Living stories

Question: How might I employ the BATHE technique in my future practice?

This week in our Principles of Clinical Medicine (PCM) class we discussed the BATHE technique. BATHE is a mnemonic that stands for background, affect, trouble, handling, and empathy. The technique is an interviewing tool designed to elicit more and better information from patients. As students, it helps us understand how psychosocial issues can have great bearing as we diagnosis and treat the people in our care. As I listened to our instructors and began to consider its value, I realized it was something I wanted to keep in my toolbox for future practice.

About an hour after I left the PCM class that afternoon, my wife and I climbed into the car in order to attend a speaking engagement in downtown Portland. The speaker was Dr. Atul Gawande, a nationally-known surgeon and author interested in improving healthcare in our country. He spoke about his experiences and a number of topics, but one of the stories he related was of a hospital and a particular doctor who specialized in the treatment of patients with cystic fibrosis. Dr. Gawande had travelled to their institution to try to understand why they were having better outcomes than other CF units while spending far less money. This particular hospital, as led by this doctor, had average survival rates that exceeded national averages by almost 42%. Their patients typically lived to be 47 years old as opposed to 34.

Dr. Gawande proceeded to tell the story of how he was observing the doctor with a patient, a 17-year-old girl, whose numbers had taken a turn for the worse. The girl was not disclosing some relevant information as to when and how she had been taking her medications, so the doctor needed to employ a more novel means of questioning in order to elicit her full story. Using a blackboard and Dr. Gawande as his foil to direct the focus off of the girl, he calculated the odds ratios for folks who take their meds and for those who don’t. He told Dr. Gawande that, given irrefutable statistics, it is quite clear that outcomes are poor for patients who do not take their meds and that it is quite obvious when meds are not being taken when poor outcomes are occurring. He cleverly persisted at inquiring in third person as to the relatively sudden change in the girl’s status as she listened from the sidelines.

The girl then joined the conversation again and finally revealed why she wasn’t taking her medicine. Her reasons were two-fold: a new boyfriend with his own apartment and some new school rules for taking medications only at the nurse’s office. He continued to question the girl and found out what was happening in her life and how she was dealing with it. He discovered more clearly the impediments to her progress. He offered workable solutions and found support from friends and family to help her stay on track. Indeed, the doctor considered her failure a personal failure of his own, and he helped her realize that she needed to see it as a failure, so she could admit where she had gone astray and choose a better path for herself.

About halfway through the story, I realized this doctor was using the BATHE technique to a large degree, and I became convinced I needed to take his attitude and methods to heart. Of course, the point of Dr. Gawande’s story was simply that the reason this doctor had such remarkable results was that he cared deeply about his patients and was willing to spare a small amount of time to gather a complete picture of how their health was being effected by the events in their lives. We need context, and we need the truth if we’re going to truly make a difference for our patients. Of course, I want optimal outcomes for my patients, and I’ll need to use every tool at my disposal. By emulating this doctor’s methods, I can begin to effectively employ the BATHE technique as I enter a practice of my own.

The Value of Tests

The first test went well. I confess I actually did a bit better than I thought I would. It was certainly challenging, and I was dawdling through the first part of the written portion, but got it in gear enough to be able to review most of the questions before the buzzer went off.

The test made me feel like I was officially in med school. For some reason I still keep pinching myself. It truly does feel dreamlike in that I can’t believe I get to do this and that I decided to do this at such a relatively late period in life. - Do I have any regrets? Not even a teeny, tiny one. I’ll be through this in a few short years and performing the best job on the planet. How could I ever think this was too hard or too late? I’ll still put in at least 20 years as a doc and probably 30 as long as I maintain my health and energy. Chances are pretty good that I will. Parents are still alive, both 80+, and I’m still training for triathlons. Feel good.

This test made me think I need to a better job of studying. I need to find a groove more quickly and become more effective via a better focus. I’m disciplined enough to take the time to study, but I find myself distracted easily. Emotional ideas often work their way into my psyche.  I need to compartmentalize better and set issues aside. I have one primary objective here: to learn as much as I can as I pursue the best specialty for me. Any day that I don’t use my time effectively to do that is a poor use of those moments. Yes, balance is important, but the education takes priority. I just need to remain human and maintain current obligations as I prepare for a new life. This kind of transition requires an exceptional effort.

Any advice about tests…? Hmmm. I suppose the most important thing is simply to look forward to them. They let you know where you stand. They can spur you on to further accomplishment. The bar is raised. Sometimes you learn more material right then and there. They make you focus harder to gather and retain material. They sharpen your skills.

I truly found myself studying with joy this week. The material is fascinating. My classmates are engaging and curious. They try hard. They inspire me. Old dogs do learn new tricks. They’ve just got to get off the porch and sniff around in the woods. Use it or lose it applies.

The Big Picture... and then there's us

My interest in healthcare at a macro level continues to grow. As the debate rages on, I confess I continue to lose faith in the possibility of a brighter future for us. I forsee higher rates, reduced services, and more pockets being lined due to the larger customer base and as new taxes are levied. I see doctors being used even more as the gatekeepers to services. Most docs don’t enjoy that much. I see only the same sad business-as-usual greed under the guise of altruism. Every party wants all they can get, and those that have plenty seem destined to get more while indifferent, distracted, working Americans will continue to pay a larger portion of their incomes to subsidize their goals. Frogs in a great big pot.

Why am I so cynical about this subject when in the last post it was considered a no-no? I suppose I can only look to the past and judge by the manner in which our country has evolved from its original high-minded objectives. I can see how taxes have been spent and how executives continue to earn monstrous salaries and obscene retirement packages. I can see how doctors are fragmented in their belief systems and lack a cohesive set of plans. Rather than being at the forefront of the discussion, many have either taken a back-seat, wait-and-see attitude or are so focused on their practices, they have little time to commit to such things. I can hear how so little information is communicated in such a muddled fashion in order to sway our opinions, to bristle our fur, and to move our attention away from the play at second base. Guess I’m just tired of the huge shell game. I imagine I will write more about this later. I hope to attend an AMA gathering in November. Maybe I will learn more there.

Our first big test is in a couple of days. Many of us are anxious and hope to do well. For the most part we think we will breathe easier after we have a sense of what the test will be like for this section of the coursework. We think it will be easier when we have a feel for the road ahead.  – I will keep studying and do my best. Hillary is coming up this weekend. Looking forward to her companionship and smile and encouragement. Will try to offer my best in return. The work is engaging and challenging but very doable. I still think the trick is to enjoy each moment. It’s cool stuff, and I get to sit around learning about it. Darn.

Mealy mouths: Do Not Enter

This week I was in a class consisting of medical, physician assistant, and respiratory therapist students. We were reviewing the week’s material and responding to instructor prompts as to the locations and names of various anatomy landmarks. One of the students in front corrected the instructor about a mistake concerning the innervation of a particular muscle (teres minor, I think), and I heard a gentleman behind me say, “She just wants to show everyone how smart she is.”

I immediately thought to myself, “Well… she did get into med school. She must have something on the ball…” But, as I began to ruminate on it, I became a bit more indignant. Truth is she may very well be full of herself and be looking to make points, but we really have no room for cynicism in our group. Over the course of my years I have seen many obnoxious and arrogant men and women save more than a few lives and improve the quality of the lives of many of us – simply due to their expansive knowledge. Truth is, too, that is hard to sit in that room and not have a tremendous potential to effect people for the better. It will likely happen no matter how shallow or petty we may be. Indeed, in light of our universal imperfection, I think it much wiser for us to set aside our smaller sense of self and rise to the occasion of lifting up our comrades in arms.

I have always been able to find some good in most every person, though, I must confess, I have written a few off as unredeemable. I place them in the hands of a higher authority. I simply do not have the compassion to find good in them. But, we do need to remember the vetting process we went through to sit in that audience, and give credit where it is due. If one of our colleagues is willing to put in the time to learn the material in pursuit of their goal to be a better physician, then by all means let us set them on our shoulders and carry them forward. They could discover the idea that cures cancer, and their hard-earned knowledge could make them a powerful ally some day. Together we may join them in building a better world.

So, if you want to go to med school, leave the bad attitude in the rearview. You won't have room for anything other than a positive outlook. Prepare to work hard and join others who came here to do the same thing. Every day is an incredible opportunity here. I think if you stay aware of those opportunities and avail yourself of them, you’ll definitely make it to Oz. It’s a little harder than tapping your heels, but you’ll get there. Just stick to the road and keep skipping.