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.

Friday, November 28, 2008

"Being a Doctor"

Once again, I seem to have started a bit of a dust-up with this post. Comments have ranged from "right on" to "you hypersensitive twit" and other, less printable versions thereof. In this case, not only do I stand by my original take, but I feel the need to clarify precisely how the dissenters are being jerks.

A recurring comment was something along the lines of "just because I'm a specialist doesn't mean I stop being a doctor." [emphasis mine] What exactly is meant by that oh-so-innocent-sounding phrase?

It seems to imply that there is some basic skill set learned in medical school; certain things that one is capable of doing just by virtue of being awarded that magical MD degree. Gee; what might that skill set contain?

We all dissected a cadaver and did a surgical rotation during medical school, so we all ought to be able to do surgery.

Didn't most of us rotate through oncology as part of our medicine rotations? What's the big deal about writing for chemo?

We all did orthopedics, too. I can look at an x-ray and prescribe an air cast and rehab for a sprained ankle.

How about ophthalmology? I can look in a patient's eyes and prescribe drops. What's the big deal?

I know, I know: all of those things, and many more, represent skills we learned in our post-graduate training and honed over years of practice. So here's my point: Why do you think that dietary counseling and lifestyle intervention requires any less training, skill and experience to do (well) than any other medical procedure? What you specialist commenters are actually saying -- in code that is so insidious you may not even realize it -- is that primary care is so easy, any "doctor" can do it. You are disrespecting my special skill set in a way that is deeply offensive. (Far more than just consulting behind your back, HH. Next time you ask for respect from your colleagues, maybe you can start by giving it.)

What we all take from medical school is the knowledge base to learn how to become whatever kind of "doctor" we end up becoming. Without special training and experience to become a surgeon, we're just assaulting people. Without special training in oncology, we're just poisoning them. Without ophthalmology training, we're just poking them in the eye. And without the special training and experience that comes from years of practicing primary care, you are just rudely telling people that they are fat.

PS: Smoking cessation is different. I agree that any doctor ought to have the knowledge and expertise to understand why smoking is bad. Then again, any fifth grader who has attended a Tar Wars presentation has the knowledge and expertise to understand why smoking is bad. Don't exactly need an advanced edumacation to figure that one out. Interestingly, though, providing effective smoking cessation counseling is also harder than it looks.


At Fri Nov 28, 10:09:00 PM, Anonymous Anonymous said...

So there's no such thing as "just a doctor?" There aren't things that all doctors know?

I understand the point you're making. But I think you've become a little overly defensive here. Doctors are supposed to work together for the betterment of patients' health; they aren't supposed to combat each other over territory (idealistic, I know). I doubt this doc turned the man off medicine forever; the man himself admitted "he was just doing his job." He doesn't know that, apparently, ophthalmologists only treat eyes. He recognizes that, whether it's true or not, he was a doctor first and then an ophthalmologist.

Anyway, why should this specialist assume the man is receiving any treatment for his obesity, or that he even knows the health risks associated with being obese? Should this ophthalmologist comment on some guy's freakish looking mole on his neck (since he remembers his ABCs from med school), or just remain silent, assuming the man knows about the mole and is probably receiving treatment anyway? Obvious dental problems? Worrying behavioral issues? Where do you draw the line?

At Sat Nov 29, 12:04:00 AM, Anonymous Anonymous said...

onc doc here:
Maybe you should try reading my post for comprehension. I've DONE you job (at least the internal medicine portion). I never said it was easy, it's not. Just how long has it been since you've wandered into an ER anyways since you don't admit your own patients? MANY people don't have PCP's in the ER. The bottom line is many of the morbidly obese don't have a clue as to secondary sequale of this disease. You may laugh at that statement, but that is the fact. Following your reasoning let's just ignore it. Don't want to hurt anybodys feelings, who cares that they are probably knocking years to decades off their lives. I don't fault the optho doc pointing this out IN THE ER, especially if the person does not have a PCP. I don't expect them to treat it (they shouldn't). That is clearly the role of a PCP (if they can find one).
PS: You know what I find disrespectful dino? When I become a defacto PCP for a patient because their primary has "signed off" due to their oncologic illness. Not to me, rather the patient.

At Sat Nov 29, 08:57:00 AM, Blogger #1 Dinosaur said...

Onc Anon: Perhaps you didn't read my post for comprehension. I have no problem with ANY doctor addressing a patient's weight when it is salient to the presenting problem. That includes most ER presentations for what are often the sequelae of morbid obesity.

As for the point that a patient may not have a family doc somehow justifies a specialist offering irrelevant, clumsy "advice" in an inappropriate setting, does that mean that an ER doc who sees a patient off the street and finds a chest full of metastatic cancer is supposed to tell that patient that he's going to die, just because he "doesn't have an oncologist"? Are you going to perform an appendectomy because the patient "doesn't have a surgeon"? The idea that any doctor can provide primary care in a pinch is what leads to suboptimal care. And I'm not talking about *you* (since you claim to have done it); I was talking about an ophthalmology resident.

As for your points about family docs "signing off" their cancer patients to you, as it happens I agree with you completely! And I don't do it. So don't go projecting your experience with lousy docs on me. Your point is valid, but irrelevant to the one I was making. If you want to get your panties in a bunch about an unrelated issue, feel free to spout off about it on your own blog.

At Sat Nov 29, 09:39:00 AM, Anonymous Anonymous said...

It was interesting to read all the "what ifs" different folks used in their response to the first post, especially the "what if" he didn't have a primary care doctor.

But in the article, he's reported as saying his primary care doctor had talked to him about his weight.

He'd also been reported to say that he'd lost a small amount of weight but gained it back (because he couldn't afford the diet food). So it might be worth the resident's time to ask if the intervention actually was useful in any way? And if yo-yo dieting is bad, as we used to hear a few years ago, then maybe the extra talk was actually harmful.

And the attending's reason: he has grey hair and has been around. Why is it that so many "older" men think they need to give directions in so many situations?

At Sat Nov 29, 09:46:00 AM, Blogger LicensedToILL said...

Word to Dr. D.

At Sat Nov 29, 10:08:00 AM, Blogger LicensedToILL said... more thing...
The whole argument that patients coming into the ER don't have PCP's is a completely 15 inch fallible argument because 1) Most people don't feel like waiting to see their PCP when their kids are sick or THEY are sick and scared don't feel like waiting for an appointment and 2) ONE CHIEF COMPLAINT PER VISIT IN THE ER. THE SECOND YOU SPECIALISTS START DOING YOUR CHINZTY PRO-BONO WORK YOU BETTER BE READY TO PAY FOR THE PRO-BONO LABS AND STUDIES: Trigylcerides, HGA1C, EKG, Treadmill,etc.

At Sat Nov 29, 02:02:00 PM, Anonymous Anonymous said...

I see your point in that specialists should leave the treatment of conditions and problems outside of their specialties to the GPs or other specialists, but I disagree that they should ignore their existence altogether. In my opinion, there is nothing offensive about the following exchange:

Specialist: "I see you have (insert obvious but unrelated condition). Are you currently being treated by a GP/other specialist?"
Patient: "Yes." Or, "No."
Specialist: "Fantastic." Or, "I would recommend you discuss treatment for this condition with your GP as soon as possible."

The end. The specialist doesn't go into discussing HOW to treat the condition, only establishes that the patient is being treated or recommends that he/she commence said treatment. No one's toes get stepped on, and the importance of care is still emphasized to the patient.

At Sat Nov 29, 02:10:00 PM, Anonymous Anonymous said...

How about if the specialist simply asks, "Do you have a primary care physician?" That way, the patient isn't humiliated by a lecture on obesity because, if the answer is "Yes," it's fair to assume the PCP is already aware of and treating the weight problem.

If the answer is "No," then the specialist can suggest it would be in the patient's best interest to find one and get checked for other health conditions.

No need to tell a fat person he or she is fat, especially when there's a more dignified way to handle the matter.

At Sat Nov 29, 03:57:00 PM, Blogger #1 Dinosaur said...

I wish some of you Anons would either choose handles or include some version of a signature.

Both of the above approaches are acceptable; neither was utilized by the Ophtho Attending in the article.

At Sat Nov 29, 04:08:00 PM, Blogger Midwife with a Knife said...

Well... empathy is supposed to be part of the core skills set of being a doctor, as is compassion. And there are empathic and compassionate ways to address obesity. Yelling at someone, shaming them is not one of them.

So even as "just a doctor", that opthamologist failed.

At Sat Nov 29, 06:14:00 PM, Anonymous Anonymous said...

In my hospital we have a cardiology group that regularly admits our patients. Recently one of our patients was admitted, and my partner asked the Card's NP if they needed anything for the patient? She said, "no, we're fine" failing to mention that she'd consulted the pulmonolgist for the patient's bronchitis. Then when the patient's glucose was out of control because the pulmonologist gave steroids without ordering insulin coverage the NP consulted the endocrinologist! I know about this because the endo was out of town, so I, the primary, ended up seeing the patient ON FRIDAY AFTERNOON AT 6:OOPM because that's when the NP finally figured out that the endo wasn't in town. Unfortunatley there is no way to practice creative discipline for this kind of disrespect because there is only one cardiology group in town. And one desperately in need of competition, i might add.

At Sun Nov 30, 12:20:00 AM, Anonymous Anonymous said...

I'm with you, Dino, 100%

At Sun Nov 30, 11:11:00 AM, Anonymous Anonymous said...

Speaking as a fat doctor, people KNOW they're fat. Other people take great glee in informing fat people that they are, indeed, fat.

They know. And unless you can offer substantiative help, and/or the obesity is relevant to the issue at hand, you're being a jerk.

Hell, I went through medical school, I delivered five babies, therefore I can do OB, right?
I'm a CORONER for God's sake. I know what I can and can't do.

At Sun Nov 30, 01:04:00 PM, Anonymous Anonymous said...

onc doc here:
Dino, what is very clear to me is that it has been a long long time since you have spent significant time in a hospital or an ER. You really need to get out of your clinic. This patient may have had a primary but many do not. I see it every day. Is your clinic open to new patients most in my area are not, all if they are medicaid outside of fed subidized ones. I would assume as a primary doc who (I assume) knows what he is doing, you have some clue as to the importanance of repitition with lifestyle behavior modification. Let alone those who don't understand the sequale of their lifestyles. I read the article, from what I can tell the optho doc did not use insulting language. If you have a problem with that, then it's YOUR problem. As I and anon 2:02 stated nobody is expecting these specialists (myself and other medical subspecialists who have stayed up on IM excepted and are forced to because of previously mentioned reasons) from treating the problem. Clearly however you have spent too little time in your local ER the last decade or so to understand what I am talking about. I've been around dino, I have seen medicine become more and more fractured. I understand the need for hospitalists seeing your patients, but you pulling your holier than thou attitude when you yourself have abdicated some of your own responsibility to the patient is laughable. I have an idea, come see your own patients in the hospital. Come to the ER YOURSELF and see what's happended the last couple of decade or so since you have admitted your own patients. It is a disaster. I admit my own patients, it is doable. I certainly would not trust a hospitalist to manage post-chemo problems. It is my RESPONSIBITY as I gave the chemo
(think about that word dino, the next time you wash your hands sending someone to the ER). Am I projecting? Yes to a certain extent. But let me tell you something, I can't remember the last time a PCP came in to see one of their cancer patient's
under my care. Not even to say hi. Honestly dino, when is the last time you did? Be honest now. Frankly, I am sick of making excuses as I too have a clinic which I guarantee is every bit as busy with a higher acuity than a PCP clinic. I don't make excuses, thats life. The point I am making is dino, there is nothing wrong a subspecialist bringing up medical issues outside their scope of training as long as they leave the treatment to those who know what they are doing (you). If you have a problem with that, then I suggest you be on the call schedule of your local ER for your patients and all unassigned to give them your expertise.

At Sun Nov 30, 03:39:00 PM, Blogger CaShThoMa said...

I agree with you....
I'm a nephrologist and we do a lot of general medicine but that's the part that scares me the most. I don't think I'm very good at it. Have given some thought to getting out of Nephrology as it is so depressing but doing general medicine is scary and daunting. I admire you guys. Truly.

At Mon Dec 01, 10:43:00 AM, Anonymous Anonymous said...

I'm failing to see the equivalency in your argument that it's ok for any MD to talk about smoking cessation, but only a PCP or a dietary specialist can tell some patient he/she needs to lose weight.

Per your argument, one could say that any fifth grader who has seen the film "Super Size Me" has the knowledge and expertise to understand being overweight is bad. Maybe you think Chantix should be OTC?

I agree the bedside manner could have been better in the example you cited ("what are you doing to control your weight?" or "What is your regular doctor doing to control your weight?") but the message to the patient was sound. The patient's PCP (if he had one) should have been saying the same thing.

My not so humble opinion.

At Mon Dec 01, 12:14:00 PM, Blogger Bookhorde said...

Thanks for this and the earlier post, Dino.
What it reminds me of is when my acne problem was at it's worst, and there was this person in the family who would always very helpfully tell me that I have a giant pimple on my nose/chin/cheek. And always with a slightly disgusted expression/tone
My whole life at that point was taken up with the frustration of feeling like I was trying everything to treat my acne and it wasn't working, and this person wanted me to know I had a gross zit. I am very proud of myself for never punching that person ... because I sure was tempted.
My skin is finally clear but that person is pretty much still a jerk.
(And to anyone who's overweight and has to deal with people like that optha, may I recommend saying "Well, I'm dealing with my weight, and I do hope you're getting some help for your personality problem.")

At Mon Dec 01, 01:47:00 PM, Anonymous Anonymous said...


No wonder my physician clients assume they know how to treat their own pets ailments. After all, how hard could it be? They're just animals.

After 4 years of veterinary school we are expected to know it all. Most veterinarians are generalists. Lately more and more colleagues are pursuing internships and residencies, so we have a large pool of specialists to refer to, and we do, but in many locales we are IT.

But you make it sound like a basic skill set is inadequate. I have assumed that most physicians do have a basic skill set; this post enlightens me to why so many of my physician clients are so misguided: they're too specialized to see the forest for the trees.

Nice to know I'm assaulting, poisoning, and poking my patients in the eye as I don't have specialty training.

Ouch, Dino.

At Mon Dec 01, 11:43:00 PM, Blogger scalpel said...

Do you really think YOUR specially-trained counseling is any more effective pound for pound than the specialists'?

The only physicians who make a difference in achieving consistent clinically-important weight loss are bariatric surgeons. Everyone else is just shoulder-patting or checking off the PFP box.

I'll repeat a comment you made on one of my posts a while back:

I like your world, Dino. Too bad we have to live in the real one.

At Wed Dec 03, 12:17:00 AM, Blogger Amanda said...

I think this comment will have to make it into my memory banks:
"Well, I'm dealing with my weight, and I do hope you're getting some help for your personality problem."
That's a great one to throw out there when my non PCP comments on how I ought to loose 40 pounds, as if I didn't already know that, and am not already working with my PCP to accomplish that goal.

At Wed Dec 03, 03:54:00 AM, Blogger Mark said...

Hear hear!

"Why do you think that dietary counseling and lifestyle intervention requires any less training, skill and experience to do (well) than any other medical procedure?"

I'm a pharmacist, not a doctor, but I couldn't agree more with the statement above.

Many physicians in Malaysia where I come from look down on the time and effort as well as the skills required to be able to perform proper counseling as well as motivating patients to engage in lifestyle interventions.

They fail to see that Family Medicine specialists, pharmacists, dietitians, nurse educators, rehabilitation therapists etc take great pains to acquire the mentioned skills and it takes even greater effort to employ them skillfully.

At Wed Dec 03, 12:11:00 PM, Blogger scalpel said...

The "skill" of which you speak is apparently just deluding patients into thinking you are helping them while appearing compassionate and offering encouragement at the minimal (and usually temporary) losses achieved.

Whoop te doo. Any nice healthcare professional should be able to do that. Thus the mention of "pharmacists, dietitians, nurse educators, rehabilitation therapists etc" in the above post. While trying to be helpful, you've just ambushed Dino's argument.

At Thu Dec 04, 12:17:00 AM, Blogger Mark said...

Gee, I gotta go back and tell all those psychologists that they're merely deluding their patients while holding their hands in a very sympathetic yet non-committal manner.

Wait, a second....

But jokes aside, my point was that it actually takes some training to perform proper counseling. While every healthcare professional should be able to do that, it's amazing how many healthcare professionals do poorly in this area.

At Fri Dec 05, 06:30:00 PM, Blogger Can'tSpell, DVM said...

The funny thing is that we vets are expected to know how to do every specialty right out of school. And nobody thinks twice of this. I would love to spend half my day sending out consults.... :)


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