18 September 2014

Doubt, but verify

(My entry to an essay contest.)

I struggled with knowing when I should believe my patients on the locked psychiatric ward. Some of my patients were reliably forthcoming and honest. Other patients’ stories were clearly unrealistic (one told me that he was being chased by black, chainsaw-wielding government robots that travel through walls). And others made prosaic claims (such as their name and age) that sounded credible, but proved untrue. After being misled several times by my patients, my attending physician advised me to become more of a skeptic. I began taking what my psychiatric patients said not just with a grain of salt, but with a heaping helping.

One day, I met a new patient, Jensen, who had been committed to the psychiatric ward that morning. He was a lanky, disheveled-looking methamphetamine addict who subsisted on begging and theft. He lived in a distant town. Fresh out of prison, he had decided to come to our hospital because he had recently contemplated suicide. A staff member who interviewed Jensen on intake suspected that he was malingering in an attempt to score a warm bed and a square meal.

When I interviewed Jensen, I asked why he had contemplated suicide. He replied that he had become depressed ever since his daughter had been raped and murdered by his best friend. I assumed a look of sympathetic concern and expressed my condolences. My empathy was forced, though. I doubted Jensen’s story. And I especially did not want to be fooled by yet another patient.

Over the course of the interview, I delicately obtained more details about the supposed crime: where it had occurred, who had been arrested, where the case had gone to trial. Afterwards, I hopped onto a computer and queried an internet database of news articles. Several articles came up that confirmed Jensen’s grisly story. I felt horrified 
and sickened. I also wondered whether anyone could experience what Jensen had gone through without being plunged into despair.

Discovering the veracity of Jensen’s story forced me treat his pain as real, and to engage with it. When I met with Jensen that afternoon, I felt more sympathy towards him. I told him that my heart went out to him for what he had suffered. Despite our different backgrounds, I felt as though I was beginning to understand him. We seemed to connect particuarly well.

The tragedy that had befallen Jensen gnawed at me that day. It marred my sleep that night. As I mulled over his story, Jensen struck me as someone who had endured a near-mythical degree of torment. Jensen’s life story seemed to be an allegory, one that embodied society’s ills and condemned the cruelty of man.

When I visited Jensen the next morning, he begged me to be released from the hospital. He told me that a friend had offered to drive him home, but only if he were discharged that morning. At rounds, my team decided that Jensen no longer appeared to pose an acute threat to himself. We acceded to his request and discharged him.

I was able to provide Jensen with more humanistic care because I verified his story online. Was looking online the right thing to do here? I am not completely sure, but I think it was. 
When I am curious about how a former patient is doing, or when I want to better understand a patient’s story, I sometimes feel tempted to search online. I nearly always resist the urge, though. “Googling” a current patient is an act fraught with ethical and practical concerns. Some information found online is inaccurate or misleading, and it could inappropriately bias a clinician. Some patients may feel it is improper for their doctors to be searching for them online.

I also worry about the potential to violate patient privacy. Companies routinely store and analyze data that include the search phrases a user types in and the exact location of their computer. If a clinician seated at a hospital computer performed a series of searches on a patient, private companies (and our government) could probably piece together confidential medical information such as where that patient received their medical care and what diagnoses they carried. (I tried to protect Jensen’s privacy by using vague search terms that could not be tracked back to him.)

In the acute psychiatric setting especially, though, online searches could have tremendous utility as a fact-finding tool. Already, psychiatrists routinely solicit “collateral information,” which might include hospital records, police reports, and conversations with family members. The collateral information can reveal whether a patient’s statements comport with reality, clarifying between diagnoses such as psychosis, antisocial personality, and malingering. Another benefit of an online search is that it can vindicate a patient such as Jensen who makes genuine statements that are not believed.

On the whole, I am leery of clinicians’ “Googling” their patients. But I think there are infrequent circumstances in which searching online is warranted, my encounter with Jensen among them. I am grateful for how confirming Jensen’s story helped me connect with him more deeply, and helped me lend a sympathetic ear.

Shortly after Jensen was discharged, I hopped into my car to run an errand. Pulling up to a red light near the hospital, I recognized the panhandler standing in the center median. It was Jensen. He saw me, and smiled and waved. I rolled down my window. I explained that I could not give him money, but told him where he might be able to get a free bus pass home. He thanked me. I wished him the best.

Jensen was standing in the median because he had invented the story about his friend with a car who would pick him up. He had correctly predicted that the ruse would speed up his discharge. And so, despite my efforts, yet another patient ended up fooling me. The difference was that now, I did not mind.

The light turned green. I drove off, never to see Jensen again.

10 September 2014


The excellent PBS program Frontline has put out an insightful and tragic documentary about life in a Sierra Leone field hospital that has been overwhelmed by Ebola.

And the WHO has recently put out a situation assessment of the state of the virus in Liberia.

Also, I recommend the well-written blog of a Médecins Sans Frontières ("Doctors Without Borders" in the U.S.) obstetrician who until recently was on the front lines.

Together, these items paint a sobering picture of the state of the current Ebola outbreak.

Ebola outbreaks can be halted (and have been halted on the past) through known methods, in particular by isolating sick patients and following up with their close contacts who may have been exposed, as well as by partnering with communities to stop risky behaviors such as funeral practices that involve touching the dead body. Although vaccines and experimental therapies are promising, we need not wait on them. Perhaps with significant investment from the international community, the tide will turn in the battle against Ebola.

02 September 2014

The unacceptable

Walking one day, I spotted one of the Google self-driving cars. It looked similar to the other cars in the road, except that mounted atop the car was a spinning apparatus that constantly scanned its surroundings.

I was quite glad to see it.

Another day, while walking from the hospital, I heard a medical helicopter overhead and looked skyward. The helicopter was swooping towards the landing pad with haste. I figured that this was not a routine transport, but a medical emergency. I spun around and headed to the trauma bay to see what was up.

An alert on the emergency department's computer screen filled me in on some of the story: the helicopter was carrying a child who had been struck by a car and was now in cardiac arrest.

The trauma bay was buzzing with activity. A pharmacist was busy drawing up medications. The trauma surgeons were contemplating their plan of action. The X-ray tech was wheeling in his machine. I perched myself in an out-of-the-way corner.

The patient arrived, bloodied and pale. Worried personnel were doing chest compressions. A nurse hooked the patient up to the heart monitor, and the head doctor asked the medical team to stop compressions (so that the heart monitor could detect the patient's heart rhythm). The patient was still. We looked at the heart monitor: it showed simply a flat line. An ultrasound confirmed that the heart had no activity. There was nothing to be done. "Time of death..." intoned one of the physicians.

This patient had been killed by a car while walking to school, becoming one of the approximately 33,783 motor vehicle fatalities that occur each year in the U.S.

A leading social scientist once wrote, "the history of public health can be written as a constant redefinition of the unacceptable."

I submit that this patient's death by car should be considered not just a tragedy, but an unacceptable tragedy. As I've written previously, a major solution to these automobile deaths lies on our doorstep: the autonomous car. With a concerted push for further research and development, many of the cars on the road could drive themselves, identifying hazards and preventing crashes.

But to get there, we need to decide that automobile fatalities are unacceptable. New York City has taken a commendable step in this direction, inaugurating the "Vision Zero" program. Below is an excerpt of the City's justification for the program:
The primary mission of government is to protect the public. New York’s families deserve and expect safe streets. But today in New York, approximately 4,000 New Yorkers are seriously injured and more than 250 are killed each year in traffic crashes. Being struck by a vehicle is the leading cause of injury-related death for children under 14, and the second leading cause for seniors. On average, vehicles seriously injure or kill a New Yorker every two hours.

This status quo is unacceptable. The City of New York must no longer regard traffic crashes as mere “accidents,” but rather as preventable incidents that can be systematically addressed. No level of fatality on city streets is inevitable or acceptable. This Vision Zero Action Plan is the City's foundation for ending traffic deaths and injuries on our streets.

New York gets it. I hope the rest of the country will follow. And perhaps within my lifetime the automobile fatality can go the way of smallpox, eradicated for good.