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.

Tuesday, November 25, 2008

Time and Place

There's a new columnist in the Philadelphia Inquirer; a young ophthalmology resident named Rachel K. Sobel MD. She generally offers a fresh view of residency training, albeit from her vantage point not just of a specialist but of a specialist training at a specialty hospital. But her column yesterday headlined "Prescription: Shape Up" has me flexing my saurian claws:
My patient came in to the Wills Eye Emergency Room with red eyes and the kind of pain that felt as if he had had a headache inside his eyes for several days. I diagnosed a recurrence of uveitis, an inflammation inside the eyes, and treated him with eye drops.

My attending, Donelson Manley, agreed with my plan, and gave some advice: "Sir, we can treat your eyes and your eye headaches," he said. "But you need to take care of yourself and lose weight. That's going to give you a bigger headache. If you don't lose weight, you run the risk of developing arthritis, diabetes, heart problems and more."

The patient looked shell-shocked and maybe a little mad. He weighed 350 pounds and was less than 6 feet tall.

I too wanted to encourage him, but I kept quiet because he looked somewhat embarrassed and I didn't want him to think we were ganging up on him. But I was glad my attending had seized the opportunity. Even though the patient's eye problem was unrelated to his size [emphasis mine] his weight was and would be his biggest medical problem.

The author goes on not only to defend the actions of her attending, but also to express the desire to emulate them in her future practice. The patient, she reports, responded by admitting they were "only doing their job" by alerting him to the health hazards of his weight.

No, Dr. Sobel; you were not doing your job. You were trying to do my job, and you (or your attending, at any rate) weren't doing it very well. I can virtually guarantee you that any person weighing 350 lbs is all too well aware that he weighs too much. His current physique is NOT the result of ignorance, so whatever "education" you believe you are providing is meaningless. So what have you actually accomplished by pointing out the obvious to your patient, especially when it has nothing to do with the problem for which he specifically sought out your expertise?

What would you have done if the patient had said, "You're right, doc. What should I do to lose weight and shape up?" Do you have any training or experience in dietary, nutrition or exercise counseling? Do you know what the literature has to say about the efficacy of different kinds of interventions in the treatment of obesity? I doubt it. You'd probably say, "Go talk to your family doctor." Besides, as an ophthalmologist, you get paid six times as much just for flushing out a plugged lacrimal duct as I would for an hour-long evaluation and management visit, including intense counseling on obesity management as well as other health matters, so it's not really worth your time.

Do you advise the mother of the baby sleeping in the stroller with a juice bottle in his mouth about the dangers of dental caries? How about warning the teen with the IPod volume turned up to a million about the dangers of hearing loss? Does setting foot in your emergency room turn these patients into a captive audience for all your generic health advice, no matter how badly statistics appear to show that the American public needs it?

Once you choose the identity of specialist, your right to intervene in a patient's health matters unrelated to that for which he sought you out is forfeit. Your "MD" now gives you no more right to advise patients about unrelated health hazards than anyone else on the street. Do you feel your standing as a physician would permit you to make a comment to an obese individual you happened to encounter at a bus stop? I would hope not.

The concept here is of time and place. I submit that an ophthalmologic emergency is not the appropriate time and place for lifestyle interventions unrelated to the problem at hand. So cut it out.


At Tue Nov 25, 09:54:00 AM, Anonymous Anonymous said...

Don't you think you're asking specialists to stop being doctors-in-general? Granted, they were not primary care physicians but I think the problem is that we're becoming over-specialized. Let's shift the example you've given.

The specialist is sitting around the dinner table with his family and the topic of cousin Bob's obesity. "So, what do you think he should? You're the doc!"

The specialist just sits there and thinks, "No, I'm an opthalmologist."

People expect certain things of doctors-in-general. One of them is that they know what healthy is and what healthy is not, regardless of how you choose to specialize. Doctors have a lot of power when it comes to what they say to their patients and if this man has managed to ignore his PCP (or who knows the circumstances there?), then maybe the added notice from a random specialist will help with the motivation. To say that it's a matter of "time and place" sets a precedent for patients such that they'll be wondering why you want to give them more vaccinations when they're just in for some lower back pain.

In the end, yeah, the specialist should just send him on his way to someone who has a better grasp on the issue at hand -- it's not his expertise, after all. But jeez, he's a doctor. It's not like he's completely lacking in the capacity to assess someone's general well-being and make a comment about it.

At Tue Nov 25, 09:55:00 AM, Anonymous Anonymous said...

Pardon the grammar mistakes!

At Tue Nov 25, 10:17:00 AM, Anonymous Anonymous said...

Hooray for you! I'm overweight (under 200, 5'4" female), have been losing at a slow rate, and am well aware of the prejudice against fat people.

Everyone seems to feel its their right to tell us how disgusting, lazy, self-indulgent, etc. we are; but many express their distaste by feigning concern about our health, and providing unrequested advice that is downright embarrassing!

I know I'm fat. I already feel self-conscious about it, but I ballooned up to this weight from a slim size 3 due to some medication I had to take for many years. Now I'm off the meds and the weight is coming off, but I'm also menopausal, so it's not coming off fast.

I would just like to strangle people -- other than my PMD, who knows what's going on and encourages me -- who feel a need to comment on this socially acceptable prejudice.

Thanks for this essay!

At Tue Nov 25, 11:24:00 AM, Blogger jen said...

Frankly, I think all this specialist did is make this patient less likely to come back to this specialist . . . .

At Tue Nov 25, 12:22:00 PM, Anonymous Anonymous said...

Here, Here!!! Dr. Dino! Yeah!!!!

My sister recently experienced something akin to your story. Pre-psychosis my sister weighed around 115 lbs at 5'6'', post psychosis, stabilized on Lithium, Depakote, and Trazadone she now weighs 174 lbs--because both of those meds are weight gainers. Fast forward in time, she is beginning to become psychotic again goes to the ER for admit so she does not mentally deteriorate even more and the hospital has no bed and says to go to XYZ place on Monday. As a special little parting gift the staff "educates" my sister on the importance of loosing weight---Rrrrrright, because the weight shpeel is so important to give as a person is descending into lunacy. Yeah!!! So what does my sister do as she furthers her decent into lunacy--STOPS taking her meds because she needs to loose weight! Wonderful. Hurray, bring on the psychosis! The only thing staving off the total mania induced psychosis IS the lithium, depakote, and trazadone. But, hey when a pt is on the precipice of psychosis and there are no beds, something has to be done right--What are her other overriding health issues? Weight, I suppose. In my humble opinion, there is a time and a place for everything. For my sister, the weight loss lecture was enough for her to stop taking her meds and progress into full blown psychosis and thus be committed on a 5150. All I am really trying to say to ER staff is, treat the presenting problem and do not create any more.



At Tue Nov 25, 12:49:00 PM, Anonymous Anonymous said...

Your entire argument presupposes that said patient has his own doctor. Around here, in the medical capital of the entire f'n world, I run into people daily that don't have their own physician. (Because that's what the ED is for.)

So while I can understand and appreciate your your point of view, I don't necessarily think what happened was 100% bad. There's too much uncertainty in the story to know for sure one way or the other, and I think assuming the worst does a disservice to both patient and provider.

(Insert joke about opthalmologists not being real doctors anymore here.)

And I wasn't aware that one needed to go through a PCP residency to have an understanding of dietary matters and nutritional counseling. That's like needing a CS degree to do basic programming. Er, I don't think so. At least this specialist is taking the time to look at the patient holistically, rather than just at his eyes -- something specialists do that PCPs regularly give them flack for.

Next thing you know, a registered dietician and/or physical trainer is going to give YOU flack for stepping on THEIR toes. (omg! the horror!)

Seriously, can't we all just get along?

At Tue Nov 25, 01:29:00 PM, Blogger The Happy Hospitalist said...

If the ophthalmologist had recommended that the patient quit smoking, would that have made any difference? Is the ophthalmoligist obligated not to recommend smoking cessation to their patients because he/she is not a smokeologist?

The vast majority of obesity, excluding medications and certain less than common treated and untreated medical conditions are genetically predisposed but encouraged by lifestyle choices.

You may have the gene that encourages obesity, but poor eating habits and lack of exercise can turn on bad genes while choosing appropriate food choices and getting the heart rate moving can turn on good genes.

We are not predisposed to failure just because our genes say we are. We make choices everyday that determine our healthy outcomes. We know exercise can prevent diabetes, heart disease stroke and cancer. Choices we as all physicians, must encourage any chance we get.

I think any physician has an obligation to tell their patient information they feel is relevant to their health. Some physicians are better at it than others.

I can find just as many comprehensive care doctors who would say the same thing as that ophthalmologist and walk away.

The issue is not what your specialty is. It's how you approach the problem.

I would disagree with you Dino. The ophthalmologist has every much an obligation as a comprehensive care doctor to encourage lifestyle modifications. However, how they do it can take lots of practice to get it right

At Tue Nov 25, 02:34:00 PM, Anonymous Anonymous said...

Hey, Dino...the next time you do a prostate check on CH, can you tell him his ears are overly waxy during the exam?

From a patient's perspective...if I'm seeing a specialist, I want that specialist to confine him or herself to the subject/target area and the issue at hand. Period. Had I been young Ms. Sobel's patient, and her attending had spoken so to me, you can damn sure bet I would have retorted with more than, "Gee, you're just doing your job." (The response would have been colorful, long-winded, and probably illegal in six states. There are many perverse ways to misuse a stethoscope, and I would have suggested them, graphically.)

"Shell-shocked and mad," indeed.

It also would have ended with me not returning to said specialist for anything -- and not recommending that specialist to anyone I might know. Followed by a call to the referring PCP (Hi, Dino) to tell them that the person they referred me to was an asshat. Possibly a knowledgeable asshat, but an asshat nonetheless.

There is a time and a place for "friendly advice." If you're a specialist, leave that shit to the PCP.

At Tue Nov 25, 06:33:00 PM, Blogger ccinnkeeper said...

After being spoken to in such a way, not only is that patient unlikely to return to that specialist for a follow-up, he is unlikely to return to that hospital and may possibly be reluctant even to return to his PCP if he has one.

Nothing like shaming a patient to make him/her feel good about the care they've received. Way to go.

I have a close friend who is "morbidly" obese (I hate that term). You would not believe some of the remarks she reports have been made to her by doctors. Would you believe a dermatologist recommending gastric bypass?

Very nicely written, Dino.

At Wed Nov 26, 12:36:00 AM, Blogger LicensedToILL said...

The attending reminded the patient he was fat. Cuz the patient probably forgot. Cuz society doesn't remind him every fucking second that he's fat. Cuz specialist's care SO much.

I'd like to pose a question to everyone out there:

What would you say the ratio is of the number of times specialists (plastic, ortho, neuro, uro, etc.) actually come in at 2 AM, to the number of times the specialist makes an assessment over the phone and deems the situation "non emergent" or "not in my area of specialty"? Hmmmm?
Even more what is the ratio of doc acting civil as opposed to a psycho lunatic when they actually DO come to the hospital?
When I worked in the ER I had a plastic surgeon beef up my personal ratio count when he refused to come in for a 27 year old female who literally had the right side of her face bitten off from her lip to her orbital canthus by her own pit bull, ONE WEEK BEFORE HER WEDDING. "Is it life threatening?" No. "Do you have any skin left?" The dog ate some but I have about a quarter of her face on ice. "Well...uh...It's a bit late. I probably can't do anything anyway."

Thanks for the soap box Dr. Dino!

At Wed Nov 26, 01:18:00 AM, Blogger C said...

I can relate to this from the patient viewpoint.

I've walked/waddled out of a good number of doctor's offices not to return in my search for treatment for specific issues made worse by my weight. It inspires real trust and confidence to be told "you are fat and you are going to die, now schedule a follow up appointment for testing, etc." Not smart on my part to just walk out, I know, but that was what I did.

Eventually I was treated by yet a different doctor with a unique approach. I fell over a rock and the rock fought back. In a 15 minute visit to treat the banged up parts of me, a few tests were done "since you are here" and I got immediate feedback that I had an A1C of 12 and diabetes was the result and partial cause of my other woes. 4 years, metformin and diet changes, 250 lbs less and still losing, and regular A1C's of 5.3 for the last 2 years later...I am a happier, healthier person thanks to a non accusing attitude of "Lets see how things are working inside you and see how you can start to feel better."

What a difference in approach can make. A doc can't treat a patient who won't listen, but a patient won't listen to a doc who judges instead of treating.

I doubt the specialist would have appreciated free unrequested advice on communication skills or fashion choices just because the patient felt the doctor needed the information for *his* own good.

At Wed Nov 26, 03:42:00 AM, Anonymous Anonymous said...

I have bad knees, last year l went to see the consultant who made noises about operations, ligaments, arthritis and a few mummbled comments.
I declined unless l had no choice so he sent me to the physio. She gave me excercises.

I eventually got back to the ortho after they cancelled my appointment 7 times (love nhs) and saw some different ortho this time a cretin.

He said there was sod all wrong with my knees, l was just fat and loose weight all will be fine. He was sighning me off as fit.

As l have spent the last 7+ years doing nights with just a few days mixed in (days mixed in only in the last 8 months or so) l asked how l could sort a sensible diet out. I was told that l was making excuses, anyone can loose weight. Go and see my dr. HAH a couple of years or so ago when l asked him about weight loss and my problems said there was leafelts outside in the hall.

I know l am overweight and l am trying to loose weight (sensible eating l hate diets, but tend to junk food) have lost 2kg in about 8 months but still 198kg and about 5'3" but just how the hell do you do it with no set routine when l do not have one due to work.

As to my knees, l have just resigned myself to the fact kneeling and standing up are hell (a lot of out job involves floor level work) go up or down stairs or often walking being painful.

Sorry bitching over.

At Wed Nov 26, 04:43:00 PM, Anonymous Anonymous said...

Angry obese people notwithstanding, you appear to advocate a system whereby only primary care providers are allowed to be doctors. If all specialists are allowed to think about is their specialty, why do they get paid by Medicare for a ROS that includes systems outside their specialty? Why do they do a physical exam outside their area? Why do they go to medical school instead of "GI system school"?

I'm sorry but "Your "MD" now gives you no more right to advise patients about unrelated health hazards than anyone else on the street" is an utterly absurd (and insultingly false) thing to say. I talk to my patients who are smokers about smoking cessation... even if it's unrelated to the current visit! If you don't like it, well, boo hoo.

At Wed Nov 26, 07:25:00 PM, Blogger Bianca Castafiore? said...

I completely get your outrage!

An extra copay might have gone to waste.

At Thu Nov 27, 10:47:00 AM, Anonymous Anonymous said...

I agree, Dino. This person is well aware that he's overweight. It used to be a convention that doctors would not meddle with issues that other doctors were handling, it was considered unprofessional.

Being a judgemental jerk is not helping. Shaming the patient is not helping. I don't even bother to mention smoking cessation to my friends who do smoke. I'm a CORONER. I do my job. I'm not a NEBBISH. There is a difference.

At Fri Nov 28, 05:42:00 PM, Anonymous Anonymous said...

Sorry I disagree for two reasons:

1: The patient may not have a PCP (as stated above). A lot of people do not. Especially those seen in the ER.

2: What'd wrong with non PCP's bringing up a life shortening disease like morbid obesity. Jeez it's only an epidemic in the US and they they are not talking about treatment options. Also, not every specialist has always been a specialist. I wasn't. I had been a practicing internist before going back into training. As an oncologist I have become the defacto PCP for 10-20% of my patient panel, sometimes due to lack of PCP's more often due to the old "have cancer hand-off to oncology" mantra exhibted by some PCP's. This includes patient's who have been cured. Given I am also a board-certified internist who has stayed up on the subject I will match up my general internal medicine skills with you anyday. So quit the "your right to intervene in a patient's health matters unrelated to that for which he sought you out is forfeit" crap. You sound like a hypersensitive twit.

At Fri Nov 28, 07:47:00 PM, Blogger LicensedToILL said...

I usually post once on a threadd but MD arrogance is really getting heavy on this one- look!- I know that a lot of you doctor types, especially the "my shit don't stink I'm a specialist" tyoes are socially retarded (I'm not fucking kidding) so I guess this has to be explained to you in simplest terms.

Just because you are a specialist who suddenly decides to point out to a fat person that being fat is bad for them doesn't GIVE YOU THE RIGHT TO DO IT UNLESS YOU PLAN TO BECOME THEIR PCP or even better, give them resources to change their ways. Do you anonymously stop people in the street and tell them they are fat? Do you tell your friends and neighbors that they are fat, you jerk off specialist? Or are you getting tired of getting slugged in the face? In which case you go to an ENT specialist to fix your deviated septum and she/he tell you that the real source of your continued breathing problems is that you had an ugly nose to begin with.
If you do decide to tell everyone you come into contact with that they are fat- you better be damn well studied in the meds, the research, and the psychology of that particular high horse's pathology.
This may be shocking to you nebbish bitches but advising a patient on weight related concerns unrelated to their seeing you is the equivalent of flexing your brain's bicep and expecting the patient to clap their hands like a barking seal is highly insulting.

At Wed Dec 17, 11:17:00 PM, Anonymous Anonymous said...

I completely agree with your blog entry. Keep them going. I am currently applying to medical school and hope to be that FP just like you.


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