Monday, October 09, 2017

Doctor-Patient Communication

The slide deck of a short sharing I gave to a group of first year medical students of Universiti Malaysia Sarawak (UNIMAS). It is indeed a good move to talk about doctor-patient communication early in their medical studies, to expose them to the intricacies, the skill and the art of communicating with patients, including how to break bad news.


Doctor-Patient Communication Skill from Chew Keng Sheng


The best resource on doctor-patient communication that I have found is Skills for Communicating with Patients by Jonathan Silverman, Suzanne Kurtz and Juliet Draper (Amazon link). This text is the first entirely evidence-based textbook on medical interviewing, describing the core skills which represent the foundation for doctor-patient communication

I have found a number of sample chapters that can (still) be downloaded free (these 2 chapters, Chapter 2 and 3, are already informative enough to give us a good grasp on this subject matter):
Chapter 2
Chapter 3

A chapter from its companion volume, Teaching and Learning Communication Skills in Medicine, can be downloaded here:
Chapter 1

Google book also provides a good sampling of the book and the full e-book version can be purchased at the cost of about RM150. Click here for the google book preview version.

And download an article by one of the co-authors of the book (Suzanne Kurtz) here.

Watch a lecture on the art of communication in medicine by Dr. Jonathan Silverman here:

Monday, August 29, 2016

Life Threatening Electrolytes




Slide deck (in pdf) for the above presentation:


Life threatening electrolyte abnormalities from Chew Keng Sheng


Perhaps one thing which I did not make clear in the video and the slide is the use of 3% hypertonic saline:
As 1g of Na = 17 mmol
therefore, 
3% NaCl means
3 g in 100 ml
or 
30 g in 1000 ml (1 L)
= (30 * 17) mmol in 1 L     [since 1 g NaCL = 17 mmol)
= 510 mmol/l 
~ 500 mmol per 1000 ml (1 L)
therefore, 
1 ml of 3% NaCL = 500/1000 = 0.5 mmol ------- Equation 1

Sodium deficit is
[Desired sodium - measured sodium] * Total Body water
= [Desired sodium - measured sodium] * 50% * Body weight (BW)

Now,
let say we wish to raise the serum sodium by 1 mmol/l  a.k.a. [Desired sodium - measured sodium ] = 1 mmol/l]

therefore,
[1*50%*BW] mmol/ = the amount of sodium deficit required

But we know from Equation 1, that 1 ml contains 0.5 mmol
therefore,
    0.5 mmol ------- 1 ml
    (0.5 * BW) mmol -------- (BW) ml

    Therefore, 1 ml per kg BW of 3% hypertonic saline raises serum sodium by 1 mmol/l

    However, as mentioned in the slide, the degree of serum sodium elevation may be more than expected. This is because as sodium is replaced, water re-absorption occurs initially. This removes the hypovolemic stimulus for the release of ADH. As a result, there will be greater degree of diuresis than expected.



    References:
    Parham WA, Mehdirad AA, Biermann KM, Fredman CS. Hyperkalemia revisited. Tex Heart Inst J. 2006;33(1):40-7. Can be accessed FREE here.


    Verbalis JG, Goldsmith SR, Greenberg A, Korzelius C, Schrier RW, Sterns RH, et al. Diagnosis, evaluation, and treatment of hyponatremia: expert panel recommendations. Am J Med. 2013;126(10 Suppl 1):S1-42. Can be accessed FREE here.







    Wednesday, July 27, 2016

    Discussion on the dilemma in bioethics using the various ethical theories




    We often discuss bioethical principles using Beauchamp and Childress (2008)'s four bioethical principles (some people would say that there are more than four) but seldom do we teach or guide students through some of these bioethical dilemma (which we often face in real clinical practice) using the various ethical or moral theories in philosophy.

    This short video starts with a case discussion follows by a short description of three common ethical theories. It's not meant to be a didactic tutorial but rather to trigger discussion among students.

    Case scenario:
    You are a house officer on duty. At 3.15 pm, you take some blood sample from a rather aggressive patient for some routine blood investigations that are due at 3 pm. Unfortunately, after you have taken the sample, you forget to label the sample bottles immediately. Worse still, one of the bottles drop on the floor and spill the sample. You would need to take a new 20-ml blood sample from this patient. You know that if you were to admit your blunder, he would ask you lots more questions than you can answer and furthermore, he is a hot-tempered man. You anticipate you will waste a lot of time with him and would result in delay in attending to other patients. Or you could lie to him and say that you need to do some additional blood tests that have just been ordered by your specialist (knowing that he would not question that). What would you do?







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