Thyroiditis is a very cool diagnosis, worthy of a highly experienced, thoughtful internist who not only took the time (that he probably didn’t have) to take a careful history AND do a physical exam, but took the additional time to palpate the thyroid. (Why did you feel his thyroid? Because the careful history you took prompted you to reclassify his presenting complaint as palpitations.)
In an under-resourced, busting at the seams ER (the norm in, say, a country to our north with excellent healthcare), the primary goal must be to identify disease that could kill the patient. And the heck with what else might be going on because there just isn’t time.
I think the failure of that ER was to focus the patient on getting a stress test at home. They should have explained that A) it wasn’t clear what the problem was, B) it probably wasn’t ischemic heart disease, C) the patient’s primary care physician would be better able to figure it out.
All that being said, the patient is very lucky to have you. I don’t know many internists who, in our modern day, corporate-run, throughput-focused system would have diagnosed and treated the problem without a whole lot more tests, more time, and an endocrine consult to boot.
I think your dominant feeling shouldn’t be curmudgeon-ness, but a quiet satisfaction that you are practicing medicine the way it should be practiced.
I’m impressed that you performed a physical exam… as a retired RN who worked in several areas over my career and performed head to toe exams on each patient of mine in the ICU, pre-op/pacu, and cath/EP lab I am very disappointed with healthcare today. My husband had an ablation for a fib/flutter this week and I did not witness a single nurse or physician auscultate his heart or lungs (much less perform any sort of physical exam). Bps are taken automatically (no one pays attention even if the alarm is going off constantly).
It is very disheartening to see that healthcare has become so tech reliant that the humans involved are insignificant.
I think that one of the core problems is the ability to LISTEN to what the patient is telling you.
I've been on the receiving end of a few doctors who had decided either what my problem was and wouldn't hear what I was telling them, saw a lab number and had to follow a protocol, or wouldn't believe me because what I said didn't fit into their reality. I've had family members with similar issues. I've seen my 20-something daughter being treated for chest pain, when her complaint was trouble breathing. They kept asking her about her chest pain, which she never complained of. I've seen notes in my mother's chart about complaints she never made. These were all different doctors.
Listening and having an open mind to differential diagnoses is important for all doctors.
Do they teach listening in medical school - really being present and listening? (I'm really asking - not being facetious).
Man I don’t know if thyroiditis is the more common or likely diagnosis in a 55 yom coming to the ED for anything. Also at your visit 2 weeks of rule out time had passed. Finally, you had baseline knowledge of his vitals and health. I think the system worked well for him in the end.
Good points. I noted what I had benefited from, right? I'd say "most common" was afib or benign arrhythmia. After the exam, it "most likely" was thyroiditis.
It’s quite a jump from a “missed” diagnosis of acute thyroiditis to conviction for cognitively lazy expensive medicine. I’m sure you’re actually just using MP’s experience to illustrate the point you wanted to make today. I don’t like that. It’s a cheap shot at the ER doc in the foreign country who did exactly as he was expected to do, determine if a threatening emergency was present or not. That is what drove MP to the ER, concern that he might be having an MI. It wasn’t curiosity about what obscure non-emergent condition was causing his difficulty.
Did the ER doc speak English? How did MP really describe his symptoms at that visit? Was his pulse 90 then? Was his thyroid tender then?
People are complex creatures and disease can be fickle and idiosyncratic. Our knowledge of human health and disease isn’t complete. Medicine, it’s not easy. I don’t think you have the evidence for conviction, judge.
Those in the ER have an incredibly hard job. I am not taking cheap shots. That said, our system is set up to get a "complaint", route the patient into an algorithm, and be done. The pressure in the ER is enormous, and incentives reward efficiency and not missing bad things. That's why we get what we got. A little time correctly characterizing the complaint would have led to a different/better outcome.
In my experience, residents are no longer taught the fundamentals much less empathy and how to conduct one’s self when examining and interacting with a patient. The standard seems to be treating a series of symptoms (likely interrelated) instead of making a diagnosis or at least a differential diagnosis. I now see a concierge physician, mostly for access, and the physical exam I receive is a joke. If an issue is anything but the most basic it’s off to the respective specialist and a 6 month wait. Oh My, another curmudgeon.
My husband and I both went to the family medicine physician recently. We both had symptoms that we wanted addressed (one GI, one more generalized constitutional type symptoms). In neither case did we disrobe. In neither case did the doctor (not an NP and not a PA - an actual "real" doctor) touch us! In my case, she didn't even shake my hand or touch my shoulder as a gesture of empathy.
As luck would have it, I actually have a medical degree, so I do have a vague idea of what the standards of medical care are supposed to be. I make it a point to touch every single patient, every time I see them. Even if it is a pat on the shoulder or a handshake. I find it offensive that this doctor can't even do a physical exam on someone complaining of new onset abdominal pain and GI symptoms. She sure can order a stool sample and refer to a colorectal surgeon (not even a gastroenterologist!!).
There, now I sound like an old curmudgeon longing for the glory days of medicine.
I used to touch every patient as well, Peaches, but then I started hanging out on the internet with younger people and learned that a sizeable fraction of young women find the hand lightly touching the shoulder during lung exams to be creepy. I like doing it because it helps me orient myself when I am not paying attention to visual input, but I've stopped doing it for people under 45 (not that I have many of those).
I stopped shaking hands w covid. If a patient offers, I'll take it, but if they don't offer, I won't initiate and weeks will go by without a handshake for me.
Many of my patients ask for and/or appear very grateful when I offer a hug so there is that.
It used to be the core of our profession. Unfortunately, it seems to have been lost somewhere in the sea of new technology. Granted, modern technology has brought incredible advances. It is a shame, though, that the art and compassion of medicine is being lost. As I type this, though, I do wonder that maybe this is the same type of thing that every generation says about the younger generations.
Medicine is an art. And the art of taking an excellent history is long gone. Ditto for a decent physical exam. Being an older doc now needing specialist care, I have experienced this firsthand, and not just once. It’s depressing.
We are designed to rule out more often than rule in. And take care of the care gaps! Go to the ER with chest pain and you get CBC, CMP, Amylase, Hep C and HIV screens, lipids, TSH, cardiac enzymes and BNP, U/A, EKG, CXR and if you happen to cough even without a fever, because the pollen count is making your car green, add Flu, Covid and RSV tests ! If you have the chugurr disease from severe Bisquits poisoning, add the HgbA1c, even when the PCP did one in last 3 weeks because no one looks at prior chart data anymore. Is this condition making you sad and you get leg pain after a day at work? Don’t forget that depression and PAD screening ! Long are the days of cardiac asthma, JVD and hepato-jugular reflux. History is a channel on your TV. Just fix all the numbers with one prescription for each because , at the end, we all shall die in electrolyte balance. :)
Today’s ER Doc and Practitioners make great charts with algorithms, copy and paste, and even some AI dessert thrown in. But, see if they touch you for exam or even spend more than 5 minutes with you. They are products of training, mandated by admin to hurry up, and every committee in the hospital will send them a letter when their metrics are down or they don’t click the sepsis button or give you a gallon of saline on the order set.
And the toradolphilia without concerns for renal function and bleeding risks, “ because it ain’t a narcotic “ … but you can reverse narcotics side effects but not AKI and platelet adhesion issues. When I or mine, God forbid , end with a deserving need for real pain relief, guess what I will not be using.
How many on dual anti platelet agents or NOAC/Warfarin besides the meloxicamination of our elderly and renal impaired patients ? The pt doesn’t come with a chief complaint of I need relief from the inflammation, they want pain relief. Use your meds judiciously. Toradol post op to “ avoid ileus and sedation” ? Not sure if benefits outweigh risks.
Thyroiditis is a very cool diagnosis, worthy of a highly experienced, thoughtful internist who not only took the time (that he probably didn’t have) to take a careful history AND do a physical exam, but took the additional time to palpate the thyroid. (Why did you feel his thyroid? Because the careful history you took prompted you to reclassify his presenting complaint as palpitations.)
In an under-resourced, busting at the seams ER (the norm in, say, a country to our north with excellent healthcare), the primary goal must be to identify disease that could kill the patient. And the heck with what else might be going on because there just isn’t time.
I think the failure of that ER was to focus the patient on getting a stress test at home. They should have explained that A) it wasn’t clear what the problem was, B) it probably wasn’t ischemic heart disease, C) the patient’s primary care physician would be better able to figure it out.
All that being said, the patient is very lucky to have you. I don’t know many internists who, in our modern day, corporate-run, throughput-focused system would have diagnosed and treated the problem without a whole lot more tests, more time, and an endocrine consult to boot.
I think your dominant feeling shouldn’t be curmudgeon-ness, but a quiet satisfaction that you are practicing medicine the way it should be practiced.
I’m impressed that you performed a physical exam… as a retired RN who worked in several areas over my career and performed head to toe exams on each patient of mine in the ICU, pre-op/pacu, and cath/EP lab I am very disappointed with healthcare today. My husband had an ablation for a fib/flutter this week and I did not witness a single nurse or physician auscultate his heart or lungs (much less perform any sort of physical exam). Bps are taken automatically (no one pays attention even if the alarm is going off constantly).
It is very disheartening to see that healthcare has become so tech reliant that the humans involved are insignificant.
I think that one of the core problems is the ability to LISTEN to what the patient is telling you.
I've been on the receiving end of a few doctors who had decided either what my problem was and wouldn't hear what I was telling them, saw a lab number and had to follow a protocol, or wouldn't believe me because what I said didn't fit into their reality. I've had family members with similar issues. I've seen my 20-something daughter being treated for chest pain, when her complaint was trouble breathing. They kept asking her about her chest pain, which she never complained of. I've seen notes in my mother's chart about complaints she never made. These were all different doctors.
Listening and having an open mind to differential diagnoses is important for all doctors.
Do they teach listening in medical school - really being present and listening? (I'm really asking - not being facetious).
Man I don’t know if thyroiditis is the more common or likely diagnosis in a 55 yom coming to the ED for anything. Also at your visit 2 weeks of rule out time had passed. Finally, you had baseline knowledge of his vitals and health. I think the system worked well for him in the end.
Good points. I noted what I had benefited from, right? I'd say "most common" was afib or benign arrhythmia. After the exam, it "most likely" was thyroiditis.
It’s quite a jump from a “missed” diagnosis of acute thyroiditis to conviction for cognitively lazy expensive medicine. I’m sure you’re actually just using MP’s experience to illustrate the point you wanted to make today. I don’t like that. It’s a cheap shot at the ER doc in the foreign country who did exactly as he was expected to do, determine if a threatening emergency was present or not. That is what drove MP to the ER, concern that he might be having an MI. It wasn’t curiosity about what obscure non-emergent condition was causing his difficulty.
Did the ER doc speak English? How did MP really describe his symptoms at that visit? Was his pulse 90 then? Was his thyroid tender then?
People are complex creatures and disease can be fickle and idiosyncratic. Our knowledge of human health and disease isn’t complete. Medicine, it’s not easy. I don’t think you have the evidence for conviction, judge.
Those in the ER have an incredibly hard job. I am not taking cheap shots. That said, our system is set up to get a "complaint", route the patient into an algorithm, and be done. The pressure in the ER is enormous, and incentives reward efficiency and not missing bad things. That's why we get what we got. A little time correctly characterizing the complaint would have led to a different/better outcome.
Agree with you 100% Adam.
In my experience, residents are no longer taught the fundamentals much less empathy and how to conduct one’s self when examining and interacting with a patient. The standard seems to be treating a series of symptoms (likely interrelated) instead of making a diagnosis or at least a differential diagnosis. I now see a concierge physician, mostly for access, and the physical exam I receive is a joke. If an issue is anything but the most basic it’s off to the respective specialist and a 6 month wait. Oh My, another curmudgeon.
We can get matching curmudgeon t-shirts.
My husband and I both went to the family medicine physician recently. We both had symptoms that we wanted addressed (one GI, one more generalized constitutional type symptoms). In neither case did we disrobe. In neither case did the doctor (not an NP and not a PA - an actual "real" doctor) touch us! In my case, she didn't even shake my hand or touch my shoulder as a gesture of empathy.
As luck would have it, I actually have a medical degree, so I do have a vague idea of what the standards of medical care are supposed to be. I make it a point to touch every single patient, every time I see them. Even if it is a pat on the shoulder or a handshake. I find it offensive that this doctor can't even do a physical exam on someone complaining of new onset abdominal pain and GI symptoms. She sure can order a stool sample and refer to a colorectal surgeon (not even a gastroenterologist!!).
There, now I sound like an old curmudgeon longing for the glory days of medicine.
As I wrote to RH, we can get matching curmudgeon t-shirts.
I used to touch every patient as well, Peaches, but then I started hanging out on the internet with younger people and learned that a sizeable fraction of young women find the hand lightly touching the shoulder during lung exams to be creepy. I like doing it because it helps me orient myself when I am not paying attention to visual input, but I've stopped doing it for people under 45 (not that I have many of those).
I stopped shaking hands w covid. If a patient offers, I'll take it, but if they don't offer, I won't initiate and weeks will go by without a handshake for me.
Many of my patients ask for and/or appear very grateful when I offer a hug so there is that.
It's so complicated!
You are not old. You practiced appropriate medicine with touch, human empathy and listening skills. That is core of our profession.
It used to be the core of our profession. Unfortunately, it seems to have been lost somewhere in the sea of new technology. Granted, modern technology has brought incredible advances. It is a shame, though, that the art and compassion of medicine is being lost. As I type this, though, I do wonder that maybe this is the same type of thing that every generation says about the younger generations.
It’s still core. We as a profession have lost our way in the sea of so called progress and technology.
Medicine is an art. And the art of taking an excellent history is long gone. Ditto for a decent physical exam. Being an older doc now needing specialist care, I have experienced this firsthand, and not just once. It’s depressing.
We are designed to rule out more often than rule in. And take care of the care gaps! Go to the ER with chest pain and you get CBC, CMP, Amylase, Hep C and HIV screens, lipids, TSH, cardiac enzymes and BNP, U/A, EKG, CXR and if you happen to cough even without a fever, because the pollen count is making your car green, add Flu, Covid and RSV tests ! If you have the chugurr disease from severe Bisquits poisoning, add the HgbA1c, even when the PCP did one in last 3 weeks because no one looks at prior chart data anymore. Is this condition making you sad and you get leg pain after a day at work? Don’t forget that depression and PAD screening ! Long are the days of cardiac asthma, JVD and hepato-jugular reflux. History is a channel on your TV. Just fix all the numbers with one prescription for each because , at the end, we all shall die in electrolyte balance. :)
Today’s ER Doc and Practitioners make great charts with algorithms, copy and paste, and even some AI dessert thrown in. But, see if they touch you for exam or even spend more than 5 minutes with you. They are products of training, mandated by admin to hurry up, and every committee in the hospital will send them a letter when their metrics are down or they don’t click the sepsis button or give you a gallon of saline on the order set.
And the toradolphilia without concerns for renal function and bleeding risks, “ because it ain’t a narcotic “ … but you can reverse narcotics side effects but not AKI and platelet adhesion issues. When I or mine, God forbid , end with a deserving need for real pain relief, guess what I will not be using.
Meloxicamination. Love it.
Our ortho friends suffer from pharmacomnesia. Thank God we don’t see Feldene prescribed anymore.
How many on dual anti platelet agents or NOAC/Warfarin besides the meloxicamination of our elderly and renal impaired patients ? The pt doesn’t come with a chief complaint of I need relief from the inflammation, they want pain relief. Use your meds judiciously. Toradol post op to “ avoid ileus and sedation” ? Not sure if benefits outweigh risks.