(Part 2) Best products from r/medicine

What helps is realizing that delivering bad news is actually a skill that can be learned. This makes it both easier for you and easier for the patient. There are a number of books on this topic, but one that I've found very useful during fellowship is "Mastering Communication with Seriously Ill Patients: Balancing Honesty with Empathy and Hope." (http://amzn.com/0521706181)
Now you are obviously not going to read this book before seeing your patient, so here are a few tips for your conversation today. *I can't find my copy of the book now, so I'm writing from my own experience using the outline of chapter three you can preview on Amazon.

1. Prepare for the conversation. This can mean practicing with a friend, colleague or family member. This may sound ridiculous, but it will improve your skill and give you real feedback which you can help for the real thing. It may also help for you to write down what you want to say or how you want to say it. You obviously won't be reading this script during the actual conversation, but it will help put your thoughts in order. Another important but often overlooked point is to make sure you have enough time for the visit. Do not book this patient in the beginning or middle of a busy day. Set aside at least an hour for this visit. If the visit winds up being shorter, that's OK. You will have more time to decompress. You want to avoid appearing stressed or rushed, so I recommend doing this on a non-clinic day, or well before or after your other patients. Make sure you turn off your cell phone and pager. Find a quiet room. You do not want the patient to feel like he has anything other than your total attention. Lastly, make sure there is a box of tissues in the room. If not for the patient, then for family.
   
   
2. Assess the patient's perception. Ask the patient directly, "What is your understanding of your condition?" or "What have other doctors told you about your condition?" In my experience, about 50% (or more) of patients already know something bad is brewing. Sure, there are some who are caught completely off guard. It will help you to know where your patient stands before you talk.
   
   
3. Ask for permission to talk about the news. Say explicitly, "Is it OK if we talk about the results of your CT scan?" This way, the patient knows where the conversation is heading. It also helps to provide some sense of control to the patient who likely feels lost and feels things spiraling out of control.
   
   
4. Disclose the news straightforwardly. Consider using a warning statement/warning shot first. "The CT scan came back and there are some serious findings we have to discuss." Then, in PLAIN ENGLISH, give the news in as straightforward a manner as possible. "There are several abnormal spots on your CT scan. There is a large mass in your left lung as well as several spots in the liver. You may need a biopsy to confirm this, but the CT scan is highly suggestive of lung cancer." PLEASE do not say something like, "You have a spiculated lesion in the right inferior lobe of the lung near the fissure as well as several well circumscribed lesions in the liver. The adrenals appear thickened which could also be worrisome and there are sclerotic changes in the bones which are indeterminate." Patients have no idea what the word "lesion" means. Do not use ANY medical terminology. I can't tell you how often people do this. I used to do this. It's an easy defense mechanism that helps bring us to a comfort zone and keeps the focus on the science rather than the emotion and the person in front of us. Keep it simple.
   
   
5. Respond to the patient's emotion. This is the part which takes the most practice, at least for me. Make sure you pause after delivering the news. Watch the patient closely and look for emotional cues. I don't think I can do this part justice without the book I mentioned above. Your patient may react with fear, sadness, shock, anger, or just stoicism. Give them emotional space and allow them to process the news. It may help to sit near the patient, or put an arm on his shoulder, but the latter completely depends on the patient and your prior interactions and relationship. Say something that shows empathy and recognition of their emotion. If they are showing shock, say something recognizing this such as, "I know that you are shocked by this news. I was also surprised when I saw the scan."
   
   The outline the authors give for this is NURSE:
   Name the emotion ("It sounds like this has been frustrating.")
   Understand the emotion ("It must be hard to be in pain like that.")
   Respect (praise) the patient ("I'm so impressed that you have...)
   Support the patient ("I will still be here, with my team, to help with")
   Explore the emotion ("Tell me more about this...")
   
   What I've personally found very useful are the statements of support. Patient want to feel that you will be there and they will not be abandoned. I often say things like, "I will be there with you every step along the way. We are going to take this on together and I want you to know that I am here for you." In your case, you won't be treating the patient, so you can use a variant of this. "Although you will be seeing a cancer specialist, I want you to know that I am still your primary doctor and I am always here for you. You can always call me with any concerns or even just for support."
   
   
6. Wait for the emotion to be addressed before moving on. Obviously, the emotion will still be there, but you cannot skip the previous step if you want to gain anything from this one.
   
   OK, so now that you are here, you should provide a plan. "We will be sending you for a biopsy to confirm the diagnosis and also to help us figure out what type of cancer this is. I will also make sure to get an appointment for you with a cancer specialist who will be able to answer more questions and come up with a treatment plan."
   
   You can discuss more details here, but it will depend on your own comfort level with oncology. I wouldn't go into too much detail because the patient is likely still in shock and is unlikely to remember many other details. They will learn more at future visits when they are coming to the visit actually prepared to hear that information.
   
   I also find that it helps to give hope. Yes, this patient has metastatic disease and is likely incurable. You don't have to mention that (and IMHO should not during your visit today unless explicitly asked.) As an oncologist, I always mention this during my first time meeting patients because they already know about their cancer diagnosis and I want to set expectations for treatment. (Other oncologists do not do this, but I think they are doing their patients a disservice.) Remember, you are just disclosing a diagnosis today. Keep it simple. To give hope, you can say something positive (and true) such as, "I know this is a difficult diagnosis, but there are some cutting edge treatments which have just been approved for lung cancer, just within the past year. We are making real progress in fighting this disease." Again, this comes down to your comfort level as they may ask more questions.
   
   You can do this. I hope this was helpful and not overwhelming. Good luck.
   
   EDIT: Thanks for the gold kind stranger!

In a sense, yes. A formal diagnosis is not a requirement, but could be helpful if that is really what is going on. It could also be a hindrance. Unfortunately, the situation in the mental health field nowadays is really complicated, particularly with the fact that so many practitioners have significant problems with pathological narcissism themselves. It is absolutely critical, if you are having a problem with pathological narcissism, that you do take the reigns in addressing the problem. In that regard, narcissistic psychopathology parallels addiction very significantly. Many practitioners even recommend 12 step programs. As you may already know, narcissistic psychopathology is very common among M.D.'s in the U.S. and elsewhere - particularly among surgeons (current estimates of NPD as high as 40%, and my guess is that is low).

Another route is to also consider how your childhood and familial experiences effected you. A good book to read is "The Wizard of Oz and Other Narcissists". Another good one is "Why is It Always About You?" (ignore the preachy Christian parts). Trying to think deeply about the stories and lessons of these books and how they relate to you, your life, and your family and friends is critical. Almost everyone is surrounded by pathological narcissism in some way in the U.S., so there will be useful lessons, to some degree, on practically every page. In particular, if you start realizing that you are suffering/effected by narcissism in your life, heed the lessons pointed out in the Wizard of Oz book - they are extremely useful, but MUST be put into practice, not simply "understood". If you seek out treatment from mental health clinicians, pay very close attention to the sections of the book where she describes how to spot pathological narcissism in clinicians and put it into use. This is critically important regardless of what your condition turns out to be. A clinician with traits or full NPD can not only be unhelpful to your treatment, but even dangerous, and they are all too common. Avoid any religiously preachy clinicians like the plague, as a rule.

Have you considered doing some workbooks? That may be helpful because it removes the personal aspect of the intervention. A good one is:

https://www.amazon.com/Dialectical-Behavior-Therapy-Skills-Workbook/dp/1572245131

You might benefit from neurofeedback. Some is better than others, so don't be put off if it doesn't work well the first place you try.

It sounds like you'll want to really pay attention to the covert/introverted narcissism components. If you read about these topics and things start resonating (which can lead to intensely strong feelings, "good" or "bad"), then you are probably on the right track. The absolute key is to be extremely honest with yourself. Really, really extremely honest and non-morally-judgemental. You may also find a lot of value in a concept called "radical acceptance". You seem to be struggling significantly with not being able to be the "Great Savior" to your patients that you wanted to be. You'll probably nee to do a lot of reflection on that and think about how it figures into your life story. Developing a journaling habit, if you don't already, would probably be an excellent idea. Getting your life story out and thinking about why things happened is key. Reflect, integrate realizations into your life story. Rinse and repeat.

I went through a multi-decade ordeal in assisting a family member (also a doctor) who was in a nearly identical situation as you. There was NPD, but also comingled with addiction (substance), mood disorder, and bipolar. It was pretty difficult to sort out, but that person is doing much, much better now. Of course, this is all routed in childhood trauma, so it may be helpful to do some basic reading on that:

https://www.amazon.com/Body-Keeps-Score-Healing-Trauma/dp/0143127748

https://www.amazon.com/Waking-Tiger-Healing-Peter-Levine/dp/155643233X

Learn what your triggers are, and mind them.

Finally, a really important concept is discussed by Ronningstam, which is often overlooked by even very good practitioners who understand narcissism quite well. It is the critical component of redirecting ego-drive into healthy behaviors; Understanding the difference between healthy narcissism vs. pathological narcissism. This is, IMO, the #1 reason why NPD, pathological traits thereof, and addiction treatment fail so often. She discusses this very well in other parts of her book.

Of course I could be completely wrong, but that's my opinion, for what it's worth. As I mentioned, if you start digging, stay honest, and it starts resonating (good or bad), you're probably on the right path.

Good luck.

I've posted a similar answer before, but can't find the comment anymore.

If you are interested in doing your own statistics and modeling (like regression modeling), learn R. It pays amazing dividends for anyone who does any sort of data analysis, even basic biostats. Excel is for accountants and is terrible for biological data. It screws up your datasets when you open them, has no version control/tracking, has only rudimentary visualization capabilities, and cannot do the kind of stats you need to use the most (like right-censored data for Cox proportional hazards models or Kaplan-Meier curves). I've used SAS, Stata, SPSS, Excel, and a whole bunch of other junk in various classes and various projects over the years, and now use only R, Python, and Unix/Shell with nearly all the statistical work being in R. I'm definitely a biased recommender, because what started off as just a way to make a quick survival curve that I couldn't do in Excel as a medical student led me down a rabbit hole and now my whole career is based on data analysis. That said, my entire fellowship cohort now at least dabbles in R for making figures and doing basic statistics, so it's not just me.

R is free, has an amazing online community, and is in heavy use by biostatisticians. The biggest downsides are

• R is actually a strange and unpopular general programming language (Python is far superior for writing actual programs)
  
• It has a steep initial learning curve (though once you get the basics it is very easy to learn advanced techniques).
  
  Unfortunately learning R won't teach you actual statistics.... for that I've had the best luck with brick-and-mortar classes throughout med school and later fellowship but many, many MOOCs, textbooks, and online workshops exist to teach you the basics.
  
  If I were doing it all over again from the start, I would take a course or use a textbook that integrated R from the very beginning such as this.
  
  Some other great statistical textbooks:
  
  
• Introduction to Statistical Learning -- free legal PDF here -- I can't recommend this book enough
  
• Elements of Statistical Learning -- A masterpiece of machine learning and modeling. I can't pretend to understand this whole book, but it is a frequent reference and aspirational read.
  
  Online classes:
  So many to choose from, but I am partial to DataCamp
  
  Want to get started?
  
  
• Download R directly from its host, CRAN
  
• Download RStudio (an integrated development environment for R that makes life infinitely easier) from its website (also free)
  
• Fire up RStudio and type the following commands after the > prompt in the console:
  
  install.packages("swirl")

library("swirl")

swirl()
  
  And you'll be off an running in a built-in tutorial that starts with the basics (how do I add two numbers) and ends (last I checked) with linear regression models.
  
  ALL OF THAT SAID ------
  
  You don't need to do any of that to be a good doctor, or even a good researcher. All academic institutions have dedicated statisticians (I still work with them all the time -- I know enough to know I don't really know what I am doing). If you can do your own data analysis though, you can work much faster and do many more interesting things than if you have to pay by the hour for someone to make basic figures for you.

Hey, I am so glad you are asking for help with this. It is an area that most med students struggle with, but not many are conscientious enough to ask for help. We really need more doctors in all specialties who can talk to patients comfortably about psychiatric issues, rather than merely calling a psych consult because "patient is tearful"

-I try to let the patient tell me his or her story in the way that feels most natural to them, so I try to aim for at least 5 min of them explaining HPI before interrupting them. That is usually enough to convey the gist of why they are here, but not so long that you get derailed. You'll have to be flexible here - they will give you their history all out of order. It is helpful to have a preprinted template on hand, so you can jot notes and revisit later.

-I usually start my interviews with a bit of social history rather than delving into chief complaint or HPI. It's not how we are taught to do it in med school, but it seems to feel more comfortable for patients when their doctor knows more about their background. Depends on the context of the interview. If you're in the psych emergency room, you may need to be more concise here than you might on say, inpatient psych or consult service.

-Child cases are tricky, but with practice, you'll get the hang of asking parents to step out of the room. There are several lines you might practice using, but as you're asking the parent to leave, emphasize that you will be sure to leave plenty of time at the end of the interview to come together as a group to discuss the treatment plan and answer any questions they might have. Some children don't want to be left alone at all, and that is ok. I really try to get at least a few sentences out of them at each session though, rather than letting the parent do all the talking.

-This book by Daniel Carlat was very helpful to me as an intern. I received a copy of this book as a senior resident, and wish I had gotten ahold of it sooner.

-Keep practicing your interviews. Remember that you will not hurt patients by talking to them. It can often be therapeutic for a patient to simply feel that another human being understands them. Just remember not to butt in during an attending or senior's interview, and wait until they turn to you and ask if you have additional questions for the patient. Remember that you are a valuable member of the team! I found med students useful for so much more than scutwork during residency.

Best of luck to you in your studies, and if you choose to go into psych, or have any other questions at all, please feel free to PM me!

From a historical perspective, birth in America was moved from home to hospital not as the result of evidence-based studies that proved it safer, but for social and economic reasons that are fascinating and too complex for me to take the time to write about here. Here's a great book on the subject. (BTW I am NOT advocating for homebirth, I'm just pointing out that the reason for the switch is really complex and interesting and had little to do with patient safety.)

It's interesting how much we want to cling onto the idea that the current status-quo of birth in America is the bees knees and how we give excuse after excuse why it can't be improved upon. When a woman's risk of cesarean is based significantly upon which hospital she chooses to birth, there's a systemic problem.

I'm fortunate to work with obstetricians, MFMs, and other CNMs who see the value in all specialties working as a team to achieve the best outcomes for our patients. My midwife partners and I provide care to all of the maternity patients in our practice, from the lowest to the highest risk, and in varying degrees of collaboration and co-management with our physician colleages. We're proud of our outcomes and I think the model can (and should) be expanded throughout the country.

People like to portray midwives as being completely anti-medicine/anti-doctor, and I agree there are some that are (usually not CNMs, though). I just implore the medical community to please consider that we can do better in the case of maternity care, and expanding the role of nurse-midwifery is part of that.

I would avoid test-prep books then-- those tend to skim the surface of things like pathophys and always seem to be more focused on important facts and associations, etc., and not on the science.

Sadly there is no quick answer for getting better at pathophys (it takes 2 years to cover the basics in med school). Working in an ED you don't have massive amounts of time to read either. As a resident I find myself wanting to review stuff all the time but am pretty busy too, so with that in mind, my recommendations would be:

-UpToDate/Dynamed/Medscape/etc. usually have nice sections in their articles on the pathophysiology of various conditions. The temptation is to skip to the "diagnosis" or "management" sections but there is usually some good stuff in those articles that you can read on the fly

-For critical illness and general physiology, The ICU Book is great and not too dry a read. If you want much more in depth stuff on medical conditions, Harrison's Internal Medicine is a great resource but reads like a phonebook sometimes. If you care about the microscopic level, Robbins & Cotran is basically all the pathology for the non-pathologist you will ever need- can also be a bit dry at times too.

-Look up the mechanism of action of meds you don't know about (Micromedex smart phone app is great for that)

-When you consult someone because you are unsure about something, ask them about what is going on (subspecialists are usually not shy about dropping knowledge if you ask for it); it may also help prevent future un-needed consults which they appreciate

Hope this helps.

I’ve been speaking Spanish and interpreting in the clinical setting for almost 7 years. If you are already fluent or a native speaker and you have a complete grasp of the language then you should not need anything more than to learn specific words and then of course to know what they actually mean. As an RN, you will already know a lot of what means what when it comes to medical terms. Fortunately medical terminology is all Latin based so many of the actual strict medical terminology is almost identical. For that, I would simply recommend a medical terminology dictionary and then to do flashcards of everything you could imagine yourself needing to use. I would recommend using Anki as it will make it a million times easier and faster. Now, that being said, the vast majority of people you’ll be coming into contact with are not medically educated. Whether that be in English, Spanish, or Cantonese. So being able to tell someone that they have pneumonoultramicroscopicsilicovolcanoconiosis doesn’t actually help you or them very much unless you’re able to tell them that it’s a disease caused by excessive inhalation of volcanic ash. Which should be easy for you to do if you’re fluent. So, while it’s nice to know medical terms in Spanish most of your interactions with the patients are going to be simplified into smaller more layman terms. If you’re going to be giving a dissertation in front of medical staff in a Spanish speaking country then that is when all your medical terminology knowledge would truly be allowed to shine. People use native speaker rather loosely around the US and I’ve found that can mean literally anyone who’s parents happened to speak Spanish which often results in “native speakers” not being close at all to what a true native speaker is capable of in the language. Which is fine, but it’s good to know where you are at and what you need work on. Working on basic organ and physical structures is a good start as that is what most of your translating will consist of. Then, move into more complex medical terms as you see fit.

Spanish-English English-Spanish Medical Dictionary: Diccionario Médico Español-Inglés Inglés-Español (Spanish to English/ English to Spanish Medical Dictionary) (Spanish Edition) https://www.amazon.com/dp/1608311295/ref=cm_sw_r_cp_api_zL.SBbEHMCFMV

This book is as extensive as you could possibly need.

If you need general improvement in your Spanish I would suggest Coffee Break Spanish podcasts from radiolingua. If you’re well-versed I would skip to the 2nd-4th seasons. Many native speakers are not formally educated and don’t actually know why things are the way they are. So while you may be able to tell me what “Yo quisiera que estuvieras aquí conmigo” means you might not be able to tell me why the imperfect subjunctive was used and the intricacies that that implies. And you don’t need to be able to in order to be fluent but it can give you a much better grasp and control of the language which in turn can make you appreciate it and your ability much more. If you desire that, coffee break will give it to you.

Goodluck :)

I haven't read this book but it's a nice hardcover with beautiful historical illustrations and is not very expensive. I doubt it's comprehensive / definitive but you'll love flipping through it and it'll look great on your bookshelf:

https://www.amazon.com/Crucial-Interventions-Illustrated-Principles-Nineteenth-Century/dp/0500518106?ie=UTF8&*Version*=1&*entries*=0

Another area I've become interested in (in my own field of expertise, not surgery) is actually buying historical texts. Find a specialty used book store in your city and browse through their medical/scientific books. Even a standard (med school-level) text from 70 years ago is fascinating when understood in the context of what has come since. And the <100 year-old books are not expensive (<$100).

abebooks.com is full of cheap old used (and expensive old used) textbooks from many countries and areas of medicine.

When I am thinking about a disease that I encounter in my practice frequently (ex. Hodgkin disease), sometimes it's fun to dip into one of my old textbooks and read something like "Hodgkin's disease is a disease of the hematopoietic organs [...] It is invariably fatal. Whether it is neoplastic or inflammatory in nature remains a matter of dispute." (Boyd, 1947).

These old textbooks are very readable. That edition of Boyd's pathology belonged to my grandfather. Every single page of it is fascinating.

Interesting. Thanks for posting this. I started taking biotin to improve my hair and nails which it really did noticably help. I was taking these at the recommended levels of 2500 mcg a day, apparently 833% of daily value. I might halve that and/or just cut down to a few days a week. They totally made my hair fall out less and a lot more thick and gorgeous though. And my nails way stronger! Word of mouth has been going around about them on a lot of beauty blogs and on /r/makeupaddiction etc... actually was recommended them from reddit! Even though I'm fairly medically fluent as an RN, your post was a nice reminder to check the dosage levels and also interactions of suppliments and to report them to my PCP as part of a med list! So, thanks!

I think overall this FDA change (if it actually happens and then ends up having any teeth) will be a super positive thing. I've been noticing an uptick over the past years in patients reporting their supplements on their med lists and have started seeing clinical research studies add certain common ones (turmeric, cannabis, fish oil) on conmed lists etc. Also more studies on things like prebiotics etc. I think this will be a timely and needed change.

I'm not a doctor but a medical writer who has been obsessed with medicine since I was a kid. Hmm, let me throw out some stuff...

YouTube is a treasure trove. Hank Green's SciShow is an excellent place to start. He's the nerdy, passionate science teacher we all deserve to have.

ZDoggMd makes video parodies that are also suitable for kids. He rewords pop songs with a medical education message.

Medicalstudent.com is a collection of free medical textbooks. Still one of the best-curated lists and non-commercial.

Textbooks can't be beat for learning the fundamentals. Most texts aren't appropriate for children, but the "Made Ridiculously Simple" series is an exception. These books are for med students and it break key concepts down with cartoony illustrations. Microbiology Made Ridiculously Simple is the best, IMO.

Netter's anatomy flashcards are awesome. They aren't cheap, but I bet your daughter would love them.

This should satisfy your daughter for a week or two. ;)

When Breath Becomes Air - Paul Kalanthi

and
This is a Soul - Rick Hodes

They're both some of my favourite non fiction novels of all time, both of which I found myself being unable to put down even after reading it over and over again. Despite it's heavy themes that places many readers on the verge of bursting into tears, I think it seriously forces you to question so many different themes and aspects of your life that you may not have considered before from their perspective, since it's written from largely an autobiographical POV.

Kalanthi is an Indian-American Yale trained neurosurgeon who has a BSc and MA from Stanford and Cambridge (Or Oxford? I forgot) who despite his overwhelming occupational success, initially overcame cancer but then went into remission. It's a thoughtful analysis of his life, his marriage on the verge of breaking down, and his decision to have children despite knowing that he only had a few years to live. I suppose on some levels, it's a novel about finding life while staring into the hollow face of death. Or at least that's how I'd like to believe it

Hodes is a Jewish-American internal medicine MD who after graduating from URochester Med School and completing his residency, decided to volunteer in Ethiopia in the 1980's during the famine. Although he had planned on staying for only 3 months, he found himself returning to the refugee camp time and time again. Up to this day, he has resided in Ethiopia for over 30 years whilst accepting a very modest salary from a United Jewish Fund something something non profit. To save the lives of 5 different children, he decided to legally adopt them so that they would have coverage under his medical insurance.

I think the most interesting aspect of the novel was that it wasn't whitewashed or overglorified in any specific aspect; rather it was just a raw documentation of his three decade long career and the choices he had made that lead to that day. On some level, I think the idealist in myself sees him as a lunatic, but as a lunatic that has made the ultimate sacrifice and became the kind of ideal that students fantasize about becoming when they were once happy and full of life. Then reality hits, we have student loans and bills to pay, some have young families to support and eventually over time we lose sight of the people that we thought we ought to become when we had hopes and dreams. I always thought being in a mission on the other side of the world was a goal that everyone spoke of at one point in time, but few keep that promise. But holy shit, he actually did it

He wasn't exempt from that, even his grandmother said "My grandson is an idiot, he could be making a ton of money like you guys but instead he's working for a medical mission in Africa." I think many people see a bit of themselves or of their former hopeful self in him, and up to this day he still continues to work for the mission in Ethiopia where whilst facing overwhelming odds, he continues to find life

Go read the very excellent book evidence based physical.

http://www.amazon.com/Evidence-Based-Physical-Diagnosis-Expert-Consult/dp/1437722075

So much good stuff in there. I heard there is a PDF copy floating around the internet, should you willing to be a swarthy medical pirate.

Anatomic Path - Sternberg

Neuropath - Ellison & Love

Forensics - Spitz & Fisher

also a fun coffee table book useful for alienating visitors to your home

https://www.amazon.com/Evidence-Based-Physical-Diagnosis-Steven-McGee/dp/1437722075

If you can find a copy, this book is interesting. There is a JAMA one too.

/u/BedsideRounds, I was just going to suggest the same thing, as I have the book and enjoy thumbing through it. I also have Crucial Interventions, which is along the same style.

Which podcast do you host? If you are uncomfortable telling us in public, can you PM me? Never mind I just read it in your starter comment.