Clinical Case: Leg Pain (Part 2)

Part 1 is here.

(As before, I wrote this at the same time as the presentation, so none of the comments are taken into account.)

The neurologist ordered an MRA (magnetic resonance angiogram) of the aorta and iliac arteries which showed:

...Complete occlusion of the right common iliac artery. Distal disease involving the trifurcations bilaterally in the lower leg, with no discernible flow within either the left dorsalis pedis or posterior tibial.

The translation is that I was absolutely correct in my original diagnosis: she had severely compromised blood flow to her right leg. She has been seen by a vascular surgeon (of great interest, it appears to be the same individual who read her original non-invasive study) and is scheduled for surgery.

A note to those who may feel duped by the fact that a neurologist ordered a "non-neurological" test: Yes, Virginia, there is such a thing as a smart neurologist. Specialists are capable of making diagnoses outside their areas of expertise (though it doesn't happen as much as they like to think it does); that's what happened here. Out in the real world (as opposed to the artificial realm of "case presentations") doctors aren't limited to certain types of testing based on their specialties, and on occasion, they save my ass by doing so.

My mistake was relying too heavily on the negative results of the first test, the doppler flow study.

The medical literature routinely discusses the statistical concepts of sensitivity and specificity, false negatives and false positives. All of these characteristics are highly dependent on the "pre-test probability" that the condition is present. That "probability" is essentially an estimate based on the history and physical; ie, the clinical impression. In this case, my clinical impression was extremely strong. She was a setup for vascular disease: a smoker with exertional pain relieved by rest. Was it incumbent upon me, in retrospect, to pursue a more definitive study before considering the diagnosis ruled out?

The ideal doctor would be completely familiar with each one of these characteristics for every single test ordered. I admit that as a busy clinician, I function more with a general sense of how reliable the test is. For example, I know that the specificity of a rapid strep test is better than its sensitivity. If it is positive, I can believe it; if negative, I send a regular throat culture to confirm it. But if pressed, I'm not sure I could quote the actual percentages for either of those figures.

Cursory web searches reveal sensitivity and specificity figures for pulse volume recordings to be in the mid- to high-90% range for detecting severe vascular disease. I did find an article about the limitations of measurements at rest. Although it recommended repeating the test with exercise to enhance specificity, it was still felt to be more an issue of identifying less severe disease.

However you spin it, it turned out I was looking at a false negative test. The patient told me that the vascular surgeon explained to her that it was likely due to the development of extensive collaterals. Because the blockages had developed slowly over a long time period, the surrounding arteries were able to dilate and carry more blood than usual; sort of like widening the surrounding network of neighborhood streets when there is long-term construction on the main highway.

The teaching point here is what to do when a test shows results that differ from a strong clinical impression.

I think the universal first reaction is to doubt oneself. This is probably more common in training, while clinical judgment is just beginning to develop. It continues well after that, though; no matter how strongly we may think we know what's going on with a given patient, we continue to be surprised on a regular basis. That's why they call it "practicing" medicine. The question here is when do you stick to your guns, and at what point do you admit you were wrong and go looking elsewhere?

This is a case illustrating just how hard it can be to strike that balance.

Afterword: Apparently my error wasn't all that obvious or uncommon. Only MSG and Artemis explicitly entertained the notion that the initial diagnosis was correct. I suspect that -- despite all the warnings I tried to give -- this was approached as a "clinical puzzle" type of case; ie, claudication was considered "ruled out" by the first test. Then again, it is a pretty darn good test; it doesn't often miss severe vascular disease. But this was real life, where these things happen on occasion.

In retrospect, or "the next time I'm in this situation," what would I do differently? That's an extraordinarily difficult question; I'm not at all sure I'd do anything differently. Chances are I'll order a couple more MRAs or CTAs that will probably be negative. Perhaps order "Stress PVRs" to enhance the test's sensitivity. I really don't know. Any thoughts?

Clinical Case (Part 2)

(Part 1 is here.)

Edited: This post was written immediately after Part 1, and held pending the comment response. ie, these are the things (in roughly this order) that I was thinking of.

To re-cap: healthy, active 67 -year-old with worsening back pain radiating around the right side over several months.

When I first saw her, things that occurred to me were:

• Incipient herpes zoster, though that idea fell by the wayside as time went on without any rash breaking out.
• Kidney stone/renal colic
• Assorted musculoskeletal etiologies; possibly unrecognized acute injury/repetitive motion injury from tennis

As she failed to respond to conservative therapy and I became more impressed with the abdominal/visceral component of the pain, my differential expanded:

• Gall stones/biliary colic
• Pancreatitis (or other pancreatic pathology, including possibly carcinoma)
  
• Abdominal aortic aneurysm (less likely in a female never-smoker)

When she went to the ER, they did a CT which showed a "penetrating" duodenal ulcer. (If you click on that link, you'll see this:)

The most common symptom of a peptic ulcer is pain.

Not perforated (no free air) and no bleeding seen at endoscopy. But her biopsy was positive for H. pylori infection, and she responded magnificently to acid suppression and antibiotic eradication therapy.

When I saw her post-hospitalization, she felt fantastic. She told me, "I didn't realize how much chronic pain I was in. I didn't remember what it was like to be pain-free." (It had been about six months from the time she had first noticed the pain.) Her blood pressure was even back to normal.

Here's the thing: I completely missed the diagnosis. I didn't even think of ulcer disease. I probably should have, but I didn't. Apologies for the red herring in the presentation, but ultrasound wasn't even the right test.

Most of the time in the blogosphere, clinical case presentations like this are meant as a way for the authors to show off their diagnostic acumen, or share stories of bizarre or unusual cases. Stories that show how smart we are, despite our modest demurrals that we're only human, and of course we make mistakes. Somehow, though, those are never the cases that (voluntarily) see the light of day. And so I offer to show rather than just tell of my all-too-human fallibility. For what it's worth, I'll be quicker to think of ulcer disease from now on. That's why it's called "practicing" medicine.

Edited to add this after the comment response:

Kudos to Red Rabbit. Well done!

Honorable mention to RM.

Regarding Sid's surgical "organ-elimination" approach to diagnosis: Sid, remind me not to consult with you about headaches.

I admit I'm surprised at the response. I was certain all you internists with your superior diagnostic acumen would zero right in on it. [No sarcasm intended; sincerity can be tricky to convey in blogging, but that is what I am trying to express.] Although it might seem I should feel less stupid for my failure to consider peptic ulcer disease given everyone else's difficulties coming up with it, it doesn't really change anything. Case presentations in this format are truly a far cry from actually talking with and examining a patient. I continue to feel strongly that many, if not most, of the clinicians who so graciously participated would have in fact asked different questions, elicited different answers, and/or interpreted the patient's presentation differently, coming up with the right answer sooner, and thus sparing the lady a fair amount of pain, had they been in the actual position of caring for this patient.

Clinical Case: Leg Pain (Part 1)

Here is another in my occasional series (ok, it's only the second) designed to illustrate specific teaching points in Primary Care. As before, this is most definitely NOT the typical case presentation of some bizarre diagnosis intended to show off how smart I am. In fact, my intent is to highlight an error in my thought process with the hope that others might learn and avoid the same pitfall in their own clinical practices. (Unless I was just really stupid and no one else would ever make the same kind of mistake I did.) I have received the patient's full and explicit permission to post this case.

A 60-year-old white female smoker came to my office complaining of right leg pain for five years. it was described as a tightness in the front of the thigh that came on after walking five blocks or less. When she stopped to rest, the pain abated promptly within one minute. Over time she had noticed it gradually increasing in severity. There was no complaint of any pain or discomfort in the left thigh, either lower leg or foot. She was taking Lipitor for an elevated LDL (224 in 1997; on statins since then.) She was on no other medications and had no other medical problems.

On examination, her blood pressure and BMI were within normal limits. The right leg was unremarkable. There was no swelling, tenderness, deformity or asymmetry of color or temperature. I thought her right pedal pulses were somewhat diminished compared to those in the left foot. The rest of her general physical examination was completely normal.

My diagnosis was claudication; pain caused by a blockage in the flow of blood to the right leg that only produced pain when extra blood flow was needed -- as with walking. As soon as she stopped and the muscle's need for extra blood flow decreased, the pain went away. Although the classic location for intermittent claudication is the calf, I felt the patient's description and timing of the pain -- along with her status as a smoker -- made it the most likely diagnosis.

The simplest, cheapest and least invasive test to document problems with blood flow to the legs is pulse volume recordings performed with doppler ultrasound. Here was the report:

Normal amplitude of the arterial curve, a normal contour of the curve and a normal systolic pressure with an [ankle brachial index] of 1.0 on the right and 0.98 on the left. This study is essentially normal, with no evidence of vascular occlusive disease involving either lower extremity.

With a report showing normal blood flow to both legs, I began thinking about other causes of leg pain with exercise that abates with rest. There's something called spinal stenosis, a narrowing of the spinal canal that exerts pressure on the spinal cord with an upright posture. Bending forward relieves the pressure and the pain. I called the patient and asked again about how her pain was relieved; does she typically bend over when she takes a rest from walking? She wasn't sure; she thought she usually sat down. It was easy to visualize someone hunching over while seated, so I thought, "Close enough." I got an MRI of her lumbar spine which showed focal right-sided paracentral disk protrusion at T12L1, but no stenosis or cord compression. The patient then requested an x-ray of her right hip, thinking the pain might be from arthritis. The films were normal.

Next, she saw an orthopedic surgeon who felt the MRI abnormalities had nothing to do with the pain. He felt it was neurogenic, started her on Lyrica and referred her to a neurologist.

The neurologist ordered another study which confirmed the correct diagnosis.

Post guesses in the comments. I expect that many, if not most, will be correct. I'll put the answer up in a few days. Remember, this is not an exercise in diagnostic obscurity. It is an example of an erroneous thought process interfering with a simple diagnosis.

Oil and Water (Sometimes): Guidelines and Real Life

I had another case the other day when I had no choice but to throw well-documented guidelines for the care of diabetes right out the window.

The patient was a man in his forties with a terrible case of diabetes. The main reason it was so terrible was that he was either completely incapable of or unwilling to comply with lifestyle changes such as limiting carbohydrates in his diet and engaging in regular exercise. His hemoglobin A1c was 13% (good diabetes control being considered less than 7%.) He'd come in at irregular intervals through the years and swear he would do better, but never did for more than a few months at a time.

He recently had a colonoscopy for some rectal bleeding, and was found to have a 4 cm. sessile polyp that was too big to remove through the scope, but did contain cancer in the biopsy specimens. The required procedure is an operation to remove the section of colon containing the cancer.

I only found out about this three days prior to the proposed procedure, when the surgeon's office faxed me a form requesting "medical clearance."

What to do?

All surgery carries risk. The risks in diabetics are magnified; both short term risks like infection and the longer term risk of impaired healing. Surgery for immediately life-threatening conditions (ie, appendicitis) trumps these risks, and the patient must be taken to the OR regardless. But the biology of cancer is such that in this particular case, a delay of three to six months -- or even a year -- is not going to realistically affect the clinical course of the patient's malignancy.

This can be counterintuitive to the general public. How is it possible that cancer is not a surgical emergency? Aren't women with breast masses rushed into surgery? Well, yes, but frankly because it is more of a psychologic emergency than a true medical one. The stress of knowing one has cancer is significant, and it would indeed be cruel to prolong the wait for definitive treatment. But when there are other conditions that significantly increase the risk of surgical complications, that risk/benefit ratio becomes a lot trickier to calculate.

In this case, though, the answer was clear. The surgery needed to be delayed at least 3-6 months so that he could get his diabetes under better control. I called the surgeon, who acknowledged that the cancer posed no immediate threat to his health and agreed to cancel the procedure for now. He told me to call him when the patient was ready to be re-scheduled.*

I hadn't seen the guy for two years, so I made him come into the office, mainly so I could explain to him face-to-face why I thought the surgical risk was unacceptably high while his diabetes was so dreadfully out of control. Here were some other things he said to me to try and persuade me to allow him to proceed with the surgery now:

1. He had already arranged to take time off from his job for the operation (which had been scheduled for the next day) and
2. If he didn't have the surgery now and lost his job in the next few months -- as he was afraid might happen, as his company was planning layoffs -- he wouldn't have health insurance to pay for it.

Add this to the stress of "I have cancer," and I had to think about it for a moment; but it wasn't a very long moment. The bottom line was appropriate medical care, even if it might be socially or financially inconvenient.

Here was the biggest problem: the patient absolutely positively could not swallow pills. Any size; any shape; couldn't swallow them. He had tried. He had swallowed one metformin tablet and it had "gotten stuck." He suffered with the sensation of a foreign body at the base of his neck -- the pill -- for days. There was no way he could do it. Even to save his life -- which he recognized was the case; if he didn't have the surgery at some point, the cancer would eventually kill him -- he just could not do it.

On the other hand, he had no problem with insulin. He had given it to his father for years before the father died (of diabetes complications, of course) so he was at ease with measuring and administering it, even to himself. (He later confessed that he had been on it for a short time many years ago with a previous doctor.)

So along with the most explicit, emphatic discussion of diet and exercise ever provided, I gave him a prescription for insulin: long-acting at bedtime, regular for meal coverage, syringes, new strips and lancets for his meter; the works, but with no oral medications.

There's no guideline in the world that recognizes this as a valid approach for the treatment of type 2 diabetes. But I don't have the luxury of treating guidelines; I treat patients, limitations and all.


*(For all you purists out there, what if the patient doesn't come through with improved control in the given time frame? As time goes on, the urgency of removing the cancer will grow and will eventually outpace even the risks from uncontrolled diabetes. Then he'll get his surgery -- as well as a postoperative infection and non-healing wound -- but at least we'll have done everything possible to avoid it in the first place.)

Clinical Case (Part 1)

There is a principle in writing known as "Show; don't tell." I offer this case as an example of that principle, though the context probably won't be clear until after the discussion in Part 2, in which the answer will be given.

A very active 67-year-old woman came to me several times complaining of mid-right-sided back pain that occasionally radiated around her right side to her abdomen. This had been going on for about one month before she first consulted me. She played a lot of tennis (right-handed) and was under the impression that she had pulled something, although she didn't recall any specific trauma. The pain seemed to be exacerbated by certain motions, though she was unable to be more specific about what kinds of movements. Sometimes it had a "boring" quality. It sometimes woke her at night. Occasionally when it came around to her abdomen it had the quality of "hunger pains" though there seemed to be no relation between the pain and eating (ie, neither exacerbated nor relieved by food, nor consistently recurring before or after eating.) OTC pain relievers taken intermittently provided inconsistent relief.

Other than that she felt fine. The pain didn't radiate anywhere else. There was no nausea, vomiting, anorexia, weight loss, black/tarry stools, melena or bright red rectal bleeding. There were no urinary symptoms. Past history was unrevealing. Her blood pressure was a little elevated, but we were just starting to keep an eye on it. She had never smoked and consumed very little caffeine or alcohol.

Physical exam was basically normal. She had full range of motion of her spine. Perhaps there was some tenderness in the right lower thoracic region, but while in the office she would usually say, "It's not hurting right now." There was no costovertebral angle tenderness. Her abdomen revealed normally active bowel sounds, and was soft. There were no masses or organomegaly, and there was no tenderness or guarding anywhere. There were no skin rashes or lesions. Lab tests were all within normal limits including urinalysis, liver function tests and hemoglobin/hematocrit.

My initial impression (shared by the patient) was musculoskeletal back pain, so she was treated conservatively with heat, massage and OTC acetaminophen. She returned several times, giving a story of increasing pain unresponsive to treatment. She felt very strongly that something was wrong with her back, so when I suggested it was time for some imaging studies, she readily agreed to spinal x-rays. I tried to explain to her my concern that an intra-abdominal process might be causing her pain, so she reluctantly agreed to an ultrasound (although she only went for the x-rays.)

Finally, she called one evening telling me that the pain was now "excruciating," so I sent her to the ER where the diagnosis was made.

Post your thoughts in the Comments.
(Hint/disclaimer: listen to the hoofbeats. No zebras here.)

Clinical Case: Taste Disturbance, Otitis Externa and Other Symptoms (Part 2)

Part 1 is here.

(Note: This post was written at the same time as the case presentation, so none of the comments are taken into account -- because they didn't exist as I write this.)

The patient's daughter had discovered a condition known as Herpes Zoster Oticus -- also called Ramsay Hunt syndrome. It is basically shingles of the geniculate ganglion, and it explains every single one of the patient's symptoms!

Essentially zoster of the ear, Ramsay Hunt consists of a painful vesicular rash in the external ear canal associated with a facial nerve palsy, vertigo, oral vesicles and taste disturbance. Treatment is with antivirals directed against herpes zoster, which I had already initiated, and steroids. (Actually, I increased the dose of the Valtrex and extended the course another week at the higher dose.)

I still believe the right pinna had become secondarily infected with a bacterial pathogen, which also speaks to the question of steroids. By the time the diagnosis was clear, I didn't think we were still within the time window for steroid efficacy, so I elected to omit them. I did offer him narcotic pain relief. No wonder his ear didn't feel better even as the bacterial infection was clearly responding to treatment!

As I said, I never heard of Ramsay Hunt syndrome. I felt certain that all of the symptoms were somehow related, as they were anatomically related to his ear (vertigo from the labyrinth medially; facial nerve passing anteriorly) but I couldn't fit them together until the patient's family did my internet research for me, for which I was grateful. For me, it was a thrill to have a single entity to explain all the symptoms.

Now 'fess up: Who else has never heard of Ramsay Hunt Syndrome until now?

Edited to address comments:

Ok, so apparently it wasn't all that obscure; oh, well. Then again, human nature being what it is, I suspect that there was a significant bias towards those who HAD heard of Ramsay Hunt saying so in the comments and those who hadn't just clicking on to something else.

As far as feeling bad about never having heard of such an "obvious" diagnosis: nope, ain't going there. I believe one of the things that differentiates me from other doctors, and especially other blogging doctors, is my ability to admit to my shortcomings; both to my patients and on my blog. Oh, plenty of people talk the talk about not knowing everything and not being perfect and such; I walk the walk. If I've never heard of something, I admit it, because that's how I learn. I'll thank my patients for finding me the information, and I'll come right out and blog about things that don't necessarily show me in the best light.

In private, dealing with patients, I firmly believe that this approach does a great deal to enhance my credibility when discussing material with which I am familiar. If they know I'll tell them when I don't know something, then when I tell them I am sure of something, they know they can trust me.

In public -- on the blog -- I've grown a thick-enough skin not to care (too much) when people berate or belittle me. Hell, I've had to! Otherwise I'd be cowering under the bed after those last two diabetes posts.

Two feeble points in my defense, though: by the time I first saw his ear, it was already secondarily infected and swollen shut, so there was no way to appreciate any vesicles in the external ear canal. As for the very first symptom, the taste disturbance (dysguesia) alone, drug reaction would be at the top of the differential. I dare anyone to even consider something as far-fetched as Ramsay Hunt when that's the only symptom. (Of course, *now* I will...)

As for sending my patient to a specialist, sure I could have called a neurologist; they would have been happy to see him in October or November. Fat lot of good it would have done him by then. And by the way, his cardiologist (with whom I remained in contact because of the recent stent and what I thought was the role of the Plavix) had never heard of it either.

Lynn: regarding your insertion of my evil twin in Chapter 17: I happen to know that book of yours has only 16 chapters.

Many thanks to all who commented.

Horse-Zebra Hybrid

When you hear hoofbeats, think horses, not zebras.

This old medical expression is the way we doctors express the truism that common things are common. It is also true that, on occasion, we see rare diseases or conditions and this is why we call them "zebra" diagnoses. Another version of this is a "zebra" presentation: a common condition presenting in an atypical or unusual way. Then there's the in-between version, like a case I had a few weeks back: a relatively common condition presenting in a common way, but with a statistically uncommon cause.

I saw an 85-year-old man with weakness and fatigue. Before you go generating hundred-page-long lists of differential diagnoses (not hard to do, I know) let me add that this was relatively recent in onset. Up until about three weeks ago, he was just fine. Mentally intact; living alone and caring for himself unassisted, although he no longer drives. About the same time this began, he'd been started on a new drug by another doctor, but because of the fatigue he'd stopped it after only three days and hadn't gotten better. Now, three weeks later, he was getting worse.

[I'm not presenting this as a full-blown clinical puzzle, in which case I'd rattle off his med list (three blood pressure meds, one cholesterol pill, and an aspirin and a diuretic) and the findings on physical exam (BP 110/50; 30 pound intentional weight loss over the last two years; otherwise nothing) now, but none of that applies to the point I'm trying to make.]

His workup revealed a calcium level of 12.4 (normal range 8.6 - 10.2)

This is a condition called hypercalcemia, and causes muscle weakness, fatigue and depression, among other things (usually kidney stones and inflammation of the pancreas.) If the level gets very high, it can cause coma and cardiac arrest. It was clearly the source of his symptoms.

What causes hypercalcemia?

The two major causes are malignancies (classically multiple myeloma and prostate cancer; basically any cancer that metastasizes to bone, which is where the calcium comes from) and an over-production of parathyroid hormone. This hormone, which increases calcium levels, is produced in the parathyroid glands. These are four little niblets of tissue nestled in the back of the thyriod gland in the neck. Sometimes one of them can grow a tumor that produces PTH regardless of serum calcium levels, which are normally held within a narrow range by multiple regulatory mechanisms.

Multiple myeloma and other cancers are more common the older you get. Prostate cancer in particular is incredibly common in men over eighty.

Parathyroid tumors are most common in women over sixty.

If you took one hundred 85-year-old men with hypercalcemia, ninety-five of them would have prostate cancer as the etiology of the condition; four of them would have multiple myeloma or another cancer.

Surprise:

This patient had just seen the urologists for a relatively slight increase in PSA (actually, it was his PSA velocity that prompted the consult) that turned out not to be cancer. Tests for multiple myeloma and other cancers were also negative. But his PTH level was elevated almost four-fold.

A true zebra-like presentation of a condition that isn't all that rare. If you went with the odds, though, you'd never come up with it. The correct diagnosis in this case came from my being thorough and ordering a test, the PTH, that I really thought was going to be normal.

I consulted with a surgeon and put the guy through a mega-workup of imaging, trying to locate a single parathyroid adenoma which could be removed. As it happened, we didn't find one and the surgeon didn't want to operate. So I sent him for an infusion of Zometa, which knocked his calcium down beautifully. I'm following him once a month, and whenever it climbs back above 10.5 -- or he gets symptoms again, now that he knows what they're from -- I'll send him for more Zometa. Three, four times a year; whatever it takes. He's 85, after all. He and his family are fine with this as a management plan, as they weren't crazy about the idea of surgery either.

So there you have it: a true hybrid between a horse and a zebra.

Clinical Case: Taste Disturbance, Otitis Externa and Other Symptoms (Part 1)

(Blogged with patient and family permission)

At last! A zebra, of sorts.

70-something-year-old man one week status post coronary stent placement presented with a complaint of two days of severe taste disturbance. He described it as "bitey"; whenever anything touched his tongue -- even water -- he complained of an acid-like, vinegary taste. All food and drink produced this sensation. There was no oral pain nor pain in the tongue. There was no complaint of dry mouth. On exam the tongue had a faint brownish coating, but nothing else; no inflamed papillae or taste buds were noted. The rest of the exam was completely normal.

The patient was on multiple medications, but the only new one was Plavix, begun after his stent placement last week. Perusal of the PDR revealed a single mention of "taste disturbance" in the Post-Marketing section of the entry for Plavix. At this point my working diagnosis was dysgeusia as an adverse drug reaction to Plavix. Unfortunately, we were unable to stop the drug, so I sent the patient out with instructions to experiment with different foods, flavors and textures to see how he might best cope with this distressing symptom.

Two days later (on a Saturday night) he called complaining of severe right ear pain. He was camping and felt he might have been bitten by some kind of insect, but now the ear was swollen, painful and draining. I met him at the office and discovered that his right pinna was markedly swollen, hot and red. The external canal was swollen shut, therefore I was unable to visualize the tympanic membrane. There was some serous drainage that seemed to be coming from several areas on the antihelix and other parts of the pinna itself. The ear was very tender to touch.

I also noted a small patch of white vesicles on the right side of his soft palate, and perhaps some slight flattening of the right nasolabial fold. The tongue appeared unchanged.

At this point I diagnosed a bacterial otitis externa, probably secondary to a possible insect bite or sting, though I thought it could also have started as a contact dermatitis. I prescribed Augmentin and hot soaks. The lesions on the palate were consistent with Herpes Simplex virus. The patient did have a history of cold sores in the past; frankly I wasn't quite certain why he now had intra-oral lesions, but I treated him with Valtrex nevertheless.

When I saw him back two days later, the ear was much less red, hot and swollen, though he stated that the pain had not decreased. There was still some serous drainage from areas on the pinna, but I could now see into the external ear canal; it was clear and the eardrum was normal. However he now had a definite right facial nerve palsy: he couldn't fully close his right eye; the right side of his mouth drooped and there was decreased forehead furrowing on the right. He was also complaining of dizziness, confirmed to be vertigo with careful questioning. In terms of treating the facial weakness (often caused by Lyme disease or a herpes virus) I had already begun Valtrex. I didn't want to give him steroids with the active bacterial infection in his right ear. I did review eye care, including the use of patching at night and artificial tears during the day. With the evidence of herpes, I did not feel it necessary to rule out Lyme disease.

I saw him again later in the week, and not much had changed. The right pinna, now normal in size and color, was still draining. The Augmentin knocked him for a loop, not unexpectedly, and he had lost a few pounds. The vesicles were now gone from his soft palate. Interestingly, the taste disturbance seemed to be subsiding. I suggested he continue hot compresses and complete the course of Augmentin, as his ear was clearly better, and that he finish the Valtrex.

A few days later, the patient's daughter called and described a discovery she had made on the internet.

Have at it! (Answer to be posted Monday.)

PLEASE NOTE: Obviously googling the symptoms is cheating, as the diagnosis is easily found. I had never heard of the eponymous condition my patient had and I'm curious about who else has and hasn't.

50-Year-Old White Female Blogger

Maurice over at the Bioethics Discussion Blog posted a recent take on an old issue: how much information to try and squeeze into that all-important "first line" of the history and physical. Should medical students be taught to include or exclude medically "extraneous" data like race, ethnicity, marital status, etc. in their case presentations? Like this:

45-year-old black female homemaker...
57-year-old married white male machinist...
74-year-old left-handed retired Asian math professor...

The argument is that aside from age and gender, all the other information about ethnicity, marital status and the like is not medically necessary. This is true. The big arguments, of course, center around race, with the presumption that certain diseases have certain racial predilections. This, of course, is also true and not true, in that race is recognized as more of a cultural construct and has much less biological significance than previously recognized, although certain conditions do indeed occur with greater frequency in persons of various genetic backgrounds.

Some other pieces of information are specialty-specific. Neurologists usually include handedness in their opening statement, because it is often germane to the conditions they encounter. Not always, of course; who cares what hand a migraineur writes with. Still, it is part of their schtick. It is also logical for Occupational Medicine notes to make prominent mention of the patient's occupation. So there are isolated instances where seemingly extraneous information becomes relevant.

The rest of the discussion centers on the perils of physicians pre-judging their patients, falling into stereotypical thinking on the basis of the descriptors included in the H & P's opening statement. I believe this fear is overblown. Hopefully doctors refrain from jumping to any prejudicial conclusions solely on the basis of the first words of a case presentation.

That said, I think the entire argument is moot.

The unspoken assumption when talking about teaching medical students "how to do a history and physical" is that there is a "right" way to do one, including a "correct" way to present one's findings to others. It is true that there is indeed a standardized format of sorts for an H&P which ought to be taught to medical students. It usually contains the following components:

• Chief Complaint (CC)
• History of Present Illness (HPI)
• Past Medical History (PMH)
• Family History (FH)
• Social History (SH)
• Review of Systems (ROS)
• Exam
• Lab, Imaging and other studies
• Formulation or Assessment (diagnosis), and
  
• Plan
  

The problem is that in real life (as students will learn their first day of their clinical studies) this format is extraordinarily context-dependent. Different sections of the history take on different significances depending on the patient's circumstances and the physician's specialty. Past medical history is usually nonexistent in infancy (aside from information about the pregnancy, labor, delivery and nursery course), and family history is immaterial after the age of 80. In essence, students have to learn a whole new H&P format with each rotation.

This is not wrong. One thing that bothered me in medical school was classmates who claimed that they had been taught to do the H&P a certain way, and by Gd that's the way they were going to do it. Um, no; when you're doing Obstetrics, it's not that important to determine what the patient's grandfather died from and whether or not she ever had her tonsils out. (Just try asking all your Review of Systems questions to someone in active labor and see how far you get.) The idea that the H&P for the initial presentation of an adult patient with a medical (as opposed to surgical) problem, as taught in medical school, is the only "right" way to do an H&P is inflexible and impractical. Similarly, the idea that "presenting the patient" is always done exactly the same, regardless of whom you are presenting the patient to (and the reason for the presentation) is nonsense.

Think of an H&P like a painting. There are many different kinds of paintings: still life, portrait, landscape, miniature, abstract, and so on. There are the basic artistic concepts of design, line, light, color, layout, but different kinds of paintings require emphasis on different principles. If you imagine all students beginning with an oil painting of a still life of a vase of flowers, how silly is it to think of them complaining that a landscape isn't a "real" painting. In our case, that internal medicine patient presenting for the first time with a new problem (as opposed to a patient in the ER, or a patient needing a pre-surgical evaluation, or a newborn, etc.) is the equivalent of the floral still life. Learning to recognize when that form is appropriate is half the battle.

In terms of presenting the patient, again, context reigns supreme. The formal version discussed by Maurice is designed for the presentation of a new patient to clinicians who do not already know the diagnosis. ie, a clinical puzzle, as seen in the New England Journal of Medicine and elsewhere. As third year medical students will quickly learn, that won't get you very far on morning rounds. "Hemicolectomy, post-op day three, afebrile, passing gas" is all they want to hear on surgery. "Mulitip at six centimeters an hour ago, comfortable with epidural" will do on Obstetrics. You get the idea.

After all that, though, in answer to Maurice's question, I'm going to come down on the side of more information in the opening statement rather than less. I'd love to hear something like, "58-year-old married female secretary who just dropped her last child off at college and started art lessons last week..." and here's why. It has to do with this quote from Sir William Osler:

"The good physician treats the disease; the great physician treats the patient who has the disease."

The more I know about the patient who has the disease, the better job I will be able to do caring for that patient. How better to get to know the patient than to describe him or her as fully as possible right from the start of the encounter. For those who worry about stereotyping, allow me to offer the following suggestion: ask the patient to describe him or herself, and then include the response in the opening statement. Like this:

This is a 50-year-old white female physician blogger with grown children and way too many animals at home who describes herself as "zaftig but generally healthy."

I don't treat diseases. I treat people, and because every person is different, I think it is better to err on the side of more description rather than less.

A Tale of Two Titties*

(*Title credit to Darling Spouse)

Two patients with similar mammograms: a vague finding appreciated by only a single radiologist. Extra views are done; ultrasounds are done; MRIs are done; all are negative. Neither patient has any palpable abnormality within the affected breast. Here’s where they part company: one patient receives a recommendation for a 6 month repeat; the other an appointment to a breast surgeon, who, although unimpressed, bows to the suggestion of the original radiologist and orders a core biopsy of a poorly defined area near the chest wall, that is not seen on MRI or ultrasound.

Suffice it to say, neither woman was happy with the recommended course of action. Here’s why:

The first patient had had a delayed diagnosis of cancer in the other breast, and although now more than five years out from treatment with no evidence of disease, was emphatically NOT willing to wait 6 months with a possible abnormality in her remaining breast. Interestingly, the original radiologist, a part-timer, was out the day I called back to confer on the initial mammogram. The doctor I talked with couldn’t even see what the first doctor had, and said, “I’d have let her go for a year.” When the part-timer got back, though, he stood by his guns and said he definitely saw an area of "asymmetry." Although he was comfortable with a 6 month follow-up, he offered the MRI now to appease the patient.

Worried less about his comfort than that of my patient, I managed to locate a surgeon (with a great deal of kicking and screaming emphatic persuasion and numerous phone calls on my part) who agreed that the best course of action for this patient was in fact a prophylactic mastectomy on the second side, all so that she “wouldn’t have to keep going through this.” (the patient’s words) She has had her surgery (with completely benign pathology) and all is well.

The second patient is actually a physician, albeit one who has left clinical practice to become a pharma shill (a term of great affection and endearment, L; great affection and endearment!) with negligible risk factors for breast cancer, who knows damn well this is nothing. Yet because this isn't technically her area of medical expertise, she is as much at the mercy of of the goddamn specialists as the least edumacated of our patients. She is willing to accept the uncertainty and settle for a 6 month (or even 3 month) follow-up, but no; everyone is playing on her emotions, guilting her into a biopsy with a bolus of "just in case," followed by a continuous drip of "better safe than sorry." All because one radiologist -- just one -- isn't comfortable with something he saw on her mammogram.

So she hems and haws, and panics (and blogs) and goes for her MRI biopsy. One might wonder how you go about biopsying something on MRI that doesn't actually show up on MRI; well, I did, at any rate. It turns out that you don't. So what we have here is a wasted morning by a respected physician who could otherwise be churning out perfectly good pharma propaganda (feel the love, L; feel the love!) Not to mention all that adrenaline that could have been used to fight a tiger or wax indignant about an anti-Gardasil post. Frankly, this strikes me as a case of Someone Asleep at the Switch. Why the hell didn't *someone* (primary doc? surgeon? patient?) put 2 and 2 together and ASK why an MRI biopsy of an MRI negative lesion was being ordered!! And the upshot is (her words):

...a repeat mammogram in 6 months as follow up. Now who was it who suggested that course of action last week? Oh right. That would have been me.

Here's my point:

A radiologist notes a subtle finding but is comfortable with interval follow-up, a course of action that is completely inappropriate and unacceptable to the cancer survivor.

Another radiologist is uncomfortable with a mammogram, so patients undergo invasive procedures to assuage the concern of their doctors.

Excuse me, but isn't this just about the most ass-backwards thing you ever saw? Since when is it the patient's job to make the doctors comfortable? Luckily (?) someone was silly enough to schedule a useless appointment (though I'm certain her insurance company will still pay for the second MRI) so my new friend wasn't actually punctured, but still; how far should she -- or any patient -- be forced to go essentially to placate the single radiologist who read the initial mammogram? Although she's not my patient, if she were, I would have supported her in her acceptance of the (minimal) risk entailed in settling for short interval follow-up mammography.

Two patients; similar findings. Different recommendations from two different radiologists based on their different comfort levels (which are -- admit it! -- fundamentally related to their fears of malpractice litigation.) Different patient preferences based on very different clinical contexts. All other things being equal, I think we should be more concerned with our patients' comfort than with our own -- or even that of our consultants.

Shooting Up the Cat

I had a very interesting day yesterday. The Mighty Hunter, who had been walking a little funny the day before, refused to put weight on his right front paw.

I tried my best to figure out what was wrong: I palpated the whole limb very carefully but didn't elicit any reaction from him. He wasn't particularly in the mood to be handled, though, so I wasn't sure I hadn't missed something. By the time I had showered and dressed, Darling Spouse was really worried about him. Our regular vet didn't have any appointments available so we decided to try a local emergency vet place we'd heard about.

TMH went into the carrier easily, something else that really scared the shit out of us. I drove; Darling Spouse held the carrier, crooning to TMH as we tried to find the place. The cat was crying; it's the only word for the sounds he was making. Then he started panting. Very uncharacteristic for this guy. Needless to say, we were getting more and more scared.

The logical, clinical part of me wasn't really worried. The overwhelming likelihood was that it was something musculoskeletal, and that we'd be sent home with anti-inflammatories instead of having to leave the dude there for surgery. I doubted trauma, even though he insists on going outdoors, because I would have expected an injury to start with symptoms at their most severe instead of the progression -- albeit fairly rapid -- that we observed. But the part of me that wasn't a vet thought, "What if it's something serious, like in his lungs?" I didn't know if an apical lung lesion could produce referred pain to a front limb or something like that.

We found the place after only a few wrong turns. Let me just say this: I'm in the wrong business. The facility was absolutely gorgeous; huge waiting room; coffee and cookies -- for the humans; a basket of doggie treats on the counter. The receptionist was awesome: friendly and attentive. I filled out the shortest form I've ever seen in a medical office. A nurse came out to triage TMH; making sure he didn't have something immediately limb-threatening like a clot, we were told later, but then we had to wait while another woman's critically ill dog was cared for.

Eventually we were taken back where TMH had his vitals taken. I have to say one thing for this cat: at least he's cooperative with medical care. He wasn't crying or panting anymore. In retrospect, I'd have to say he was taking his emotional cues from us, and we were feeling better about him now that we were doing something for him. The nurse set him down on the floor and sure enough, he began walking around on three legs, confirming that he was lame. (At first we were worried he'd walk perfectly normally and were reassured that that actually happens all the time. Not this time though. Definitely something wrong.) We left him on the floor while we waited for the doctor. After cruising the room he came back over to where I was sitting on a small bench next to the exam table. He carefully jumped up onto my lap and then back up onto the table; definitely guarding his right front limb, but we were encouraged.

The vet was great; young; very cool. Seemed to appreciate TMH's dudeliness. Did a complete exam. (Totally cracked me up later to read the documentation: "Neuro: cranial nn intact; proprioception intact; mentation good." WTF? He never asked TMH what his name was or if he knew the date or where he was.)

In order to do a very thorough exam of the right front limb we held the cat for him: on his back, cradled in my arms instead of right against the cold metal table; rubbing his belly. Once again, TMH cooperated beautifully. (Anything for a belly rub.) The vet was pretty sure the dark marks on the right paw pad were specks of dirt and not dried blood, but he said he couldn't be sure there wasn't something in there. He thought the metatarsal pad was a tiny bit swollen and a bit warmer than the other one. Darling Spouse and I looked at each other, suddenly remembering the broken glass in the street next to the driveway left by the garbage men. Had TMH stepped on some and gotten a piece stuck? I would have expected it to hurt a great deal more than TMH was letting on if that was the case. Still, x-rays were definitely indicated.

Off we went to the waiting room while TMH was radiated, but then we were invited back to view the films on a monitor in a gorgeous wood-paneled office area. The glimpses we got on the walk back showed that the rest of the facility was just as impressive as the waiting and exam areas. There on the monitor was an enlarged x-ray of a cat's paw. (Now, of course, I regret not taking him up on his offer to burn me a CD of the images. I wasn't thinking of blogging at the time.) "Right there," he pointed. Sure enough, the base of the fifth metacarpal had a small but definite non-displaced chip fracture.

How the hell had he done it? No idea. What to do? Let it heal. No cast or anything. Just three days of an anti-inflammatory. (It turns out cats' livers don't tolerate NSAIDs very well, hence the very short course.) Which one? Meloxicam; Mobic, for humans. Metacam for animals. Same stuff, of course.

TMH had already received a dose SQ (subcutaneously.) They were going to send us home with two more oral doses for him for the next two days. I looked at TMH. He was actually much better about letting vets handle him than us. The idea of catching him, immobilizing him (I couldn't squirt something into his mouth while rubbing his belly) and forcing something into his mouth that he didn't want filled me with something between trepidation and terror.

"Can I give it to him sub-Q?" I asked. I've had cats all my life and have seen all of them get shots. It really did look ridiculously easy.

I said the vet was cool. "No problem. They have so much skin, it's ridiculously easy." He showed me how to lift the skin of the back and inject into the V formed by pulling it up. "He won't even know you're doing it."

Back home, TMH looked almost stoned. I wasn't sure if it was the drug or the relief of being home. He slept very well all day.

This morning it was shot time. I took one of the two syringes they'd given me ($14 apiece; I told you I'm in the wrong business) each containing 0.1 cc of Metacam, then found TMH upstairs on our bed. I lifted the skin with my left hand and went to pull the cap off the needle with my teeth. The needle came off the syringe; it wasn't a Luer lock. I let the cat go, shoved the needle back onto the syringe and pulled the cap off.

Let me interject here that I give shots all the time; immunizations and allergy shots; obviously this is flu shot season. I usually use needles that are 5/8" long, going in at a 45 degree angle for SQ and a 90 degree angle for IM. (Yes yes yes; I've been told a million times I need to use longer ones; but I've hit bone going into a small toddler's arm with the 5/8", and I've also read that there's no difference in efficacy if it doesn't get into the muscle, so that's what I do.) This was a tiny little 1 cc syringe; I was expecting a similar sized needle.

So imagine my surprise at having uncapped a one inch, twenty gauge weapon I was supposed to stick into my cat! Ok; they have a lot of skin; the skin on the back -- where I was injecting -- is probably the thickest skin on their body (like humans; only place thicker is the soles of the feet.) Here goes nothing.

I lift up the skin on the back and poke the needle into the V, inject as quickly as I can (one whole whopping tenth of a cc) and get it the hell out.

The cat doesn't even notice. In fact, he rolls back over and waits for me to rub his belly. Which I did. Interestingly, within five minutes he's fast asleep. I go in to shower and when I come out of the bathroom, he's still passed out, spread-eagled on his back.

That meloxicam must be some great shit.

Having it Both Ways

I cannot stand specialists who pad their patient load by trying to do primary care in addition to their specialty practice.

There's more to specialty training than just a huge collection of esoteric facts and high-tech procedures on a single organ system. (My father likes to joke about the guy who's a specialist in diseases of the left nostril. If there's something wrong with your right nostril, you're out of luck.)

The essence of specialty training is a mindset: the mindset that you are the expert; the go-to guy; the one who will leave no stone unturned to get to the bottom of whatever is wrong with the patient in front of you.

There is nothing wrong with this mindset. It is necessary and useful when faced with difficult or obscure diseases. Keep in mind, though, that the appropriateness of this approach depends upon two important assumptions that are seldom articulated:

• Whatever is wrong with this patient requires your expertise.
  
• The patient's condition actually falls within your area of specialization.

That is to say, the specialty mindset is appropriate for patients who have been referred by another physician who has either been unable to figure out what is wrong, or who has determined that the patient requires a procedure that the first physician is unable (or unwilling) to perform. This implies that the patient has already been evaluated by another competent physician who has decided that the problem is not within the scope of practice of primary care. That first physician has also narrowed down the range of diagnoses to the point of selecting the appropriate specialist.

Patients who self-refer to specialists screw this whole thing up. They're the ones who are more likely to have common conditions that don't really need the specialist's level of expertise, and in whom an extensive (and expensive) workup is unlikely to yield any useful information. In fact, chasing trivial findings discovered in the course of an unnecessary workup is probably one of the biggest sources of wasted money in health care. The other inefficiency of self-referral is going to the wrong specialist. The classic example is the patient with chest pain who goes to the cardiologist, and only after the negative (but lucrative) cardiac workup is found to have pain of gastrointestinal origin, and vice versa.

Primary care training emphasizes keeping an open mind as part of the process of diagnosis, and the recognition that common things really are common along with the constant awareness of when there is something different enough about a given patient to spur the zebra hunt. We develop a tolerance for uncertainty; the kind of uncertainty that drives a specialist crazy. We can do this, in part, because we know that our ongoing patient relationships means we can trust them to come back if/when the clinical picture changes. Very few specialists are willing to use time as a diagnostic tool.

The nature of their training leaves specialists at a huge disadvantage when trying to diagnosis and manage unselected patients. They know a great deal about their specialty, but their knowledge of other specialties is superficial at best. It's the old adage found, among other places, on Dr. Bob's sidebar:

If the only tool you have is a hammer, you tend to see every problem as a nail.

But what if there aren't enough nails around to make a living?

I'll never forget how pissed I was the first time I heard an Internist say that he did "Family Practice" because it was "better marketing." I also once had an orthopedic surgeon say to me, "I can do primary care. I can take a blood pressure, find that it's high and send someone to the cardiologist." I wanted to answer, "Hey, I can be an orthopod: I can tell someone with a sprained ankle to ice it, wrap it and keep it elevated," but I couldn't actually believe my ears at the time. What better way to illustrate either ignorance of or disrespect for what I do!

This ignorance/disrespect leads many specialists to believe that primary care isn't really that difficult. So when a specialist in an overserved metropolitan area finds he can't fill his appointment book with specialty patients, the decision is made to do things like this:

• Allergy and Primary Care
• General Pediatrics and Pulmonology (sorry, Flea; that always bugged me.) (Apologies for the pun, too.)
• Family Practice and Rheumatology
• Internal Medicine and Infectious Diseases
  

The problem is that specialist do not do primary care very well at all. They find high blood pressure and refer to the cardiologist. They see an elevated blood sugar and refer to the endocrinologist. They all say "Stop smoking" and think of it as tobacco counseling. Virtually none of them do immunizations, especially gynecologists, who like to think of themselves as providing Primary Care for women. (Obstetricians can't treat ear infections to save their lives, even in a pregnant patient. I've cleaned up more than one of their misadventures, though most of them just refer to ENT.) "Family Practice" rendered by specialists is nothing more than a circular exercise in mutual masturbation.

Don't jump down my throat with the occasional exceptions: sure, the nephrologists take decent primary care of their dialysis patients, though they're not so good about sending the women for mammograms and other screenings. (They probably figure their ESRD will kill them first, which isn't always the case.)

The bottom line is that the primary care mindset and the specialty mindset are mutually exclusive. A true specialist cannot turn it on and off at will. They can't have it both ways.

Road Trip

I have just returned home from a lovely three-day road trip to the New England area. The event was an open house at the college my younger son (previously and hereinafter referred to as The Nestling) will be attending in the fall. What made the occasion extra special for me is that it is also the college I attended; he will graduate thirty years after I did.

The weather was glorious and the traffic was light. The half-way point was a lovely diner with a menu leaning towards Greek but with all the usual greasy-spoon staples done up just right. The Nestling and I share tastes in conversation and music, so the CD case was packed with mutual favorites, paused frequently for assorted commentary. My laryngitis is still trying to hang on so, after singing along with the sound track from Wicked, two of the three discs from The Remains of Tom Lehrer, as well as Don McLean and others, my speaking voice was hoarse again. Worth it, though.

The campus was recognizable, even with some old buildings gone and several new ones in unfamiliar places altering the landscape without ruining it. The official presentations were boring as hell, but one of them (the parents' forum) was held in the actual gymnasium in which I had received my diploma twenty-six years ago. During the buffet luncheon (what my father likes to call "courteous and efficient self-service") I tried to locate the pre-health advising staff, planning to offer myself as a resource to the pre-meds to infect them with the passion of primary care before they get to medical school and have it ridiculed out of them. (No, the Nestling has no interest whatsoever in medicine.) I settled for leaving my card with one of the higher-ups, while the Nestling finished his lunch at a table full of kids he had met on Facebook.

After lunch we made our way to one of the classes that was open to the "pre-frosh" visitors. We chose Introduction to Biochemistry for two reasons: it is the Nestling's intended major, and it was being held in the classroom where I took my very first college class, which happened to be Inorganic Chemistry. We met up with another parent/nestling pair on the way over, so the kids sat together while the other parent and I selected seats a small distance away. Unfortunately the actual professor was out of town, but the class was taught by a perfectly competent grad student. The topic was something the Nestling happened to be having some trouble with in one of his high school classes at the moment, and afterwards he went down to thank the teacher for helping him finally "get it."

Because the rest of the official forums and sessions looked dull, we wandered instead. While the Nestling went to get his bag out of the car and stow it with the luggage of all the other kids planning to spend the night with accommodating students, I perused the bookstore, which had been moved from its old location. Finally we met up on a wide expanse of lawn outside the new student center. The Nestling spotted a group of guys throwing a frisbee around and headed over to join them while I sat and read the irreverent gag newspaper. I later sent the writers a two-line email:

You guys are seriously disturbed.

Keep up the good work.

The final official event of the day was a choice of "Master Classes;" lectures in various disciplines provided specifically for the prospective students. The Nestling and I were torn between two of them, based on their titles alone:

• The Forensics of Human Sacrifice

and

• Channelopathies: When Good Membrane Proteins Go Bad

We went to the second, which was taught in the lecture hall in which I had taken a year and a half of Physics.

What a cool talk! Given by a full Professor of Biochemistry who had apparently been there when I was (though I didn't remember him at all; I was straight Biology) it was as accessible to the bright high school seniors who were there as it was fascinating to me. The computer graphics showing membrane proteins alone were mind-boggling!

The next day we were on our own. This time I led the way up to the area of the campus where I had spent most of my time; the quad where I had lived three of my four years; the campus pub; the student center where the bookstore used to be, and to the mailroom where I quickly found my old mailbox. (Force of habit: walking into that building, my feet were on auto-pilot.) This part of campus hadn't changed as much, and the nostalgia was as warm as the sun that finally deigned to emerge. We settled on a grassy knoll under the statue of the University namesake and chatted with a pair of students who were likewise enjoying the sun. Amazingly, the Nestling wasn't radiating the violent rays of anti-parent embarrassment virtually endemic to adolescence. In fact, he was the one who mentioned my alumni status. He seemed to actually enjoy my company.

After another stop in the bookstore for the obligatory purchases (sweatshirt with the college name for him; t-shirts for Darling Spouse and myself; decals for the cars) we drove north to spend some time with my brother.

My brother is also a doc, but in a specialty that renders most of his clinical experience and essentially all of his administrative issues completely irrelevant to mine. He had recently moved to a new office and had to wait while an alarm system was installed. Fortunately the Nestling had brought along a deck of cards, so we whiled away the time pleasantly enough. By the time he had whupped me at a game of Rummy 500, my brother was ready to go. After a delicious dinner of Tequila-Cilantro-Lime Scallops over rice pilaf followed by homemade ginger ice cream for dessert, we headed back up to his house. His wife and daughters were away so we didn't get to visit with them, but my brother took the Nestling for a ride on the back of his motorcycle that evening and again the next morning when we went out for breakfast at a charming little haunted tavern on the edge of a hand-dug manmade lake. So New England!

The ride home was a repeat of the journey up. We played almost all of the rest of the CDs in the case, and stopped for a meal at the same Greek diner. I even bought an enormous loaf of the sweetest challah I've ever tasted, to share with Darling Spouse.

Although I was only out of the office for two working days, I find myself tremendously refreshed mentally as well as physically. There was a schedule, but not one so rigid as to compromise that wonderful relaxation. The kid had a good time; I had a good time. The Nestling is on track to have a wonderful college experience. For today at least, life is good.

So-Called Choices

Dr. Schwab has once again waxed eloquent, this time on the issue of immediate versus delayed breast reconstruction after mastectomy for breast cancer. One of the things he admits is that he has a bias, in this case a bias against immediate reconstruction, but that he tries not to let it sway him in how he counsels patients. I have no issue with the specifics of breast reconstruction timing, but I'd like to address the issue of physician bias -- and not at all to bash Sid!

I agree that not only do we all have our biases, but I would like to point out that it is the nature of the physician-patient relationship -- as a practical matter -- to use those biases all the time to make choices for our patients.

That is our job.

This is not a bad thing. We make very good choices for our patients almost all the time. Oh, we tell ourselves that we give our patients all the information they need to make their own decisions and that we respect the choices they make. I submit that we are being dishonest with ourselves, and here's why: when patients make choices with which we don't agree, we call them "inappropriate" and do not honor them.

I am not speaking of paternalism, the essence of which is that the patient should blindly agree with whatever we say. Although we are making the decisions, it is still incumbent upon us to explain to our patients -- in sufficient detail, and at a level they can comprehend -- why the course we are recommending is the "choice" they should make.

Many times, as a practical matter, the only way a patient can make a different choice is to consult another physician.

Look at some examples:

• A patient wants antibiotics for an upper respiratory infection.

I can explain until I'm blue in the face that this is not a good idea, that they don't work and won't make him feel better any quicker, the risks of allergy and resistance and everything else. Although this interaction can be described as explaining appropriate therapy for a URI, the reality is that the patient has made a choice I don't agree with: he has chosen to treat his URI with antibiotics. That's why he's come to my office. My options are to stand my ground and explain my position, or give in and write him the prescription ("honor his choice.") The patient's options are either to come around to my way of thinking (if I'm persuasive enough) or he can go see old Doc Jones up the street who gives out Amoxicillin like candy.

• A woman wants her breast cancer treated with diet and Reiki.

Similar to the above, but with much higher stakes. Everyone will be all over this lady about what a poor choice this is. The unfortunate truth is that in some tragic cases, these patients will not be convinced. There will always be someone -- Reiki masters and NDs -- willing to do whatever it is she wants; who "honors her choice."

• A family wants to continue life support for a patient with no hope of recovery.

This is a frequent occurrence in the ICU setting. My guess is that most physicians would gently explain the limitations of futile care, trying to persuade the family to withdraw heroic measures, ie, disagreeing with the choice they've made, and persuading them them that a different choice would be better.

Now how about this one:

• A family wants to withdraw life support but the physician feels the patient still has a significant chance for recovery.

I know this one is tough to imagine, but imagine a self-limited condition in an otherwise healthy patient; say temporary ventilatory support for pneumonia. The family says, "Dad didn't want to be on a breathing machine," and we rush to say, "That doesn't apply here at all! He's not terminal; the ventilator is only temporary." The family comes around quickly -- and appropriately -- but what really happened is that a family was guided away from making what we felt was a poor choice.

This has been addressed elsewhere:

• A woman wants an abortion but her doctor is morally opposed to the procedure.

Different doctors respond differently to this scenario, but clearly the physician's bias is the major determinant of whether or not the patient's choice -- legal, and hers to make according to standard medical practice -- is honored.

Patients make bad decisions ("wrong choices") all the time. They decide they're sick enough to need an ER, but medical personnel disagree with them, so they wait until others who are correct in their assessments of how sick they are can be cared for first. Much of the time, we as physicians can agree that one given patient decision is better than another, or even that some are "wrong." On the other hand, that agreement is far from universal; witness the abortion "choice" above.

In addition, there are plenty of other clinical scenarios where we can agree there is no clear cut "best" choice: surgery or radiation for prostate cancer? Beating heart CABG or cardioplegia? Immediate surgical repair or casting for Achilles tendon rupture? In cases where the evidence is not yet complete (or where a doctor is unaware of, or chooses to ignore the evidence) physicians have their biases, often very strong ones. Certain urologists truly believe in their hands, prostatectomy is better than radiation. Some orthopedists will never operate on an Achilles tendon; others insist it's the only way to go, and so on. This is where "physician bias" comes into play. We usually call it "experience" instead of "bias" because we often feel we have a rational basis for the decision (let the patient process the cancer experience before going through major reconstructive surgery, per Sid) but all we've done is legitimize our bias. I'm not saying there's anything wrong with it, but it is still a bias.

I have a friend who needed a valve replaced in her heart. The research she did was exhaustive: hospitals; doctors; complication rates; techniques. As medically sophisticated as she was, how did she -- or anyone, really -- have the expertise to choose between multiple tertiary care centers and different surgeons each telling her his approach was best? Here's what I told her: If there were one clearly superior procedure, it would be the only one. The more different people there are telling you different things, the less it matters; your chances of doing well are good whatever you choose.

How are patients supposed to figure all this stuff out?

They're not. We're the doctors. We're the ones who are supposed to know about these things. We are the ones who should be making the decisions. There's nothing wrong with this. It's our job. As long as we communicate with our patients, get to know them and their preferences with regard to their health (ie some people prefer a cheaper med even if it has to be taken multiple times a day, and have no trouble with adherence; others feel the convenience of once daily dosing is worth paying more) and take those factors into account when we make our recommendations, we are indeed collaborating.

As Sid pointed out and as others are sure to echo, many of our patients will ask us, "What would you do if it were you/your family member?" The only way to fully avoid expressing a bias is to refuse to answer, and I don't know many doctors who can do that. Virtually everyone will eventually answer that question: they will tell the patient which choice they ought to make. If that isn't the same as making the choice, it's too close for comfort.

None of what I've said absolves the physician of the responsibility to make as certain as humanly possible that patients understand their conditions, what the treatment options are, and why the doctor is making this specific recommendation at this time. But at the end of the visit, when the pedal hits the metal and the rubber meets the road, we are the ones making the choices.

What's my point? That instead of foisting off the final decision on the patient by citing "patient autonomy" as the ultimate good, we need to recognize that in the end the responsibility is ours. Making these decisions thoughtfully, transparently, in consultation with the patient -- and with the awareness that we are making them -- is more intellectually honest than telling ourselves that "the final choice is up to the patient."

Limits Gone Wild

I saw a little girl the other day with a splinter in her knee.

Her parents had done their best to get it out, but didn't think they had gotten all of it. When I took a look, I saw what looked like a tiny splinter remnant about 3 millimeters long (ie, really small) nestled in the bottom of a small cut. I pressed on it gently and asked the kid if it hurt. From experience both clinical and personal, I've found that this is a fairly decent way to tell if there's anything still in there. She didn't complain much, so I wasn't all that worried.

I got my splinter forceps, pushed upward on the visible part of what might have been the rest of the splinter and managed to grasp it. Then I pulled...

And kept on pulling, until lo and behold a full half inch (11 mm; I measured) of splinter materialized before my eyes. It was impressive, given that it must have gone straight "down" into her knee, as opposed to tangentially along the skin, which is what the original wound looked like. The kid did great; nary a wince and not a peep. I put the splinter into a little tube and gave it to her to take home to show Daddy, along with stickers (my office goodies-of-choice.)

What does this have to do with limits? In the course of the visit, the mom mentioned to me that school nurses are no longer allowed to take out splinters when kids acquire them at school. That struck the both of us as pretty stupid. Why make a kid suffer with a splinter all day instead of at least trying to give it a little tug. It doesn't really apply to this case, but it struck me as just the latest in the slow and lingering death of common sense as it succumbs to the continued onslaught of the lawyers. The new prohibition is clearly the result of increasing liability fears.

I've posted several times bemoaning the failure of assorted medical personnel to recognize their limits. As it happens, I do feel that there are some groups of people who are better at this vital life skill than others. Among them tend to be school nurses (and often, parents.) This family only brought the kid to me after giving it their all to get this nasty splinter out on their own. I'm pretty confident that a school nurse would be even quicker to punt. But forbidding them to even touch it in the first place? The nanny state strikes once again, when fears of lawsuits outweigh a child's comfort.

That was one impressively big-ass splinter, though.

Skeptic's Alert: Another Community of Crazies (Old News)

I ran across this post at Freakonomics the other day:

[My dentist] told me that tooth decay in general, even among wealthy patients, is getting worse and worse, particularly for people in middle age and above. The reason? An increased reliance on medications for heart disease, high cholesterol, depression, etc. Many of these medications, Dr. Reiss explained, produce drymouth, which is caused by a constricted salivary flow; because saliva kills bacteria in the mouth, a lack of it means increased bacteria, which leads to increased tooth decay. Given the choice of taking these medicines versus having some tooth decay, I’m sure most people would still choose the medicines—but I am guessing that most people haven’t thought about the link between the two.

followed by this in the comments:

The dentist's comments are a classic example of anecdotal beliefs espoused by many healthcare professionals to their patients without the backing of evidence-based medicine; i.e. clinical trials. If Dr. Reiss could back up his assertions with some evidence I would be more prone to believe them. And in case you are wondering, my skepticism arises from his broad claim that most medications used to treat modern chronic medical conditions cause dry mouth. Many medications do cause dry mouth, but of the ones I know that are used for today’s most common conditions, none of them stand out as particulary drying to the oral cavity. Furthermore, there is an alternative explanation that seems to me to more closely follow Occam's Razor, an explanation I might add that is popular among many other dentists. The increase in tooth decay seen in modern times can be linked to the increased popularity and pursuant consumption of bottled water, the nonfluorinated cousin of regular tap water. And of course we know that one of the greatest things you can do for your teeth is consume adequate amounts of fluoride. Go figure.

A little further along there was this:

I thought if a child ate enough toothpaste, he’d die of fluorosis – is this urban myth?

Dino to the rescue! (Someone else beat me to it, though.) I was researching an answer to the effect that no, fluorosis was a cosmetic discoloration of the tooth enamel (but the author may have been thinking, correctly, of the danger to children from mouthwash with high alcohol content) but in the process of finding links to document my comments, found this:

The Fluoride Action Network: A group vehemently opposed to the poor little halide.

Minimal googling on my part, though, came up with these reassurances that while I've been off nibbling the tops of the trees and losing the name Brontosaurus, nothing has changed. Just the tip of what I found:

CDC Fluoridation Home Page
Surgeon General 2004
Why Fluoridation is Important (QuackWatch)
American Dental Association
World Health Organization

In fact, Quackwatch has that very same Fluoride Action Network on their NOT RECOMMENDED list of information sources. I suppose I'm only just stumbling across this nonsense now because I'm the new kid on the block. Have people like Dr. Bartram, Flea and the Woo-Meister already demolished these pretenders before I got here, and/or is it time for more exposure?