Musings of a Dinosaur

A Family Doctor in solo private practice; I may be going the way of the dinosaur, but I'm not dead yet.

Monday, March 24, 2008

Doctors, Patients and Fools

I like the Happy Hospitalist a lot. Most of his economic analyses of medical care are quite accurate, although, like Panda, he sometimes resorts to hyperbole to make his points. Still, his essential observations that patients need to assume more financial responsibility for their care and that medical liability needs to be seriously re-worked are spot on.

And I'm not mad at him.

However, his disclosure a few posts back of his diagnosis with primary hypothyroidism and his intention to manage it himself raise another issue I believe worthy of discussion: the doctor as patient. HH himself quoted Sir William Osler:
The doctor who treats himself has a fool for a patient.
yet he didn't seem to feel it applied to him in this case. Frankly, I agree with him.

Primary hypothyroidism is not difficult to treat; certainly less so than diabetes, which patients are often taught to manage, and self-monitoring of anticoagulation, a procedure that also has its proponents. Yet it occurs to me that it might be the beginning of a slippery slope; a shallow one, perhaps, but with the potential for some problems along the way.

At the other extreme, for example if he needed surgery, a cardiac cath or other invasive procedure, I don't think HH would hesitate to place himself in the care of a trusted colleague. Even for certain conditions he can and does easily manage every day -- pneumonia, kidney stones, COPD (though I agree he's probably at the same ridiculously low risk of that particular ailment as I and other non-smokers) -- I believe he and most other physicians would agree that self-management is not appropriate.

The problem is the middle ground. What about acute, self-limiting conditions: bronchitis; Bell's Palsy; UTIs? How about chronic conditions like asthma, diabetes or migraine? I think answers to the question, "Should a physician treat himself for these ailments?" would be all over the map. Some would agree that a doc could safely and effectively manage the illness himself, where others would feel strongly that he should not. Specialty matters here. I think neurologists are probably quicker to treat their own migraines and pulmonologists likely to self-prescribe for their asthma. Doesn't anyone else have a problem with this? I think Dr. Osler did.

How about this twist: should a rural oncologist manage his own chemotherapy? He's perfectly competent; he does it every day; it would be so much more convenient not just for him and his family, but also for patients he could continue to treat. I think it would be a bad idea, but it wouldn't be up to me.

What about self-limited but painful conditions like shingles or sciatica? No need for MRIs or other extensive testing. Everyone knows it will get better on its own, but how do you feel about doctors self-prescribing narcotics? Suppose HH knows he has no personal or family history of addiction issues; he's perfectly capable of managing narcotics. What's the big deal? The problem, of course, is that although plenty of doctors have done it safely, some have gotten themselves into big trouble; even some who thought they knew better.

As things stand now, these decisions are made by individual physicians on a case by case basis. I don't deny that everything works out fine the vast majority of the time, but I believe there are suboptimal outcomes frequently enough to prove Sir William correct. So without denying HH's ability to successfully manage his own thyroid replacement, I respectfully suggest that he consider the wisdom of taking this opportunity to forge a relationship with a primary care physician of his own. He may not really *need* one for this, but the benefits of consulting with someone else -- who may, perhaps, some day, who knows?? know certain things he might not -- are real, even if he can't see them right now. If nothing else, it is the opportunity to avoid becoming a fool at some point in the future.


At Mon Mar 24, 07:13:00 PM, Blogger The Happy Hospitalist said...

Nice Read.

I agree with everything.

Are you taking new patients?

At Mon Mar 24, 07:46:00 PM, Blogger Ian Furst said...

Perfect retort HH. "Look wise, say nothing, and grunt. Speech was given to conceal thought. " Sir William Osler

At Mon Mar 24, 08:12:00 PM, Blogger Margaret Polaneczky, MD (aka TBTAM) said...

I tend to treat myself for simple things like the strep throat I diagnosed with cultures myself, and my HRT (Since my colleagues all send their tough HRT patients to me, who was I going to see?) and occasionally do my own transvaginal sonograms. When I was a reswident, I did not wish to see any of the male attendings in our hospital and had no time to go elsewhere so I actually did my own pap and read it with the pathologist while I was on my path rotation. (That was when I was younger and much more flexible than I am now....)

I actually went to a doctor recently for my worsening asthma - that was too scary to treat myself.

Great post (as usual...)

At Mon Mar 24, 10:02:00 PM, Anonymous Anonymous said...

Hmmm, as an FP I treat a lot of stuff but would rather have somebody else treat the long term stuff. A UTI I can manage, but would rather have someone else's advice on HRT, even though I do a fair amount of that. I think it keeps me honest.

At Mon Mar 24, 11:56:00 PM, Blogger Midwife with a Knife said...

Are we allowed to self prescribe narcotics? For some reason, I thought controlled substances were off limits for self-prescribing.

It's funny, all we're taught in med school or residency (officially) about this topic is, "Don't do it.". And like many unreasonable expectations (not unlike abstinence until marriage), "don't do it" is not good education.

We all do it. I have suffered the consequences of my less than ideal care multiple times. But then, I usually try to "wait it out.". That doesn't work so well when you have pneumonia and attempt to wait it out because your running assumption is that it's just a funny cold. Since my usual assumption is that I'm a wuss and should "wait it out", I don't have enough insight to know when I should take things seriously. I don't know when I'm really sick until I'm in the emergency room after having passed out while operating a tad hypoxic with bilateral pneumonia and a temp of 39.3 and then trying to talk my internist out of admitting me (she's a lot easier to convince when I show up in her office instead of the emergency room).

So, personally, I feel like I shouldn't be treating myself for much other than my prilosec for gerd.

The oncologist should probably not treat himself. It's probably fine for him to write his own chemo orders but he still needs to see an oncologist himself once in a while, just to keep him on the right track.

At Tue Mar 25, 01:51:00 AM, Anonymous Anonymous said...


I diagnosed my own melanoma when I was a resident after a Derm professor said "I wouldn't biopsy it"; ultimately had to treat my own chronic daily headace with Elavil after numerous failed treatments by a Neurologist; treat my own chronic GERD with PPI samples, take an occasional Provigil on a bad afternoon when my third and last cup of coffee doesn't help. My patients diagnose themselves all the time (often accurately) and only come to me to write the script. I don't think it's ideal but it is practical. I wish I had a good PCP that I didnt know who didn't know I am a doctor. I would have to travel pretty far to find such a person.

At Tue Mar 25, 05:31:00 AM, Blogger Sara said...

Thank you for bringing up that this might not be the sin of sins it is made out to be. I have tried always to NOT do this, and ended up putting myself through so much bureaucratic shit that I could have avoided by doing the same thing they do in the end anyway.

And to whoever did their own Pap, holy hell, how long are your wrists?

At Tue Mar 25, 09:38:00 AM, Anonymous Anonymous said...

i watched a urologist stick an ng tube down his nose once. that was pretty amazing to me.

anyhoo, it is not happy since i see he is regularly exercising, but there are a variety of potential nonacute benefits to having a primary care provider once the need arises. i guess happy can just follow his own bmi and cholesterol numbers and glucose and manage his own joint complaints with acai juice if he wants to, but not everyone would be so thorough. certainly there are a large number of obese physicians who need counseling who would be well served to see someone, even if it were simple to manage hypothyroidism.
as always

At Tue Mar 25, 11:10:00 AM, Blogger mark's tails said...

I finally diagnosed my chronic cough due to GERD and managed myself with OTC H2 blockers. Just before I got married I decided it would be a good thing to have a PCP even though I am in good overall health. He's a good guy who knows I'm a Doc but listens and we often discuss the evidence and utility for various tests together, before making a decision. ie getting an EGD since I have had GERD for almost 10 years.

There still are a lot of good, common sense Docs out there and I'm glad to have found one.

At Tue Mar 25, 11:29:00 AM, Anonymous Anonymous said...

I beg to differ somewhat with the assertion that hypothyroidism is simple to manage.

For many of us, it isn't.

Learning about it from a medical textbook is one thing; actually living with it and experiencing the symptoms and finding the optimal medication level are quite another thing.

HH no doubt has the skills (and the authority) to order lab tests and self-prescribe and titrate his dose, but I honestly think he would benefit from the input of another physician. Two heads are better than one, and all that.

At Tue Mar 25, 11:34:00 AM, Anonymous Anonymous said...

Nice post. I try really hard not to self-prescribe. Occasionally had to do so for a very common non-narc med that I ran out of in a pinch. But now I'm golden because I found a PCP whom I adore. He's got a "concierge" practice (hate the term) - complete price transparency, low fee/service rates, and he is paid for what he does (email, phone calls, etc.) He's pretty much available to me 24/7 - only catch? Doesn't take insurance. But I save so much by having low monthly payments for a high deductible plan, that his fees actually save me money. And he has no coding/billing headaches. Works for me and him.

At Tue Mar 25, 03:54:00 PM, Anonymous Anonymous said...

Not a doc, but I think it would be better to go to one for the most part, especially when it comes to prescriptions. I think it's better if all of your prescriptions are noted by somebody (like a PCP) to track patterns. Let's face it, if you treat yourself you're likely not keeping a record of it.

Besides, there's nothing wrong with getting a second opinion. ;o)

At Tue Mar 25, 06:46:00 PM, Anonymous Anonymous said...

I think you should do what you feel comfortable with and of course you should reconsider the situation from time to time. I have been treating my own hypertension for a while now and I am happy with it.

At Tue Mar 25, 07:40:00 PM, Anonymous Anonymous said...

Everyone - even doctors- deserves the care of a primary care physician that they trust and with whom they have a good rapport. As a GP I have, of course, slipped into the sample cupboard for PPI and OC but I try my darndest to see my own doctor for most medical conditions or atleast get the input of one of the other doctors in my office. Can't tell you the amount of times I have had someone at the office "listen to my chest" or take my BP- my gyne exams however I leave to my GP.

Dino- I've been reading for a while (by way of TBTAM) really enjoy your blog

At Tue Mar 25, 08:58:00 PM, Anonymous Anonymous said...

Of course, it's kinda disappointing when you realize that your patients are getting better care than you are. My next to last gynecologist never checked a heart/lung/neck exam and never checked my height the last 3 years I went to her (which ALL my patients get, and I'm an FP) and it turned out I'd lost 2 inches and had osteoporosis when I got one of my partners to order a BMD. (That's one of the reasons she's my previous doctor. The new guy at least checks, dunno if he knows what he's hearing but he tries). Oh well, back in the 80's I was doing GTTs on my OB patients before the OBs were. I did my own so I'd get one....

At Wed Mar 26, 09:56:00 PM, Blogger Mom MD said...

Nice post and an interesting question. As a resident I'm currently pregnant with child #2 and have only been able to make the bare minumum of ob appointments. I will show up for my glucola soon (not that there's any evidence it changes outcomes) but otherwise, to an extent, I'm treating my own pregnancy.

What scares me more than treating myself is treating my family: What if I'm wrong? Sure, I'll prod my husband to go get that sleep study but if I ever misdiagnosed Hubby or my 2.5 year-old self-proclaimed Fairy Princess, it would break my heart.

At Sun Mar 30, 09:39:00 PM, Anonymous Anonymous said...

Heck, no, I wouldn't touch the kids except for somehting simple like an otitis. And my husband never listens to me, anyway.


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