By David M Sack, MD

A number of years ago, Dr. Jerome Groopman published a wonderful book for the benefit of patients and their physicians, entitled How Doctors Think. It is an excellent description, illustrated by anecdotes, of the cognitive processes by which doctors arrive at diagnoses, and the pitfalls that are inherent in such calculations owing to the inherent strengths and weaknesses of human thought processes. For example, our tendency to consider conditions that we have seen recently, or those for which can easily imagine examples, is one habit discussed in some depth. It is a fascinating read (or in my case, listen, as I heard it on a CD in my car over the course of a couple of weeks.)

So Dr. Groopman has exposed well how doctors think. But how often do we reveal just what we are thinking? No more often, in my opinion, than we reveal our inner thoughts to friends and relatives in our personal lives – and in fact, considerably less often if we value our professional success. We occasionally let slip our attitudes in a moment of carelessness, a gesture, or the infrequent loss of temper. But for the most part, we try to embody the ideal of “equanimitas” that was advocated by one of our icons of modern medicine, the great doctor William Osler. There have been many learned treatises on this quality as to its benefits to a physician and his patients, and I have little of great insight to add on that topic.

But wouldn’t it be nice to occasionally allow ourselves to express what we really think?  I always enjoy arriving home  – usually somewhat later than I promised – to relate some of the triumphs and tragedies of the battles of the day. And this, of course, is when I get to say what I really think. It has occurred to me that I might even collect enough material to publish my own book, What Doctors Think.

My wife suggested an alternative or a sequel entitled Do Doctors Think?

I am choosing to ignore the suggestion for the purposes of this post.

I recently receive a letter from another specialist I had occasion to consult. It was an excellent evaluation, clearly dictated, and in a style not yet of the computer-generated boilerplate type that is becoming commonplace now that the electronic medical record is taking hold.

It began with a “thank you” for the referral, a glowing description of the “delightful” character of the patient, and ended with another expression of gratitude for the opportunity to assist in her care. In other words, the same sort of letter I always send to my referring physicians. It struck me, as it always has, how stereotyped these phrases are, so that they, too are really just insincere pleasantries. I am especially amused when I know full well that my patient is anything but delightful and his next visit with my consulting physician will not likely be greeted with delight. The fact is, we all need to be stroked, and being commended for sending a patient will very much increase the likelihood that I will send another. Of course the converse is true. It led me to wonder what sort of letter I might write if I truly expressed my opinion.

So during a tedious session at my laptop during a weekend getaway marred by bad weather, I found my mind wandering from the editing of office notes and reviewing of labs I was doing remotely. In a moment of malicious glee, I started to compose the following consultation note as a parody of everything I have ever been tempted to dash off to my referring physicians. It soon finished itself. For the non-physician readership, please be advised that the following does not represent the actual views and attitudes  of the writer, the American College of Gastroenterology, the various institutions that will disavow any connection with me, or those of the medical profession in general.

Dear Jerome,

I am not sure how to  thank you for asking this most unpleasant gentleman to see me for colorectal cancer screening. So I won’t.

Although the patient appears to be entirely well, he offers a litany of gastintestinal complaints that might not have occupied me for the better part of an hour had he not had an unfortunate tendency to veer of onto other concerns both political, economic and pertaining to the general state of mankind , not to mention the unfair manner in which the world has treated him personally.   Even after returning to the topic of his GI tract, I was unable to determine whether he was magnifying the  severity of his symptoms, except in regard to his complaint of excessive flatulence, which became more and more verifiable as our interview proceeded.

The past medical history was obtained with some difficulty, the patient insisting that there was nothing really wrong with him and all of his current diagnoses had been made up by the 6 or 7 previous physicians who had attended him, none of whom was fit to care for his cat.

His medication list  consists exclusively of herbal and natural remedies that he is prescribed by his chiropractor, naturopath, personal trainer and his reiki therapist. He insists that they have done him more good than that penicillin some quack he recently saw had wanted to give him for some imaginary condition, that he thinks was called “STD”.

He reports having had allergic reactions to cortisone, prednisone, benadryl and all foods that begin with the letter “R”. He is intolerant but not allergic to foods that conclude with the letter “L”.

He has a 40 pack-year smoking history which he incurred during his 2-year stint in the Congolese mercenary army; he no longer smokes. He proudly informs me that his alcohol intake has recently diminished to only two 6-packs of beer a day at the advice of his naturopath, who has sold him an amazing product that when consumed at 3 quarts daily has had a miraculously salutory effect on diminishing his capacity for beer.

The surgical history includes traumatic amputation of the right 3rd digit in a barroom accident, multiple fractures of the lower extremities, and a circumcision that occurred in the course of his 9th and most recent sexual relationship.

The family history is largely unavailable, as he is estranged from his parents, his siblings, his children, and a large number of people who only vaguely remind him of other family members.

The social history is significant. Although the patient stated he was unemployed and unmarried on our intake form, he was accompanied in the exam room by two young women who appeared to be under the age of 16. Also noteworthy is that he has no insurance and insisted on paying in cash, but only after inspecting our waiting room and my exam room as if he was looking for something.

Physical Examination:

The vital signs were unremarkable except that we were unable to weigh the patient due to his inability to balance himself on the scale.

He is a somewhat easily distracted gentleman in no acute distress who was found looking through the supply drawers when I entered. He appeared resentful and malodorous. He is wearing an exam gown over his clothes.

HEENT: Muddy sclerae and muddy cap with logo “I’m with stupid”.

Neck: Unable to find

Chest: Dullness with diminished breath sounds due to increased soft tissue. When asked to inhale he had to be reminded to exhale as well.

Heart: Sounds obscured by scratchy noises from hair on chest during respiration and patient insisting on speaking during exam

Abdomen: Upon lifting pannus it revealed a bottle cap and  a large cast brass belt buckle showing a pair of young female silhouettes back to back.

Genito-urinary: deferred and denied

Extremities: Tattoos on the extensor surfaces of proximal phalanges spelling “Joann” on the left hand and “Tr_sh” on the right. (missing letter and finger; patient says it was an “i”). I decided against having him remove his boots.

Skin: Multiple tattoos some of which appeared to have been professionally done but distorted by body habitus.

Neurologic: Sluggish pupils and sluggish in general. Startled easily by ring-tone on his phone despite 3 signs in room asking patients to place their phones on vibrate.

Impression:

This gentleman has attained the age of 50 years in spite of multiple risk factors for death by tobacco, alcohol, firearms and trauma, and one might argue that having navigated circumstances that would have put a period to a less fortunate soul, he can only be described as “lucky” and therefore in need of no preventive measures. Guidelines do, however, call for colorectal cancer screening  at his age. On the other hand, one might also argue that the patient’s pre-test probability of demise in the next 10 years is great enought that his post-test probability would not be significantly affected by cancer prevention. On the other hand, if I recommend against doing a colonoscopy, I am sure you will refer him to some other gastroenterologist who will  be happy to do one. Thus, the benefits for me of the procedure greatly outweigh the risks to me. I am not greatly worried about the patient’s risk, as it is well known that God protects children, drunkards and fools.

Recommendations:

I have discussed the rationale for colorectal cancer screening and the benefits, alternatives, techniques and risks of colonoscopy in detail, including but not limited to bleeding, infection, perforation, surgery, colostomy, stroke with temporary or permanent loss of function, heart attack, death, aspiration pneumonia, drug allergy, phlebitis, motor vehicular accident due to absconding after the procedure having falsely claimed to have a ride home,  need to reschedule as a result of factors such as failure to follow prep instructions with inadequate prep, blizzard, hurricane, earthquake, other acts of God, spontaneous combustion, and The Rapture. The patient had an adequate opportunity to ask questions. His only inquiry was, “I’m not going to know nothin’, Doc, RIGHT!?” Accordingly, a procedure has been arranged.

I can only hope that the next patient you send this way will offer me the  honor and a privilege of participating in the care of a somewhat more pleasant gentleman.

Sincerely,

David M. Sack, MD

I can’t wait to hear back from my referring physicians what they really think of my consultation notes!

David M. Sack, MD, is a Fellow of the American College of Physicians. He attended Harvard and Johns Hopkins Medical School. He completed his residency at Lenox Hill Hospital in New York City and a gastroenterology fellowship at Beth Israel-Deaconess, which he completed in 1983. Since then he has practiced general gastroenterology at a small community hospital in Connecticut. This post originally appeared at his blog, Prescriptions, a series of musings on medicine, medical care, the health care system and medical ethics, in no particular order.