brain damage." But I can empathize with them. It wasn't easy to watch her whole body tremble, wondering whether she'd have a seizure or something worse. Remembering this helps me understand patients' anxiety. Sharing my experience reassures them, since they know I've gone though the same thing.
Similarly, struggling with my own illnesses has helped me diagnose the same things in patients. For example, I used to test for Tinel's sign in carpal tunnel syndrome by tapping over the wrist. When I developed the condition, I discovered that the most sensitive area was the middle of the palm, not the wrist. Now I tap all the way from the wrist to the proximal palmar crease, and I've diagnosed some patients who don't have wrist symptoms.
I've learned about diseases from my family, too. I found out about nursemaid's elbow after dislocating Rachel's radial head while trying to stop her from falling off my back during a "horsey ride." It was late, we thought she was tired, and we let her cry herself to sleep. But when she woke up four hours later from the pain, we brought her to the ED. Now when I see a child with this problem, I can instantly fix it by pronating the forearm to put back the radial head. And pointing out that I delayed getting care for my daughter can assuage a mother's guilt for not bringing her child in sooner.
When a patient procrastinates getting treatment for his own problems, I no longer ask, "Why did you wait so long before coming in?" I've done it myself. I developed a tinea infection that began in a 1-centimeter patch and then enlarged over the next few days. I ignored it until it covered a 4-centimeter area and the itching became too intense to bear. Fortunately, the cream I used rapidly shrunk the patch. But just like many of my patients, after the itching stopped, I forgot to apply the cream. The rash roared back, covering a 4-by-6 centimeter area. It resolved only after I found a way to remind myself to apply medication regularly.
And I no longer rattle off instructions to patients, expecting them to remember and carry them out. I learned how hard that was after I was diagnosed with reflux esophagitis and started on several medications. When my physician adjusted my medication regimen during a follow-up visit, I had to take notes. And when I reported back to my wife, I had to consult them to remember what he'd said. Now I write out instructions for patients or give them a handout.
My reflux esophagitis also taught me to seriously encourage lifestyle changes for the treatment of illness, rather than just giving them lip service. When the esophagitis didn't completely respond to medication, I stopped drinking alcohol, propped up the head of my bed, and avoided eating anything for three hours before bedtime. Those simple measures worked better than the $4-a-day pills I'd been taking. Now I share my experience with patients and tell them they have to take some responsibility if they want to get better. If there were a magic treatment that didn't require restrictions, I say I'd be taking it myself.
Not everyone wants to hear about my medical problems, though. One patient said, "You always talk about your kids and yourself, but I'm here about my problems." Since then, I've kept my advice short and monitored patients' expressions for feedback on how they're receiving my advice. But I still think it's helpful for patients to know I struggle with the same problems they do, and that I'm not asking them to do the impossible.
Gil Solomon. Experience is the best doctor, too. Medical Economics Dec. 9, 2002;79:87.