I have written many times about how I have made a better diagnosis than the doctor who saw my patient in the emergency room. That doesn’t mean I’m smarter or even that I have a better batting average. I don’t know how often it is the other way around, but I do know that sometimes I’m wrong about what causes my patient’s symptoms.
We all work under certain pressures, from overbooked clinic schedules to overfilled emergency room waiting areas, from “poor historians” (patients who can’t describe their symptoms or their timeline very well) to our own mental fatigue after many hours on the job.
My purpose in writing about these cases is to show how disease, the enemy in clinical practice if you will, can present and evolve in ways that can fool any one of us. We simply can’t evaluate every symptom to its absolute fullest. That would clog “the system” and leave many patients entirely without care. So we formulate the most reasonable diagnosis and treatment plan we can and tell the patient or their caregiver that they will need followup, especially if symptoms change or get worse.
Martha is a group home resident with intellectual disabilities, who once underwent a drastic change in her behavior and self care skills. She even seemed a bit lethargic. A big workup in the emergency room could only demonstrate one abnormality: Her head CT showed a massive sinus infection. She got antibiotics and perked up with a ten day course of antibiotics.
A month later, her condition deteriorated again. It was on the weekend. This time she had a mild cough. Her chest X-ray showed double sided pneumonia. She got antibiotics again and started to feel better.
You don’t really need a medical degree to know how to follow an immunization schedule, to recommend a colonoscopy, or order a screening mammogram (as long as, in this country, there is a standing order – in some places, mass screenings are done outside the primary care system).
You also don’t really need a medical degree to enter data into an EMR.
And when you decide to order a test, how many of the EMR “workflow” steps really require your expertise? I mean, borrowing from my iPhone, you could say “order a CBC” and facial recognition could document that you are the ordering physician. Really!
And you don’t really need a medical degree to, as I put it, open and sort the (electronic) mail; an eye doctor’s report comes in and if the patient is a diabetic, I have to forward it to my nurse for logging, and if not a diabetic, just sign off on it. And don’t imagine there is time in our day, evening or weekend to actually read the whole report. Patient A saw their eye doctor – check. Next…
Primary care in this country is pathetically arcane and inefficient. And we have a shortage of primary care physicians, they say. If we could all practice at the top of our license, perhaps not. It’s time to reimagine, reinvent, reinvigorate!
A lot of people don’t know much about how the body works. One of my jobs as a physician is to explain how things work in order to empower my patient to choose how to deal with it when the body isn’t working right.
On my blog I have written about this many times, for example in the 2010 post GUY TALK:
One of the first challenges I faced as a foreign doctor from an urban background practicing in a small town in this country was finding the right way to explain medical issues to my male patients. They were farmers and fishermen without much experience with illness, medications or medical procedures. Most of them came to see me reluctantly at their wives’ insistence.
Gradually, I found my voice and a style that has served me well over the years. As a Boy Scout and grandson of a farmer with more than an average interest in automobiles, I have found enough analogies from my own experience to be able to cross the cultural barriers I have encountered in my new homeland.
I may explain risk aversion by talking about why some men wear both a belt and suspenders. Heart attacks and angina are, obviously, related to plugged fuel lines. Beta blocker therapy is similar to shifting your manual transmission into fifth gear. Sudden discontinuation of beta blocker therapy is like releasing an inadvertently engaged emergency brake while driving with your gas pedal fully depressed. Untreated hypertension is like driving down the highway in third gear, and orthostatic hypotension is a lot like getting poor water pressure in an attic apartment.
We’ve all heard the adage, leave it to the professionals. It’s typically used when an individual has wandered out of his lane. How many folks go beyond their knowledge and skills with home projects, for example, who must then hire a real professional to mop up the mistakes? Luckily for me, the only tools that I – a gastroenterologist – know how to use are a colonoscope and an endoscope, so there’s no chance that I will be tempted to perform any plumbing or electrical tasks at home.
Although patients are not medical professionals, they routinely bring me results of their own medical research which suggest possible diagnoses and treatments. Often, these are patients whom I am meeting for the first time. I applaud patients who strive to be informed participants in their care. Indeed, there have been instances when a patient has brought me a valuable suggestion that I had not considered. But these are uncommon occurrences. A few computer clicks by a patient is not equivalent to the judgment and experience of a seasoned medical professional. It’s unlikely, for example, that I will agree that a patient’s elevated temperature is caused by malaria, despite this appearing on a patient’s internet search on the causes of fever.
However, even when I feel that a patient’s research results have no medical merit, the ensuing conversation is always valuable for both of us. I am in the room and can address the issue directly in real-time. I am the patient’s guardrail to protect him from careening off the road. I can explain right then the importance of being guided whenever possible by sound medical evidence. So, while I truly welcome the dialogue and recommendations from patients, I think that the maxim leave it to the professionals applies. Isn’t this why patients come to see us?
There’s a new player on the scene masquerading as medical professionals dispensing medical advice to the public. And in this case, there are no effective protective guardrails protecting patients as we doctors routinely do. I am not referring to middle of the night telemarketers or companies promising that probiotics are the panacea of our time.
As absurd as this sounds, politicians are now authorizing medical treatment for various diseases and conditions. Politicians? Could this be true?
It happens in eClinicalworks, I saw it in Intergy, and I now have to maneuver around it in Epic. Those EMRs, and I suspect many others, insert a stop date on what their programmers think (or have been told) are scary drugs.
In my current system all opioid drug prescriptions fall into this category. For a short term prescription that might perhaps be a good idea but for a longer-term or occasionally needed prescription it creates the risk of medical errors.
In Epic there is a box for duration, which is very practical for a ten day course of antibiotics. If I fill in the number 10 in the duration box, the medication falls off the list after 10 days. This saves me the trouble of periodically cleaning up the list.
In some practices, patients with seemingly simple problems are scheduled to be seen by a nurse or medical assistant. Sometimes they can even just drop off a urine sample in case of a suspected urinary tract infection.
This is a dangerous trap. What if the patient rarely gets urinary infections, has back pain and assumes it is a UTI instead of a kidney stone or shingles on their back just where one kidney is located; what if they have lower abdominal pain from an ovarian cyst or an ectopic pregnancy?
Another dangerous type of “nurse visit” is when patients focus on one symptom or parameter, thinking for example that as long as their blood pressure is okay, their vague chest pressure with sweating and shortness of breath isn’t anything serious. It’s one thing if I want a couple of blood pressure checks by my nurse, but a whole different thing when it is the patient’s idea, assumption or self diagnosis.
In many cases, a telephone call with the provider or a triage nurse can be safer and more diagnostic than starting with a nurse visit. Because the symptom history is usually more important when making a diagnosis. And nurse visits tend to be skimpy when it comes to the clinical history, even though the provider assumes responsibility for the diagnosis and treatment of a patient they didn’t talk to or examine.
Almost two years into this new age of varying degrees of self quarantine, I am registering that my own social interactions through technology have been an important part of my life.
I text with my son, 175 miles away, morning and night and often in between. I talk and text with my daughter and watch the videos she and my grandchildren create.
I not only treat patients via Zoom; I also participate, as one of the facilitators, in a virtual support group for family members of patients in recovery.
I have reconnected with cousins in Sweden I used to go years without seeing; now I get likes and comments almost daily on things that I post. I have also video chatted with some of them and with my brother from my exchange student year in Massachusetts 50 years ago.
I have stayed in touch with people who moved away. And I have made new friends through the same powerful little eye on the world I use for all these things, my 2016 iPhone SE.
Members of my addiction recovery group stay in touch with each other via phone or text between clinics. They constantly point out the value of the social network they have formed, even though they only meet, many of them via Zoom, once a week. The literature has supported this notion for many years and is very robust: Social isolation is a driver of addiction.
In the tech world, we have come to expect our devices to become outdated and obsolete very quickly. The biggest tech companies in the world didn’t even exist a few years ago. Bitcoin, a virtual currency which at least I can’t wrap my head around, seems to be more attractive than gold.
I get the sense most people embrace or at least accept the speed of change in tech.
But medical advances that occur rapidly are frightening to many people. Vaccine hesitancy, for example, involves concerns and characterizations like “unproven” and “guinea pigs”.
But can we as a society strive for and reward rapid progress in one area and reject it in another, especially if we feel threatened by outside forces or phenomena – be that a virus, climate change or the collapse of our economy’s infrastructure like supply chains and raw materials.
Tech has its own momentum, more driven by profit motives than altruistism or a desire just to make peoples lives better. Medicine clearly has profit as a driving force, but also a goal of improving life for people. Curing or mitigating disease must rank higher than making life more convenient.
Before Johannes Gutenberg invented the printing press in 1450, books in Europe were copied by hand, mostly by monks and clergy. Ironically, they were often called scribes, the same word we now use for the new class of healthcare workers employed to improve the efficiency of physician documentation.
Think about that for a moment: American doctors are employing almost medieval methods in what is supposed to be the era of computers. Why aren’t we using AI for documentation?
The pathetically cumbersome methods of documentation available (required) for our clinical encounters is only one of several antiquated presumptions in American healthcare. Other inefficiencies, often viewed as axioms, especially in primary care, make the trade I am in chock full of time wasters.
Whereas in most other “industries”, people talk about reach, scale, leverage and automation, primary care is still doing things one patient at a time. The automation in our field is not one where processes happen without human involvement according to preset patterns. Instead, it is an ongoing effort to make medical providers behave in automatic fashion with patients on a one-on-one, one visit at a time basis. The value of one-on-one is when you individualize, give unique advice considering multiple individual parameters; saying “in your particular case”, rather than “everybody should eat a healthy diet”.
Primary care here is wasting time in many ways:
When health maintenance and disease prevention is done by physicians. I keep writing about this, but a standing order to offer pneumonia or shingles shots, diabetes or lung cancer screenings and so many other things to people over a certain age or with certain risk factors can be handled by non-physicians. This would keep the six figure problem solvers doing what only they can do. It would also (a not-so-wild guess) probably double physician productivity.
Leo Dufour is not a diabetic. He is in his mid 50s, a light smoker with hypertension and a known hiatal hernia. He has had occasional heartburn and has taken famotidine for a few years along with his blood pressure and cholesterol pills.
Over the past few months, he started to experience a lot more heartburn, belching and bloating. Adding pantoprazole did nothing for him. I referred him to a local surgeon who did an upper endoscopy. This did not reveal much, except some retained food in his stomach. A gastric emptying study showed severe gastroparesis.
The surgeon offered him a trial of metoclopramide. At his followup, he complained of cough, mild chest pain and shortness of breath. His oxygen saturation was only 89%.
An urgent chest CT angiogram showed bilateral pulmonary emboli and generalized hilar adenopathy, a small probable infiltrate, a small pulmonary nodule and enlargement of both adrenal glands, suspicious for metastases.
He is now on apixiban for his PE, two antibiotics for his probable pneumonia and some lorazepam for the sudden shock his diagnoses have brought him.