Tuesday, January 17, 2006

Attending Effect

Those who have suffered through internship, any internship, can attest to what I like to term the “Attending affect”. An embarrasing event which happens after taking a thorough history from a patient. Initially you may have believed that he/she may have extremely worrisome disease but based on the answers the patient provided you’ve managed to rule out most of the more dangerous pathology. The next morning you give a great presentation to the attending pointing out how you’ve asked all the appropriate questions. And then everyone as a team, including the Attending, comes to examine the patient.

The entire story suddenly changes. Every lethal complication you’ve managed to rule out on the basis of history the patient manages to rule back in and all of your hard work goes out the window.

“What? Sure I had crushing chest pain and a very difficult time breathing. Of course I did!”

“No, it only happened to me one time before, you know, before I had that emergent cardiac catheterization I forgot to tell you about”

...As you feel the blood rush to your cheeks and the neck suddenly loses all ability to continue holding up your head.

How the same story changes overnight I’ll never understand. I can sympathize with the poor intern, just another victim of an undefinable phenomenon. This adds yet another challenge to the first year of doctoring. A year filled with unexpected obstacles.

No lesson, though, is more embarrasing than that of the “pleasantly demented” elderly. And every intern, on one occasion or another, will fall pray at the hands of the pleasently demented.

This newly demented individual is so slick that they can obscure this fact quite well, especially if a deeper investigation of the fact is not taken. Usually, the morning presentation is smoothless. The patient is “Alert and Oriented times three”. The intern rejoices in his own glory.

Later, when we find that the patient believes it’s 1969 and that the Mets are actually a good team, all accounts of the story can be filed along with the recycled trash being picked up in the basement. All the hard work for not.

When you “assume” you make an….

Once again, the intern has fallen pray to the adorable forgetful, the pleasently demented. And such a fall from glory, especially when your peers are watching, is always fun to watch.


Blogger Echo Mouse said...

LOL I don't envy the pressure or being prey to the demented, but this is funny.

7:21 PM  
Anonymous Kel said...

At one point during my 4th year of medical school I got a wink and a nod after such a dramatic overnight changing in the patient's history and physical that I soon learned that if it didn't happen, we were missing something.

Now when my 'terns and med students say "but the history was different last night" I reassure them it happens all the time.

4:21 AM  
Anonymous Judy said...

They don't have to be demented, medication does interesting things too as I discovered when someone took a history from my husband while he was under the influence of morphine and Xanax.

They decided to get better information from me when I interrupted the delivery of peanut butter cookies by asking if they were trying to kill him or if he'd simply forgotten to mention his allergies.

4:07 PM  
Anonymous Anonymous said...

This phenomenon is also known as "historical drift".

8:43 PM  
Blogger DrEtak said...

How about the story changes within the HOUR of the itnerview? And suddenly the patient, resistant to the intereview, is suddenly as placid and compliant and sweet as a little kitten.
"Why of COURSE I am depressed, Doctor!" she coos. "I'd LOVE some medicine!" This after I can barely get her to talk to me.
And we walk out of the room, and my attending chuckles and says, "That look on your face--that's what I LOVE about being an attending!"

11:33 AM  
Anonymous Health Blog said...

This adds yet another challenge to the first year of doctoring.
A year filled with unexpected obstacles.

2:02 AM  
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6:19 PM  

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