Experiences and Impressions from Clinical School (Part 5: Clinical Patient Interactions)

“Robert” (TERMINAL CANCER) Last Semester, I spoke to a patient called “Robert” who had an M1 cancer (cancer that has metastasized), and was considered to be terminal (incurable, patient will die from cancer complications). He was one of the first terminal patients that I spoke to. A classmate recommended that I speak to him coz he had “interesting” physical presentations and was nice but was feeling quite sick. I wanted to see his physical presentations, but was initially hesitant on doing him coz he was feeling sick, and may not have wanted to spend energy speaking to another medical student, but I decided to try, because that’d be the only way to find out, and I didn’t like the uncertainty of never knowing what happened to him.

I went into the room, greeted Robert and introduced myself and asked if he could answer my questions regarding his medical history. He consented, and so I asked about his symptoms. He noticed a few lumps in his chest earlier last year, which later grew in size and became very painful to touch, and he felt a pain akin to being “hammered in the chest” whenever he breathed normally. He visited a GP and complained about the pain, in which he was prescribed analgesics. Eventually, investigations for his chest pain (X-ray, CT, biopsies) indicated that he had cancer which metastasized to his chest, and he was planned to start on “chemotherapy” quite soon. He was still experiencing a lot of pain in his chest and back, and found it disruptive and upsetting. I was able to see several lumps on his chest, and on his sternum.

He said the doctors may be considering radiotherapy as well, but he wasn’t looking forward to it because he thought that surgery would’ve been better (even though surgery isn’t usually indicated for his metastatic kind). Although I wasn’t 100% sure that his cancer was terminal (I only knew that when I spoke to the Oncologist later on), I suspected that the radiotherapy wasn’t curative, and was to treat the bone metastases, aiming to reduce its prominence on his ribs. I wanted to try to make my thoughts be more “valued” by him so I had to figure out what was of his biggest concern atm, which I (luckily) guessed was pain. I was confident that he was going to die within a few years or even a few months coz of his Cancer staging, and felt that long-term survival would be more important, but I DIDN’T DARE TO SAY THAT TO HIM coz I thought that informing him about death wasn’t my role yet, and I was scared that being an NT, he’d be more likely to get angry/offended instead of facing reality. This led to my hypothesis that he cares more about his quality of life.

I told him that he’s experiencing a lot of pain and it’s one of the negative things directly affecting him, and that the chest pain is likely to be caused by the metastases, and that if the radiotherapy targets the tumours and make it smaller, it may place “less pressure” on the intercostal nerves, thus producing less pain in the long term. He was pleased by this explanation and changed his attitude towards the radiotherapy and was optimistic, saying “oh that’s great then!” I wasn’t sure if he only thought of cancer as causing pain, and that he was aware that the radiotherapy was most likely not curative, but more to alleviate pain, and systemic complications leading to death are still highly likely. I didn’t want to instill false hope and tell him that it was going to be a cure, so I was trying to talk about the benefits of the treatment in terms of what he valued, and he was joyful. I initially felt kinda guilty coz I made radiotherapy sound really good (although it wouldn’t restore life, I didn’t say this) but I looked back and realized that I technically didn’t lie, and I’m sure that his priorities may have been different to mine, hence his response countered my initial concerns.

I was aware that he had pain, and I asked what medications he was on. He said he was currently using Endone and Oxycontin (IR and SR-oxycodone), Panadol, and an anti-inflammatory drug. I asked him if he felt constipated, nausea and loss of appetite on the Endone/Oxycontin. He said yes, and that it accelerated his weight loss, and that he can go for days without passing a bowel movement even if he ate 3 meals/day. I also asked him if it made him feel drowsy or spaced out, and he said yes, he felt sleepy and spaced out with poorer short term memory. He was happy that I knew what he was going through and said that I was the first person on the ward to tell him about these possible side effects, and said that I knew how he was feeling.

This experience made me realize that while I’m unable to intuitively empathize towards most patients, I could simulate “empathy” for most patients at a technical level by studying the common side-effects of varying medications at a pharmacological/physiological level, and ask them about these experiences. It can then give these patients the impression that I know what they’re going through, and that I value their experiences and “psychically” know them “better” (even though that’s sometimes not the case). The statistically more predictable effects of medications has given me more inspiration to study pharmacology in more detail when I have spare time, coz it enabled me to connect to patients (especially NT patients) more easily and make them feel a bit more comfortable even though I’m not the one looking after them.

His daughter phoned him, and he let me say “hi” to her on the mobile. I didn’t know why he asked me to say hi to her as I didn’t know her, but the gesture made me happy, coz it indicated that I didn’t piss him off, and I felt good that I made him feel a bit more comfortable that day even though his prognosis was technically poor.

I recently checked the patient database this year and discovered that he died a few months after my encounter (in the Palliative ward). RIP…

Self Directed Learning (as opposed to Didactic Education)

I should’ve posted a few months ago, but I was busy with other tasks and was “procrastinating”, my apologies. I hope everybody has had a safe and happy Christmas (or another festival if you don’t celebrate Christmas) and New Year’s Day.

This is a relatively controversial post, certainly among the medical academic staff and students, but I can’t resist my thoughts any longer, and I refuse to shut up and be “politically correct” in this regards. I’ll type about less “bitchy” things later on.

I’m rather disdainful of the concept of “Self-Directed Learning” in Med School, as I personally find that for me, it is counterproductive and obstructive to my optimal acquisition of knowledge, and I get frustrated by it. Yes, there’s definitely an element of personal responsibility in studying and putting in the effort to visit patients, speaking to them, and writing your own notes, but I feel that the burden has been placed way too much on the student, with insufficient guidance from the main medical faculty.

To put it in simpler terms, the concept of “Self-Directed Learning” primarily involves med students planning out what topics to learn and to what detail, with less didactic education given by lecturers/tutors in past medical curriculi. While this may sound simple and practical, this is far from the truth for me (and possibly many other students). A major issue is that the field of Medicine is so broad, and that there are so many medical conditions to learn, and so many textbooks, websites, medical papers discussing them, it’s hard to gauge which medical conditions should be studied (besides the really obvious ones like stroke, diabetes, cardiovascular disease, epilepsy), and how much we should know. I do receive handbooks for each of my rotations, but from experience I’ve noticed that other “significant conditions” that get discussed by consultants are sometimes not mentioned in it, instead including more “rarer conditions” instead! Also the handbooks don’t give a generic idea on what boundaries we should learn up to, before it becomes excessive/overkill. There are a few objectives that are vaguely stated, but I find this to be insufficient, especially when they don’t even tell you the steps on how to do it.

As an Aspie medical student, I have a much stronger tendency to process information as details and have trouble seeing the big picture (not just medical academics, but in social situations and generic reading comprehension for fiction). I also have a strong tendency to want to know a lot of details about the particular aspects of a medical issue, because I feel uncomfortable simply memorizing facts and I want to know the deeper aetiology/physiology/cause. I was aware that you don’t need to know, eg, 10 pages of the genetics of Marfan’s Syndrome, but it’s very hard for me to modulate how much depth of each section to learn. I feel guilty and uncomfortable if I only learn a few sentences about one aspect, and I feel like I’ve wasted my time if I learn too much about something when it’s not going to be examined or used (in a pragmatic sense) in the clinical setting for a JMO (junior medical officer).

I get frustrated by how each block is “only” around 6 weeks long comprising of 2 - 4 medical specialties, eg Haematology, Gastroenterology, Cardiology, and yet we’re somehow meant to learn the major conditions for those specialties in that time limit, without them telling us which is more important and how much. IMO 6 weeks is barely enough for 1 specialty, let alone 2-4. It feels like a very strenuous task, and later in the Semester, I tended to spend more time in the library trying to type notes on a condition (that might be trivial but still mentioned in the exams from experience) when I personally would much rather spend more time on the wards trying to practice my Clinical Communication skills and Physical Examination techniques with patients. I feel that I’m eating, sleeping and shitting Medicine and studying inefficiently through insufficient guidance when I could’ve had more time to talk to patients or even spare time for myself. I was very tired, and may be really tired/burnt out again when I start my next Semester.

People have told me the following - “If you don’t like the course, then leave.”

- “This is how your Uni arranged the curriculum, just accept it. Who knows, in 50 years’ time, the curriculum will change again, and the med students then will have to accept it with their heart.”

- (even more insultingly) “Suck it up, you’re just not trying hard enough.”

- “Self directed learning is to prepare you for the workplace, where you’re not getting spoonfed anymore.” (this operates under the assumption that everyone has adequate insight into the clinical setting + medical issues, which isn’t necessarily the case)

It’s not just frustration for my own comfort at the moment, but also for my future vocationally-wise. I DON’T want to end up accidentally hurting a patient through negligence of certain information coz I was spending so much time learning more trivial minutiae in med school. WE'RE LOOKING AFTER PEOPLE’S HEALTH/LIVES. The generic purpose of the Medical course is to prepare medical students for Internship, where they start engaging in “paid” service-provision in the care of patients, under the supervision of more senior medical staff and working in cooperation with nurses and other allied health people. IMO I don’t think the current medical course (maximally) efficiently prepares students for internship given the lack of practical guidance, and there’s a risk that students may spend too much time studying topics and details just for the sake of passing the exams, as opposed to improving their functioning on the wards. Yes, the work is applied knowledge, and medical information gets updated all the time, and yes I don’t expect to be completely spoonfed, but I really think that at the stage of a medical student, the faculty should provide more clear-cut guidelines so everyone can learn the imperative basics before moving on and learning things independently as they become more senior medical staff. Now, it’s all a mish-mash, VERY wishy washy and nebulous.

There has been speculation that some medical faculties are emphasizing on “Self-Directed Learning”, and not breaking the medical subjects down into more specific categories (eg Anatomy. Physiology. Pharmacology.) and teaching it didactically coz they wanted to save money. I can’t comment on that, but if that was true, then I’d be very disappointed. However, there were a few studies, starting from Canada, which came up with findings that “Problem-Based Learning” with a weekly-based medical issue is somehow a superior way of learning medicine compared to previous didactic styles, but I’d like to digress as I don’t think it that alone sufficiently addresses the amount of information we need to know, a block having 6 X weekly medical issues when the handbook contains 40+ (and probably at least 10 more that aren’t listed), ie not a complete substitute. The studies may show it works, but in practice I don’t think it’s noticeably superior.

Ideally I would prefer to receive extra time for each medical specialty (at the expense of graduating later), and/or be told directly what the main issues are along with generic boundaries for med students in their clinical years.

Compensation strategies (outside of official sources) that I have used include:

- Limiting myself to 2 or 3 pages for each medical condition, (painfully) forcing myself to limit each section (eg Symptoms, Investigations, Treatment) to a specific textbox.

- Limiting myself to only 2 or 3 textbooks, a major one being “OXFORD HANDBOOK OF CLINICAL MEDICINE” which happens to summarize the information for me (so I don’t have to figure out how to summarize it).

- Speaking to patients a certain number of times each week (but have to moderate it, otherwise I’ll be “occupying” too many patients and not giving other classmates a chance).

- Asking a family friend (who’s a doctor) for help, he tells me what’s important and what conditions I should just leave til I’ve covered the others.

I hope these strategies work for now and the future, but I’m somewhat displeased with how things are going atm. Even then, me artificially restricting myself as a preventative measure to avoid learning too much about each aspect of the condition may prevent me from gaining sufficient knowledge of areas that might need to be learnt to a deeper depth. I feel like I’m going to become a super duper Jack-of-all-trades just to cope, the lowest of the low : (

We'll see what happens for this Semester...

Experiences and Impressions from Clinical School (Part 4: Clinical Patient Interactions)

“Ben” (BROCA'S DYSPHASIA): I met a patient called “Ben” who had Broca’s dysphasia. Broca’s dysphasia is the condition in which a person knows what they want to say, but can’t retrieve the words for it and/or express it in a coherent manner. This is typically due to a lesion (eg stroke) in the brain called Broca’s area, situated around the border of the frontal and temporal lobe in one hemisphere. That isn’t to say they necessarily have an intellectual disability, as many of them have preserved verbal and reading comprehension and cognition, especially if the lesion was purely isolated to Broca’s area. The condition can range from very severe (extremely little or no coherent expression) to a milder form which sounds “stilted” and/or “jerky” with circumlocution/substitution in the attempt to find the correct term.

I didn’t have a stroke and while I officially don’t have Broca’s dysphasia (*NB*), I could empathize for him in imagining it would be very frustrating and I automatically knew how to communicate to cater to his condition without having to ask anyone for assistance.

I asked numerous very direct questions so Ben only had to say “yes”, “no”, a number or a short phrase. It was very important to break the burden of what he wanted to say into smaller fragments, otherwise it would be too overwhelming for him. I also gave him extra time to try to express himself, and if I couldn’t fully get what he wanted to say, I then paraphrased it and asked him if that was what he meant. I also drew a few pictures and wrote some individual words on paper in the attempt to trigger his “correct” word.

It was very time consuming given the highly numerous very specific questions asked (instead of several broad questions) and patiently waiting for a reply and trying to clarify it, but I got most of my desired background info at the end.

When asked if he was very frustrated coz of this issue, he said “Of course!” and was shocked that such a phenomenon could occur. He wasn’t made upset or aggravated during the conversation, but appreciated the accommodations I made for him.

I felt very comfortable and relaxed speaking to him, partly because I could communicate in a way that benefitted both of us, but after the conversation a very disturbing epiphany hit me. It turned out that although he was one of the few patients I was intuitively very empathetic for, I was also comfortable in the sense that he wouldn’t be a threat to me verbally. I NEVER exploited or abused him and had his consent to speak to him and he said he wasn’t offended at all, but his condition in a sense was an “extrapolation “ of the expressive language difficulties faced by many people on the Autistic Spectrum, where they have trouble with verbal fluidity for complex things on the spot. This is one of the major factors that’d make them very vulnerable to being bullied, manipulated or framed by NTs (from my past experiences and experiences of other ASD adults) as they have difficulty immediately and eloquently arguing back in a coherent and emotionally pleasing manner (to the NTs) unless they have already memorized numerous sentences, studied advanced debating tactics in their spare time, or managed to incorporate the argument into a pre-designed algorithm in which they will give moderately programmed responses with some editing based on the context etc. IE A POWER IMBALANCE IN EXPRESSIVE FLUIDITY/VERBAL FLUENCY, WORDS ARE SO POTENT.

I felt guilty after this epiphany, because I thought I was gaining comfort from his newly acquired impairment, but later I decided not to feel guilty anymore as I had no malicious intentions, and would never take advantage of his vulnerable state. Other clinical staff shouldn’t feel guilty about Ben’s condition either, they’re all trying to help him with neurological investigations, treatments, monitoring and rehabilitation (including speech therapy). Likewise it would be excessive and unnecessary to feel guilty/remorseful for someone else’s condition that you didn’t cause and have absolutely no intention of maliciously exploiting even if you could technically detect a weakness, eg a patient having a broken leg, or a patient who has endured ototoxic side effects from certain medications. You can sympathize for what they’ve gone through, but to feel guilty about it is going too far imo.

NB: I also have difficulty explaining more complex thoughts on the spot in a smooth manner although it is much milder than the ones with the official diagnosis of Broca’s Dysphasia/Aphasia. This isn’t an anxiety issue, as it occurs to me even when I’m with people that I’m comfortable with. It’s like I have difficulty organizing the sentence structure, so I compensate by my very strong preference to speak in sequential blunter phrases so I’m less likely to “get lost in my words”. This may be a working memory/executive dysfunction issue. It was also comfortable as I had the innate preference for honesty anyway. Unfortunately during speech this can get interpreted by NTs as arrogance or rudeness, and could be deemed as being unempathetic to their ever so important emotional needs. An alternative is to laboriously/exhaustingly memorize the more verbose (yet “polite”) expressions by rote, as it is very unnatural for me to use these phrases.

Example: “If at any point in time you feel too tired or uncomfortable to continue, you are welcome to say stop.” ("polite")

INSTEAD OF

“If you want to stop talking, just say so any time.” ("rude")

The brute rote memorization still accomplishes the need to simulate verbal fluidity that sounds pleasing to them, even though it’s tiring. Fortunately this issue isn’t as obvious in writing and internet communications as there’s MUCH more time to form and edit what you want to say on the computer before submitting it, unlike speech where if you accidentally say something “rude” or have difficulty explaining things to patients in urgent situations, in which you’re screwed to some degree.

Very strangely Pubmed searches indicate rather few medical papers that discuss Broca’s area in relation to people with ASDs. It would be a major discovery if this is one of the several cortical areas implicated in the condition, which may contribute to noticeable verbal communication impairment in adults and teenagers who are more severe on the spectrum. I’d be extremely interested for more neurological investigations to be done on this area in ASD individuals so perhaps a treatment (if pathology was discovered) to address this specific issue may be developed.

Experiences and Impressions from Clinical School (Part 3: Clinical Patient Interactions)

Patients Concealing Anxiety and Depression

I’ve observed that a lot of the patients could openly talk about their physical medical conditions (and Diabetes), but are reluctant to talk about Depression or Anxiety. They might even “lie” about feeling happy and calm, which was contrary to the notes in the patient file which indicate a prescription for antidepressants and sometimes note “panic”, “sadness about [XXX incident] happening”. I’ve already memorized some facial expressions and certain body postures of NTs which typically imply certain feelings, so I try to observe the “upset” one in the patients when seeing them speak. I was told by a friend (who is NT and usually sees patients with me) that mental health and psychiatric conditions are often stigmatized by the majority of society and tend to get hidden away should it be regarded as a “personal failing” or a “mental weakness”, and that they chose to be depressed/anxious.

Furthermore we were taught in a tute that to perform a Depression screening, you have to ask questions which sound like they’re not related to Depression, but are actually factors of it, as many of the patients apparently don’t like to be confronted with the direct question “Are you depressed?”. Eg

“How has your sleep been recently?”

“How’s your appetite?”

“Are you looking forward to anything after leaving the hospital?”

“Do you still enjoy [YYY activity] these days?”

and in the worst case scenario, you may ask “Do you ever feel life isn’t worth living anymore?”

I find it disappointing that society at large seems to stigmatize mental health/Psychiatric conditions and perpetuates the pressure on people with Depression, Anxiety etc to hide how they truly feel and act cheerful and complacent just to keep up appearances and not “ruin the atmosphere”. I wouldn’t be surprised that such suppression of how one truly feels for fear of ostracism/”punishment” upon open expression would exacerbate their mental health conditions even more. It’s also possible that some people feel that Anxiety and Depression is something to be ashamed of and it’d hurt their pride if they revealed it and/or it'd affect how people viewed them, but I feel that society’s prejudice plays a factor into this impression. Apparently this phenomenon is even worse in Asian countries, where society is more hierarchical and conformist and there’s a greater lack of mental health and psychiatric services.

Other Notable Patient Encounters (fake names used)

“David” (dead son has undiagnosed Asperger Syndrome): David was in the hospital waiting for an operation. After asking him about his history of presenting complaints, I asked about his family. He said that he had a son who left the home and committed suicide at age 41. I told him that I’m sorry to hear about that, and asked if he happened to know why his son committed suicide. He then said that his son said he “couldn’t take it any longer” and that his son displayed all the clinical traits of Asperger Syndrome.

I told him that I had been diagnosed with Asperger Syndrome and asked him numerous questions regarding his son’s childhood and adolescent years (with his consent). His son had a mild speech delay, narrow interests, and would spend hours upon hours reciting scripts from Shakespeare at the age of 8, could do calendar calculation, hated eye contact and soft touch, and had difficulty forming reciprocal friendships with NTs. His son got bullied a lot at school, and even when sent to a boarding school where there was routine, got ostracized by other NT students. He also went to TAFE but dropped out due to not being able to tolerate the social atmosphere.

I explained to him that Asperger Syndrome was a relatively recent diagnosis (introduced in DSM-IV in 1994), and that the concept of an Autism Spectrum was very unheard of prior to the late 80’s/early 90’s, and that the clinical definition of Autism was much stricter prior to that time (predominantly classifying Classical/Kanner Autism), hence most people who now have Asperger Syndrome went undiagnosed throughout their childhood and young-middle adult years and deemed as “weirdos” or “nerds”, or they get misdiagnosed with Schizophrenia, Childhood Schizophrenia, Bipolar Disorder, Borderline Personality Disorder etc and get medicated/treated incorrectly, to further detriment of their cognitive functioning and emotional wellbeing. I told him that due to the huge lack of awareness of high-functioning Autism and Asperger Syndrome before that period, it wasn’t his fault nor his son’s fault regarding the tragic suicide, and that had his son been born much later (circa 1995), he would’ve easily received the Asperger Syndrome diagnosis by age 15 and received the appropriate support and accommodations at school.

David understood everything that I told him regarding this issue and didn’t say he was offended or upset about it. He understood that it was just bad luck that the condition wasn’t known then, and that to grow up and live as an adult with all these social stresses and being constantly pressured to put up a façade of “NT normality” even though that’s against his pure behaviour, difficulty with executive functioning, multiple phases of unemployment due to constant workplace bullying by intolerant NTs and not knowing what the cause was, would be traumatizing and lead to suicide.

For me, the death of David’s son was concerning as this was an example of the reputed “Middle Age Autistic Burnout” where an unsupported ASD individual is typically pressured on a daily basis at work (at a workplace with superiors who are unaware or intolerant towards ASDs), with “friends” or in public to be a “square peg in a round hole”, to fake their social skills and behaviour to primitively simulate an NT to avoid bullying, discrimination and getting fired for trivial issues not directly related to the work. It eventually becomes too cognitively exhausting and their coping mechanisms are eventually insufficient, so they reach an episode of severe depression and fatigue, and are no longer able to work in such oppressive/conformist environments anymore, and often quit their job, become really sick or very reclusive, or commit suicide. Sadly, modern research seems to be woefully inadequate in regards to studying the needs, prognosis and mental health of adults on the Autistic Spectrum.

Experiences and Impressions from Clinical School (Part 2: Clinical Patient Interactions)

I haven’t spoken to as many patients compared to medical students at the other Clinical Schools, but I feel that I’ve spoken to enough to make some primitive observations. I have had reasonably positive experiences with most of the patients that I’ve spoken to, in that they’ve never been aggressive to me or abused me, however the accuracy and clarity of what they say varies, so in terms of medical content for collecting data, the quality varies. This is probably why a few nurses tell me that some patients are “better historians” than others.

Lack of Insight or Denial

Some patients are rather lacking in insight into their medical conditions. While I understand that they’re not doctors or nurses or necessarily have a background education in health, I would’ve thought that they know about a few aggravating factors or physiological mechanisms regarding their condition as the doctors explain to them (in a more layman manner, less jargon). I’m not sure if this phenomenon is more prevalent within the public hospital system, though I suspect it is.

A classmate and I met a patient who was being hospitalized for an increased frequency of tonic-clonic seizures and was already diagnosed with epilepsy several years ago. After he asked her about her history of presenting complaints, he then proceeded to ask routine questions. When asked about alcohol consumption, she said she drinks a slab of beer (24 cans/stubbies) every weekend. When asked if she felt that the beer might’ve been the cause of more frequent seizures (alcohol usually lowers seizure thresholds), she said “Nah, the beer’s alright.”This was despite taking into consideration numerous psychosocial factors, the doctors already informed her in a polite manner suited to her preferences of the great risks associated with binge drinking for someone with epilepsy.

Another patient that I saw with a classmate said he was diagnosed with hypertension when asked about other active health problems, but he claims that it’s because he has successful children (one of them a doctor), and that he leads a happy life which causes it. At the time I found this very hard to believe, seeing that his son has a medical background, and the patient himself also taught Science (biology/chemistry/physics) for numerous years, so should’ve understood the basic physiology of blood pressure. I thought it didn’t make sense to have hypertension from having a happy life, unless he happened to be using psychostimulants or certain antidepressants (especially MAOIs) every day. He also said he was diagnosed with Type II Diabetes, and he was overweight. By Occam’s Razor, it seems implausible that happiness alone causes high blood pressure; on the contrary it’d be more likely to be constant stress, poor diet that’s high in sodium or obesity. I checked his patient files. No surprise, he was diagnosed with Depression as well and was prescribed an SSRI antidepressant. At the time, I was quite annoyed coz I felt that he was deceiving me, but I spoke to other people about this issue, and they suggested that he may be feeling happier instead primarily due to the antidepressants, which allow him to be more euthymic and appreciate what he has in life (family). While he might not have understood the mechanism of antidepressants in making him happier, I felt that it was most likely that he was in true denial of the real causes of his hypertension, seeing that the SSRI he was on wasn’t supposed to significantly increase blood pressure.

For other patients, when I ask them if they have any other medical conditions, they say no, but their patient files state that they have hypertension, Type II Diabetes or hypercholesterolaemia. How a patient didn’t regard Type II Diabetes as a medical condition is beyond me, but I’ve been told by other people that Type II Diabetes has existed in many patients for 1 or more decades that they’ve grown accustomed to it, and no longer regard it as abnormal. This is why from now on, I always ask “Do you have high blood pressure/Diabetes/high cholesterol?” after asking “Do you have any other medical conditions” and them responding “No”.

At the time I’ve been very tempted to confront these patients and point out their misinterpretations or reduced insight into aggravating factors, but was told that this is the job of the doctors and nurses to do, not the Medical students. Therefore I’ve restrained myself from doing so, which is frustrating for me internally, but I’ve gradually accepted it as part of life, and decided to focus on learning more about their medical issues by reading their patient files, as opposed to just getting bitter and angry about it.

Asking Open-Ended Questions

I initially had the tendency to ask direct, specific questions to patients, but have been told that this may make the patients (majority NT) feel that they’re being judged subtly. They explained to me how certain direct questions can make patients feel that you’re judging them, but I felt that these impressions were excessive and I had no intention of judging/denigrating them, and that the patients are just being whiny and overly sensitive. After all, many NTs obsess about appearances and “keeping up with the Joneses”.

However after the first few weeks of Clinicals, I’ve realized the importance of asking open-ended questions. I know that it goes against my Aspie-trait of automatically focusing on details, and I originally thought that asking open-ended questions would mean that I’m “selling out” to conform to NT standards like a sheep, but I’ve realized the systematic usefulness of asking open-ended questions, which is probably the only Aspie-friendly excuse (to me) for using it.

For example, when asking about someone’s cigarette use, by asking “Have you ever smoked cigarettes?” at the start allows you to step into the topic broadly. If the patient says yes, then you can ask if they’re still smoking, when they quit smoking (if they quit already), and how much they smoke/day. If I had asked “How many cigarettes do you usually smoke per day?” as my first question, then I may have missed out on their previous history of smoking had they said “None”.

Therefore it is more systematic and easier to remember for some topics if I ask them from a broad/open-ended--> detailed fashion. I can then remember the flowchart of questions for that topic in a specific order. The questions are also ordered in a way to provide the least offensiveness and “judgmental impression” that is experienced by NT patients, so in fact a flowchart of questions from broad/open-ended --> detailed “Hits two birds with one stone” in that it appeals to both NT and ASD mindsets. Most NT patients wouldn’t be offended if you told them that you’re going to be asking routine questions, and then asked them if they’ve ever smoked cigarettes. However they might’ve felt judged if you asked “How many cigarettes do you usually smoke per day?” at the very start coz they feel that you assume that they smoke cigarettes, and especially if they have some sort of cancer (especially lung cancer), that the cigarettes are a contributing factor to their medical condition, and that the question is too confronting as it addresses their “fault” in smoking, hence making them feel guilty/bad as well.

My example for smoking history is below (click on picture for enlarged version):

I was lucky in that I managed to follow this flowchart for smoking (and a similar one for alcohol) after a few weeks. It was initially surprising to me when I learnt about other sensitive psychosocial factors that can be mentioned/triggered when I perform the history for both.

Soon after I followed this flowchart, I spoke to 2 patients.

For 1 patient, when I asked an elderly woman “have you ever smoked cigarettes?”, she said she used to smoke when she lived with her husband, and then she quit to make her husband happy, and then she started again after her husband died, and she started crying.

I felt awkward and sorry for her. Admittedly I didn’t know the direct cause of her crying. I couldn’t tell if she was crying coz she started smoking again, or coz her husband died. An (NT) teacher who was sitting down and observing my interaction with her said that it was due to the latter (husband died), and that asking the smoking question reminded her of her husband’s death. I was so surprised that asking an open-ended question could’ve released so much info from her, but she may have been an exception due to specific familial circumstances that happened to have smoking intertwined with it.

I then remembered the ICM video about what to do when a patient cries: you’re supposed to stay quiet and maintain a pause for at least 10 seconds while handing a tissue box to them to take a tissue to wipe their tears. I did that, and the patient said thank you. The teacher then asked her if she was alright with continuing the conversation, and she said yes. And so the interview proceeded.

The other patient I spoke to on another day, I later asked “have you ever drank alcohol?” and she said “Never in my life!!!” She then said that she grew up in a household where her Dad was an alcoholic, and would be abusive to her, her siblings and her mum. She had a traumatic childhood and to this day never drank alcohol. She said that she finds it very upsetting and judgmental when other doctors ask her “How much alcohol do you drink?” because they automatically assumed that her liver cirrhosis was due to alcoholism and that it reminded her of her abusive Dad, when in reality there must’ve been some other aetiology to it. She was actually kinda upset that I asked that question, but the teacher (who watched my interaction again) did tell her that I stated it was a routine question and that it wasn’t meant to judge her. She later calmed down and proceeded with the interview.

I think after these 2 incidents, it really “hammered” it in that if I had asked the direct/detailed questions first instead of the open-ended ones (according to the flowchart), I would’ve gotten into deep shit or created a lot of friction/tension with the patients.