Patient

[liv]

I think working in a medical school may have irrevocably messed up my interactions with doctors.

I've had a minor cold more or less since I got back from spending several hours on a plane with lots of disease vectors and recirculating air. And although it's not making me feel particularly ill, it's also sitting on my chest and making me constantly on the verge of asthma. I haven't been able to start up my regime of running again; I tried once and was severely breathless by the end of the brisk walking warmup, and had full-on asthma symptoms after 5 minutes of very gentle running, so at that point I sensibly gave up, took my inhaler, struggled home (could barely manage the uphill part of the walk in that state), and endured an uncomfortable couple of hours. And I'm waiting until it stops being painful to take deep breaths before I try again.

I decided that seeing a GP was probably the responsible thing, not because I really expected them to be able to do anything about a cold, but in case they had any sensible asthma-related advice, and because you're supposed to check if you have even minor symptoms for longer than a couple of weeks. The uber-fancy, newly renovated practice has signs all over the place saying that as of summer 2013 they're a teaching practice and they may ask permission for a medical student to observe your consultation or indeed lead it under the guidance of a qualified clinician. That would be our medical students, very likely people I taught during the more campus-based part of their course.

Anyway, I wasn't asked if I would be willing to guinea-pig for a medical student; instead I had an appointment with a GP trainee (that is, someone who is qualified as a doctor but not yet qualified as a GP). And he asked me if he could video the consultation in order to have his consultation skills assessed and possibly provide training materials for the medical students. Knowing how hard it is to get enough footage of genuine (rather than staged) consultations, and how valuable that material is educationally, I was totally happy to say yes. I asked not to be videoed if we ended up removing my shirt in order to listen to my chest, because I don't mind generic hypothetical med students seeing me topless, but it could be awkward in the case of my students. This wasn't a problem; apparently even if I hadn't specified it's normal practice to switch off the video for any part of the process that involves disrobing.

So I sign the consent form, and the doctor asks me to leave the room, knock and re-enter, so that he can demonstrate his ability to open a consultation according to the standard protocol, without the distracting discussion of the video camera. And he proceeds to take a history which ticks most of the boxes in the checklist of good consulting skills. Thing is, not only have I been the person ticking off which criteria were met, I know the Prof and most of the team who did the research leading to devising the checklist. I know what's on the checklist, and I am pretty familiar with the evidence for why it's in the format it is.

One of the items on the checklist is explaining technical medical stuff. So this young trainee gives me a careful explanation of how colds are caused by viruses, and how the body responds to viruses by activating the inflammatory response, and how ongoing inflammation leads to bronchospasm, which is contraction of the muscles in the parts of your lungs which etc. Not wanting to mess up his precious training video, I nod and make encouraging noises, and refrain from pointing out that, one, I'm a cell biologist, I understand the inflammatory response well enough that I could have corrected minor errors in his account. And two, I have had asthma for more than 30 years (I would guess probably since before this guy was even born, though he could just about be my age), I have a pretty good idea what bronchospasm is.

He stepped through a bunch of diagnostics that I'd pretty much already crudely run on myself, ruling out opportunistic bacterial infection and embolism, and graciously explained what he was ruling out and why his conclusions from the evidence were that, to nobody's surprise, I have a cold which is caused by a virus and I have to wait until it goes away on its own. I was in some ways quite proud that I had already thought of most of the likely scary interpretations for my symptoms and that I had already decided for myself that they were unlikely; apparently I've picked up more than I thought I had about how to do a respiratory history just from hanging around while other people learn about it! I mean, I don't trust my own judgement in this because even a qualified doctor shouldn't self-diagnose like that, which is why in fact I went to see this poor trainee in the first place. But yeah, he did pretty much what I would have predicted he was going to do.

He didn't quite go as far as to say outright that he was giving me advice even though there's nothing useful I can actually do, because research shows that patients feel more satisfied if they go away with advice. But I could pretty much see him thinking it. The advice was to increase the dose of my preventer (*sigh*; I am unconvinced it will actually help given that this asthma is caused by an inflammatory response to the infection and not an allergic response, which uses a different pathway, but anyway, it won't hurt much either), and to eat lots of ginger, honey, lemon and echinacea. I must have failed to hide my skepticism, because he assured me that ginger genuinely does have anti-inflammatory properties and they have to tell patients on certain medications to avoid it in their diets. I went home and looked up the excellent meta-analysis of dietary supplements with claimed medical properties infographic, which puts echinacea in the promising category, though what the Cochrane review actually says is

Echinacea preparations tested in clinical trials differ greatly. There is some evidence that preparations based on the aerial parts of Echinacea purpurea might be effective for the early treatment of colds in adults but results are not fully consistent.

So, pretty equivocal, then. Interestingly the infographic lists ginger only as an anti-nausea treatment and doesn't mention anti-inflammatory effects at all. Maybe I should have challenged the doc for the evidence base of his recommendations, but I felt kind of sorry for the poor guy. And it would probably have made the video less useful for teaching, because it would have made me less like the typical patient I was pretending to be.

Comments

[lilacsigil]

Ginger can increase the risk of bleeding when taken with NSAIDs so is generally not recommended in combination, but I can't recall it actually being anti-inflammatory in itself.

I was a practise patient for a medical student recently but unfortunately it was one of those things where I'm under specialist care for a complex and unusual situation so I had to instruct the doctor on what my blood test results were meant to be. Oh well, I suppose it's good for them to see that information comes from lots of sources!

[liv]

Thanks for that about ginger. "Can interact with medications" is not really good evidence for "is medically effective", and I'm a bit peeved that the doc tried that line with me.

And yeah, having to instruct the doctor about interpreting your blood tests sounds like a slightly unfortunate situation for training. I know we do teach our medical students that patients with chronic conditions are likely to be more expert on their medical stuff than most of the doctors treating them, but that's a slightly different scenario from generally having a medical-ish background.

[lilacsigil]

Fortunately there were other things in the consultation as well so the student got to see those too!

[highlyeccentric]

At least ginger is tasty? I recommend versions of this soup for all your ginger-lemon-garlic needs. Or the greek lentil soup I posted a link to a few days back.

[liv]

Thank you! Pretty much what I did was come home from this appointment and make your Greek lentil soup. Only I garnished it with fresh grated ginger instead of more rosemary, because why not? Thanks for the feisty soup rec too; it's fairly similar to the absolute basic tomato soup I do, and definitely a good thing to have in my repertoire.

[highlyeccentric]

The chilli in the feisty soup is a stroke of genius. I'd normally use sweet paprika in a tomato-based soup, but chilli and lemon... mmm.

[kaberett]

I think that training experience of People Like Us is actively useful, actually. ETA I mean clearly we're a relatively small proportion of the population, and clearly having enough training material about people not like us is also a major concern, and clearly you are very well placed to make the call as to which is more helpful! But also, doctors not getting pissed off that I keep up to date with developments in the study of my chronic conditions would be nice. [Ditto it would be nice if doctors didn't prescribe me oral steroids in spite of the repeated boldface warnings about DO NOT GIVE TO ANYONE WITH EVEN THE SLIGHTEST WHIFF OF A FAMILY HISTORY OF DEPRESSION, then tell me that I'm anxious ~because I'm coughing~ when I reappear 16 hours later in one continuous massive panic attack.]

(I am never forget the poor kid on rotations who was observing one of my appointments with my gynae. I got called in. Gynae is all "... so have I operated on you?" I responded "yes, on date." He looked gently baffled and said "... did I find any endometriosis?" I said "yes, [details x y and z]," at which point he cut me off and went AH yes I find your notes now, cool, so, what are we here for, and went off into a proper high-level discussion with me.

... the poor kid looked increasingly horrified as I gave a detailed accounting of my medical history using correct terminology and my consultant just accepted it. I mean, my consultant is great, I've been seeing him for years and I wouldn't have him any other way, not least because for all he can't do paperwork and he is incredibly forgetful he is very competent and treats me like a scientist.)

[liv]

I mean, absolutely, you're right, doctors do need to be able to handle people who are highly medically knowledgeable and a lot of the time they do a poor job of it. But I think you probably want to be teaching that specifically in a context where you're intending to teach it, not necessarily in the middle of a training session about, this is how you introduce yourself, this is how you establish a rapport, this is how you work systematically through asking all the questions you need to know about the history, this is how you reflect back to the patient to make sure you've understood what they said correctly, this is how you ask open questions to encourage them to tell you stuff you haven't thought to ask about...

Also, there's a problem in the opposite direction, that a lot of the time doctors practise their consulting skills on peers or trainers and the kind of people who volunteer to become model patients. And there's a bit of a tendency for those people to be more articulate and more medically knowledgeable than the general population. So doctors trained like this may meet people who, you know, aren't up on the latest research and don't know medical jargon, and assume they're totally ignorant and stupid.

We do actually teach our medical students about the sociological research on expert patients and how to handle people who know more medical science, and certainly more about their own conditions, than the doctors do. The ideal is that you want people to be really flexible and adapt to the level that's appropriate to the person they're talking to. That's a pretty advanced skill, though, and first of all you want to get the basics of asking questions in a structured way and eliciting information from people who might not necessarily know the medical implications of what you're trying to find out from them.

I am glad you have a consultant who gets this particular thing right and acknowledges your scientific training; that's the kind of doctors I'm trying to develop, I promise, and it's not just me, it's the whole ethos of the medical school. But yeah, actually listening when patients report adverse effects is basic, it really shouldn't matter whether they're scientifically knowledgeable or not, it's utterly atrocious to do anything else.

[karen2205]

My experience as a lawyer dealing with legally knowledgeable clients is that once you've got the basic skills sorted and you're feeling reasonably confident in your own abilities, it's easy to differentiate what you do up to match their level of understanding and not much different to the equivalent opposite skill of repeating/simplifying/checking understanding etc that you do when someone isn't following or is confused.

Mainly for me the skill is in being prepared to say "I don't know, I need to check xxxx" or "it's probably xyz, but might also be abc" and communicating around the limits of my knowledge/about uncertainties.

[liv]

That's a really interesting point. Adapting to someone who knows as much as or more than you is a similar skill to simplifying for someone who knows less. I think it may be culturally harder for doctors to admit to not knowing than lawyers. I mean, they can admit they don't know what your symptoms mean, because there's always uncertainty around that, but they can't admit they don't know what the underlying mechanism is. But I do admire you for being able to communicate in that way, it's really critical that people in positions of trust don't invest ego in pretending to know something they actually don't!

Communication

[(Anonymous)]

[i]Mainly for me the skill is in being prepared to say "I don't know, I need to check xxxx" or "it's probably xyz, but might also be abc" and communicating around the limits of my knowledge/about uncertainties.[/i]
Excellent point which should be broadcast widely.
When I started training as a patent attorney, I was interviewing highly skilled inventors whose minimum qualification was a Chemistry PhD, whereas my maximum qualification was A Level.
Every professional will tell you that it is fatal to attempt to bluff your way through an issue. In addition, I learnt very quickly that I was granted much more respect if I said, "I am sorry. I don't understand thermodynamics. Please explain in simple terms."

I am, of course, telling all of you how to suck eggs but any neophytes may find this useful.

Southernwood

[owl]

Wow, that's useful to know about the steroids. Thanks!

[kaberett]

I am never taking those fuckers again unless I am actually an in-patient.

[emperor]

I try and be polite when interrupting my various GPs to save our collective time! Though I hadn't seen your linked infographic and am intrigued that zinc might actually be useful against rhinoviruses (he says, sniffling through an annoying cold right now).

[liv]

Yeah, I'm always polite, there's no merit in me being a dick about how much medical knowledge I have; I wouldn't want the doctor to do that to me and I'm not going to treat them like that either. I think if we hadn't been doing the video I'd have interrupted and said, yes, I know how inflammation leads to bronchospasm, thanks. But I do think it's good to include the "explain the technical jargon" step in general, so I was happy for that material to make it into the video even if it wasn't directly helpful to me.

That infographic is great, because it auto-updates when there's new studies published. Totally my favourite portal for tracking down the studies of any claimed effects of food supplements.

[jack]

*hugs* Well done for going to the doctor, even though it didn't really help. It was the right thing to do. I hope the cold clears up :(

And well done for cooperating through the taping, that's a good thing. If you get fed up of pretending to be a layman you could mention that you teach in a medical school -- hopefully that's enough to get the doctor to think before saying anything patronising, but not so much they feel you're challenging them. But only if you feel you need to.

I've picked up more than I thought I had about how to do a respiratory history just from hanging around while other people learn about it!

That makes sense. I mean, just seeing it a few times gives you a feel for the most likely outcomes, which are right most of the time.

[liv]

Thank you, supportive Jack! It definitely was the right thing to go to the doctor, I don't feel like I've wasted my time at all. I did want to actually check that the cold dragging on like this isn't a sign of something more serious.

Because I have Dr in my title, the first thing the doctor asked me was "are you a medical doctor" and I said "no, but I teach at the medical school", so he did know that I know stuff. I don't think he was being patronizing, actually, I think he was demonstrating his ability to carry out all the correct steps in a consultation. So I was sort of pretending to be a layman, but only for the camera, not for the doc himself.

[jack]

Oops, sorry, I should have realised that would happen anyway. I don't think there was necessarily anything wrong in this session, though I got the idea it might get tedious if the explanations got long or frequent.

[kaberett]

I am increasingly tempted to start answering "yes" to that question, to be honest, as and when it becomes relevant to me, because I am sick of people like That Sodding Pain Doctor, etc. (Sorry, I am getting rage all over your comments!)

[liv]

Rage is completely understandable. I'm treating the encounter as humorous because for one thing I wasn't really ill, I just wanted an expert opinion on some minor symptoms. And for another, the sort of health I have, most doctors I encounter are willing to take me seriously and give me appropriate healthcare. I do appreciate this stuff isn't really funny for a lot of people.

I wouldn't claim to be a medical doctor, tbh; I am not sure it's really an effective way to get better medical care, patronizing gits are still patronizing to their fellow doctors. Also I'm not sure you could pull it off; you know enough about the science, but probably not about the subculture. And if they rumble you, the last thing you need is for anyone to think you're a fabulist, that is really not going to go well. I would say "I have a medical background" and fudge any follow-up questions.

[kaberett]

This is an eminently sensible piece of reasoning to combat the frustration with!

[pj]

I'm not part of a study, but ginger tea definitely helps my arthritic joints (osteo, not rheumatoid) feel better along with kicking ass on stomach pain/gas.

Echinacea I take to boost my immunity around the sickly viral laden public. It may be bullshit, but I get less sick. So even if it is my headspace boosting my immunity I'm good with it. (I do realize you didn't speak to echinacea and immunity boosting abilities. That was my part. *grin*)

[liv]

Sounds perfectly good to me! I'm not really fussed whether something works in a biochemical or a psychological way, if it works. And most treatments are a combination of both anyway. I strongly suspect the doctor was treating my mental state rather than the actual annoying combination of cold and asthma, because he was making me feel like he cared about me and like I'm "doing something" and both of those are more effective than turning people away and saying, sorry, there's nothing I can do for you.

I'm glad to know that ginger tea helps you; I haven't been able to find any pre-prepared stuff lately and it's a bit of a pain to make ginger tea from scratch from fresh ginger root.

[pj]

If you can tolerate the sting to your tongue chewing a slice of the root works just as well for me.

It does indeed sound like he was "doing something" and not just turning you away. I find it hilarious that you knew what he was doing the whole time.

I have fun with doctors frequently because YoungerBoy and his chronic digestive illnesses has kept us tightly wrapped in the medical system for decades. Plus I remember medical details really well.

[liv]

Sorry to hear you've learned to be a medical expert through dealing with your kid's illnesses. I hope you do mostly get doctors to respect that and take you seriously.

I've always known quite a lot about medical science, I work in a medically-related field. But now I'm picking up stuff about the actual practice of medicine, which makes interacting with doctors a whole different level of interesting!

I may well try just chewing the ginger, if I can't be bothered to make tea.

[kaberett]

Something that got pointed out to me last winter is that if you want lemon-ginger-honey on hand, the easy way to do it is to take a jar and put in thinly-sliced lemon and ginger, then fill it up with honey. Leave it to stew in its own juices, then use a spoonful at a time in hot water as a drink...

[liv]

That is a seriously excellent suggestion. I shall retrieve "my" honey jar from synagogue (we used a small amount of honey for ritual purposes at New Year) and make myself up a concentrate. I take it the lemon keeps ok in that sort of preparation?

[kaberett]

Yep, lemon is quite hard to make go off if you preserve it in sugar/salt and its own juices. I've had my current lot on the go for about a year and it's fine.

(I can't remember where I first saw the suggestion, but I think it might have been Tumblr.)

[(Anonymous)]

Honey supposedly kept Herod's wife's body in good condition for seven years (b. BB 3b), so I would hope it would keep some lemon slices from rotting!

[redbird]

Interesting. I've never worked in a medical school, but in your place I probably would have agreed to the video and all, told him that I love ginger but wasn't having any sort of stomach upset, and pointed out that the best they can say about echinacea is "needs more study, we aren't sure it's useless" (and Cochrane tends to err on the side of "might be useful" rather than "save your money" when discussing supplements).

[liv]

It's totally true that you do get genuine lay patients who are skeptical about miscellaneous medical claims for foodstuffs. I think I was either going to agree to be videoed or start arguing about the effectiveness of echinacea etc. I strongly suspect the doc was ticking the box on the checklist which says, always close the consultation with a suggestion of a specific action for the patient to take, even if there's no medically effective option available. Which is fine, there is good evidence that specific advice helps even if there isn't good evidence that echinacea helps.

I also didn't know off the top of my head how good or otherwise the evidence is for echinacea in colds, I had to look it up when I came home. You're right, Cochrane is always cautious about dismissing treatments completely useless. I'm wondering if I should save the dietary supplements infographic as a bookmark on my smartphone for the purposes of instant access to relevant meta-analyses in the consulting room. But for one thing I'm not sure technically if that infographic works on smartphones, and for a second thing I'm not sure morally if that's a polite and helpful thing to do.

Might have been better if I'd asked, all innocent respect for the wisdom of the doctor, what's the evidence base for echinacea? But I think the problem with being a medical educator is that it's made me more sympathetic in the sense of, oh, the poor thing is only learning, I'll cut him a break. If I thought he was actually trying to pull rank on me or didn't respect my intelligence, I would have been bolshie.

[hatam_soferet]

If you want, you can grate an inch or two of root and mix it into brownies. I'd suggest putting it in at the butter-and-chocolate-melting stage. VERY GINGERY BROWNIES.

[liv]

That sounds an excellent plan. And VERY GINGERY BROWNIES will totally make me feel better. (Except that I have to confess, I've lost the recipe we transcribed / translated from UD's notes; it's the one piece of paper that didn't end up making it all the way back to England. Can you mebbe scan the index card and send it to me again? Although it's possibly too faint to scan well, and I don't want to cause you lots of hassle.)

Chag sameach, a badger!

[hatam_soferet]

Let's see if I can remember it. Melt together 100g chocolate and 150g margarine (and some VERY GINGERY GINGER if you like). Add 1.5 cups of sugar (this is about 12 oz), stirring it in. Then 3 eggs. And 1 cup of flour (8oz or so). A teaspoon or so of salt, ditto vanilla essence. A cup of chocolate chips. Ditto nuts if you like nuts. Turn into a greased and floured 8-inch pan. Bake at 350F until a knife stuck into the middle comes out gooey but not too gooey, probably about 45 mins.

[liv]

Thank you so much, this is super-helpful. Yay medically recommended ginger brownies :-)

[kaberett]

This is my standard recipe, if it helps! It is very forgiving to having changes made to it.

[liv]

Ooh, brownie recipe, many thanks for that. hatam_soferet's partner's recipe worked well for me, plus we had a hilarious time playing, can we guess the meaning of these instructions in Israeli handwriting based on our knowledge of baking and analogies from classical Hebrew – most of the vocab overlaps apart from 'chocolate' and 'sugar' which are just 'tzokolad' and 'sukar' so plausibly guessable... And it looks like yours is similar, starting with a base of really good chocolate mixed with butter. I might have to make both kinds so I have a proper control for comparison (and the fact that I might incidentally end up with twice as many chocolate brownies is no hardship either!)

[naath]

I'm always more sympathetic to claims that "eat this tasty thing" will help than claims that "take these pills that are distilled essence of tasty-thing" will...

I've no idea whether ginger has ever actually helped any cold I've had but ginger and chilli sometimes temporarily affect the amount of snot in my nose in the pleasant direction.

[liv]

Well, yes and no. I mean, in a case like this I will have a lot more fun out of eating tasty meals with ginger in than I would taking essence of ginger pills. But I'm kind of suspicious of claims that you should eat plants because they're "natural" but shouldn't take pills made from the active ingredient of the plants because that's a "chemical".

[naath]

Well, yes, that's very true. But tasty-food is pleasant, so that's a benefit *even if* the claimed health-benefit is not present; whereas the pills are only doing anything good if the claimed benefit is present.

[liv]

Yes indeed. And there is something very satisfying about medical advice to eat tasty food.

Remedies for a Cold

[(Anonymous)]

I once said to a GP friend that my treatment of a severe cold is to take a really hot bath and then retire to bed with an Irish coffee. He replied, "That is the sort of remedy we classify as a placebo."

He is correct but it does make the symptoms more bearable.

Southernwood

Cure for a Cough

[(Anonymous)]

"Put a hat on the bedpost and drink whisky until you see two hats. Then you will be cured."

Is there any evidence for that piece of folk medicine beyond the rather fun literary style?

Southernwood

Guiness (RTM) is Good for You

[(Anonymous)]

According to Ga-Ga, Guiness was always on the daily trolley in the NHS hospitals serving Liverpool's docks.

Southernwood

Re: Guiness (RTM) is Good for You

[liv]

I think that culturally we've got more prudish about alcohol since then, but it's also the case that alcohol interacts with just about every drug because it swamps liver metabolism. I have never heard of whisky as a useful cold remedy, I think it's another one of those, you can't do anything so you might as well just distract yourself from feeling miserable type cures.

Re: Remedies for a Cold

[liv]

Absolutely, the best way to deal with a cold is to distract yourself from the unpleasant symptoms! The issue here is that I don't have any severe symptoms to speak of, I'm a bit sniffly and sneezy is all. The only part of this cold that's a problem is that it's making my asthma flare up, and really nothing is going to help, even a placebo, until I clear this virus out of my system.