"But Whatever Happened to Physical Diagnosis?"

OLD DOCTOR AS PATIENT

With apologies to Sir Archibald Doggerel, OSJ,OBE

In the ER against my will
the doctor there stood tall and still
around his neck a stethoscope
which quickly gave me added hope
But it was just a decoration
like a TV show sensation
What's your name? Where do you hurt?
listened to my lungs right through my shirt
through the shirt, through the blouse
is he the only doctor in the house!?
Checked my liver with his knuckle
didn't know it's my belt buckle
Off to X-ray for a scan
then ABGs, is that a plan?
Why not have me just undress
check my heart, lungs, and the rest
ask me if my toes are numb?
I may be old, but I'm not dumb
I'm a patient, show some caring
save me from my silent swearing
maybe it's my own neurosis
but whatever happened to physical diagnosis?

George Finlayson,MD

Dr. Finlayson (alpha omega alpha, Western Reserve University, 1953) is retired from practice in Internal Medicine.

Thanks to Alpha Omega Alpha's The Pharos, the first publisher, for permission to reprint the poem from the Summer 2006 issue in this blog.

This poem clearly reflects several wrong medical professional behaviors which unfortunately can happen, and perhaps not uncommonly. First is the usual "rush" in emergency room attention and care which if not controlled can lead to taking inadequate amount of time for a necessary history and performing an appropriate physical exam. But then, this doesn't have to occur in an emergency room but also in a busy doctor's office. Then the rush to the next patient continues with requesting testing with an order but without a thought out and supportive physical diagnosis. (In other words, the testing is believed to make up for the inadequate history and physical.)

Finally, there is the VIP treatment sometimes given to physician patients where the attending physician may, for one reason or another, not wish to disturb the patient with taking a detailed history or subject the doctor patient with what the attending doctor might consider an embarrassing or uncomfortable or overly detailed physical examination.

The old doctors had less tests and more time and more attention to the patient. Whether they could do a better job in diagnosis and treatment of the disease than more modern medicine is doubtful. But one thing is clear, they had the time to do a better history and physical and their treatment of the whole patient might be looked upon as superior. What do you think? ..Maurice.

Estimating Medical Risks: Physician vs Parents:Who Can Do the Better Job?

Society takes a responsibility for the care and life of children. This is in addition to the responsibility that parents naturally hold for their children. If society finds that particular parents fail to accept that responsibility, then in the United States, as an example, individual states will take on the management and decision-making for these children.

Parental surrogates for their children actually have considerable latitude in the care, education and development of their children. They also can and do make many medical decisions toward their health. The question arises in various specific cases brought to light by the news media whether parental medical decisions are really in the best interest of their children or whether the state is overreaching its authority and denying parental rights. An Idaho case in the news, follows:

“The parents of an infant who was given a spinal tap against their wishes hope to change the way medicine is practiced in Idaho.

U.S. District Judge B. Lynn Winmill recently ruled that the state violated Corissa and Eric Mueller's civil rights when a Boise police officer took custody of their 5-week-old daughter so a doctor could give her a spinal tap to check for signs of meningitis. But Winmill left several issues for a jury to decide, including whether the system to determine imminent danger in medical cases is flawed.”

Read the entire AP description of the case and then return with your comments.

One issue is whether there are some subtleties in medical diagnosis and treatment that are obtained by physicians only through education and experience and which only trained physicians can evaluate one risk against another. Of course, the physicians should then describe their estimation of the risks to the parents. Then the parents can evaluate and decide what is best for their child. Should the parents such as in the Idaho case, who do not have the medical education and experience estimate the medical risks on their own and then make a decision based on what they consider the risk probability? ..Maurice.

Telling Bad News and Not Walking the Walk

Not Walking the Walk

By Maurice Bernstein, M.D.

The doctor
Sits there looking into your eyes
He has told you
The bad news.

It came out swiftly
He told bad news to many, but
He wonders
How will you respond?

The doctor
Has never been told the same bad news
He wonders
How will he understand?

I have discussed the need for the physician to have empathy with the patient’s story. Empathy requires that the physician have had some similar experience in life so that there is a true understanding of the patient’s burden. That means that the physician has walked the walk. Patients, I think, can sense when the physician is simply only talking the talk. The talk becomes generic and may gloss over the very concerns that the patient has developed in response to the news. What should a physician do who has to tell the patient the bad news without personally having experienced a similar burden? After the physician tells the patient bad news, what should the patient expect next? What has been your experience with a physician telling you or your loved one the bad news? ..Maurice.

A Doctor’s Free Speech: When is It Unprofessional?

Medpundit today has brought to the visitors attention an article in the Detroit Free Press Freep.com website titled “Is Dr. Blogger telling too much?” It deals with the blogger physicians getting close to not abiding with the federal government’s Health Insurance Portability and Accountability Act of 1996 (HIPAA) regarding patient confidentiality or emptying crude and graphic descriptions of patients onto their visitors. This all might be called “free speech” but we must decide whether it is beneficial for the public to read that stuff. Is it good to have blogger physicians tell the public exactly what they think and feel about their patients so we can all see that they are human and can have concerns, biases or wild thoughts about their patients. Or on the other hand should these expressions of the physician’s thoughts be considered bad and unprofessional, actually hurting the entire medical profession? Read the story in both Medpundit and Freep.com and then tell us here what you think. ..Maurice.

Old Fathers, Sick Children?

Leslie Feldman has suggested to me that there is beginning evidence to suspect that the father’s age at conception may affect, by genetic changes in the sperm, the presence in the offspring of disorders such as autism and schizophrenia. She writes about this and lists her documentation in the EBDblog. The literature offers genetic explanations for how advancing age may affect the incidence of these and, in fact, other disorders.

If statistics regarding the age-incidence relationship are valid, the question becomes what is the risk? Is the risk only based on age or are other factors known or yet unknown more important? Is the risk sufficient to try to find ways to reduce the risk and therefore possibly reduce the incidence of these disorders? Would there be a well established optimum age for the father’s sperm to be the most “genetically healthy” so that one might encourage potential fathers to cryo-preserve their sperm at the ideal age for later insemination? Finally, is anyone looking for genetically beneficial conditions that might be transmitted to the offspring by the elderly father, not available in the younger ones?

We have already discussed on this blog the ethics of elderly mothers, through one method or another, bearing children. This ethical issue was whether the parents would be living long enough to provide what was felt to be essential parental attention to their young children. With the information brought up by Leslie, the issue also becomes whether, from a genetic point of view, the risk of producing ailing offspring become something, by itself, to discourage. ..Maurice.

Ask Your Doctor and You May Receive

The study published in the March 12 2007 issue of Archives of Internal Medicine may help explain how direct to consumer advertising may affect physician prescription writing, the topic as discussed in the last thread. But more than that it could explain, if confirmed by further study, the mechanism by which the costs of medical care may be rising through the physicians’ response to the public’s medical consumerism.

As summarized by the physician’s medical news publication “First Watch”,

“ Researchers interviewed patients in waiting rooms just before their visits; those expressing a wish for a new drug, test, or referral were invited to participate by having their visit audiotaped. In 200 such clinical encounters, some 250 expectations were communicated and 67% were met. Expectations for drugs and tests were met more frequently (both about three-quarters of the time) than were referral requests (just over a third of the time).

Physicians, when asked on a post-visit questionnaire to report requests their patients had made, said that, had the patients not asked, they would not have fulfilled almost half of the 138 requests so reported. They said they felt ‘uncomfortable’ about fulfilling 8 of the requests.

The authors comment that the unmet expectations did not seem to negatively affect patients' satisfaction or trust.”

I would ask my visitors if they have had any experience asking their physicians for specific drugs, specific tests or specific referrals and whether their requests were met. ..Maurice.

Polypharmacy: Is It Truly Beneficent?

I recently received the following poem from
a physician with no particular attribution:

SPECIAL POEM FOR SENIOR CITIZENS



A row of bottles on my shelf



Caused me to analyze myself.



One yellow pill I have to pop



Goes to my heart so it won't stop.



A little white one that I take



Goes to my hands so they won't shake.



The blue ones that I use a lot



Tell me I'm happy when I'm not.



The purple pill goes to my brain



and tells me that I have no pain.



The capsules tell me not to wheeze



Or cough or choke or even sneeze.



The red ones, smallest of them all



Go to my blood so I won't fall.



The orange ones, very big and bright



Prevent my leg cramps in the night.



Such an array of brilliant pills



Helping to cure all kinds of ills.



But what I'd really like to know...........



Is what tells each one where to go!





To me, “where they go” is not the issue with the prescription of and the daily use of multiple different medications (polypharmacy). To me, the issue is whether the medical practice of polypharmacy is a truly beneficent practice both to the individual patient but also to society. The goal of the physician prescribing a medication is that of providing a therapeutic benefit to the patient. The benefit should not be looked upon simply as the value of each drug to relieve a specific disease or symptom. Consideration of the benefit should include whether the drug is contributing to the total health benefit to the patient. Physicians and patients should keep in mind that the effect of one drug on the total health benefit is dependant not only it’s direct effect on the condition for which it was prescribed but whether the drug itself has harmful or detrimental potentials such as side-effects, toxicities or harmful interactions between the prescribed drug and the other medications that the patient is already taking. Benefit should also be measured by whether the addition of another drug with its own schedule for administration will disrupt the patient’s compliance with the taking of the other medications. Will the shape and color of the new pill be confused with other pills the patient, especially the elderly, is taking? Benefit should not only be measured by the parameters noted above but also whether the net wanted results of prescribing and taking a drug are sufficient to trump the drug’s expense to the patient and the healthcare system. Drugs that are very expensive might either not be purchased by the patient or the patient may discontinue or reduce the prescribed dosage of other drugs in order to afford the new one.

If the physician fails to include in the history of the patient identification of the medications already being taken and not consider the potential interactions with the new drug or the potential disruption of the dosing schedules or the costs, the physician is not performing a service. There is also the need for the physician at the outset to be confident that the patient truly needs an additional drug added to the list of drugs already being taken. Are there indications based on the patient’s symptoms, disease or lab tests that require instituting a new medication? Or is the medication being prescribed either out of a unsupported assumption, out of patient demand or out of a desire to relieve the patient’s concern that by, the conclusion of the office visit, something is accomplished. And that “something” is a prescription.

Finally, I would like to make a comment that ties into the previous thread on the media an medical practice. I think that direct-to-consumer advertising should be discontinued and there should be further ethical restrictions on direct-to-physician advertising. I don’t think any of this should represent a limitation to ordinary free speech. I think that such advertising is education slanted away from education of unbiased evidence-based pharmacology and is directed to the pharmaceutical companies own pocketbook and shareholders. These directed advertising practices, I think, inappropriately influence the public to unwarranted use of the advertised drugs for their own symptoms or illness concerns and encourages physicians to inappropriately add another drug, perhaps one that has not yet been fully tested over time, to their patient’s “row of bottles on the shelf.” ..Maurice.

(By the way, how many pills do you take?)

Media Influence on the Practice of Medicine: Good or Bad or Misunderstood?

Dr. R. tells his long time patient Mr. K that he now needs a liver transplant. Mr.K has anticipated the need and had read in the news about the poor transplant outcomes from a particular hospital. When Dr. R., who is affiliated with that hospital, suggests that Mr. K. sign up for a transplant there, Mr. K. rejects the suggestion and explains what he has read. Dr. R. can explain that the news doesn’t tell the whole story, the sicker population the hospital has received skews the statistics and that the hospital is the proper place to have his surgery. But Mr. K. may still not understand or agree. Here the media has possibly placed a wall between a previously successful doctor-patient relationship.

I provided the comment article about this scenario in the current March 2007 issue of the American Medical Association’s Virtual Mentor. The topic for the entire publication this month is “Media Influence on the Practice of Medicine.” There are many ways in which the media can influence medical practice either for the good or for the bad. There are a variety of articles on this very topic at Virtual Mentor and I encourage my visitors to go there and learn and maybe return back and comment here about the topic. ..Maurice.