As an ER doctor with 60 years experience and a missionary to third world countries for decades, I relate to your encouragement to look for the most-likely cause of our patient's symptoms. This is exactly the dilemma of what we face in both extremes:
One of the differences missionary (and humanitarian) doctors must face when treating individual patients in Third World Countries is: how can we provide standard of care to our patients? Under the circumstances that we encounter, we cannot possibly provide the same level (Quality) of diagnostics or treatment that we are required to provide in the States. On the other hand, we provide something of much more value than we can provide in the States. This takes considerable re-orientation in our approach and re-adjustment in our thinking.
For me, as a board-certified emergency medicine specialist, I had to come to grips with this dichotomy. For example, when a patient comes into the emergency room complaining of a headache, we automatically shift into our modus operende to; what is the worst possible situation this could be? We think of subdural hematomas, hemorrhagic strokes, brain tumors, abscesses and temporal arteritis. It would be a critical mistake to miss any of these diagnoses. So, we order all kinds of tests, such as CT scans, MRI scans, a bevy of laboratory tests, and ultrasound. We may call in a specialist to help us on our quest to make a diagnosis. If we cannot make a definitive diagnosis at least we can reassure our patients that they do not have one of these sentinel events. The same goes for chest pain or abdominal pain. There is a list of “never-to-be-missed” diagnoses that we must always consider and rule out before admitting the patient to the hospital or discharging them to home. We cannot be lulled into deciding; What is the most likely diagnosis? Because that could be fatal for our patient and end our career.
One time a 21-year-old lady came to our emergency room complaining of chest pain. The ER doctor knowing that a myocardial infarct (heart attack) was a near impossibility for a young healthy female, looked for other causes and reassured the patient. She was sent home only to return in cardiac arrest an hour later and died of a heart attack. That doctor got caught by not ruling out the worst possible diagnosis and acted on his experience of the most likely. So, in US medicine our minds are always operating in the realm of the most serious, not the most likely.
In missionary medicine, we do not have the luxury of CT scans, ultrasound, or laboratory diagnostics. We have to depend solely on our experience, training, physical findings and prevailing diseases in the area. Besides, we do not have time to consider or rule out every possibility for their complaint. We may only have 5 minutes per patient, because of the sheer number of patients we have to see per hour. So, when a patient complains of a headache, we give them Tylenol (or whatever medicine we happen to have) and wish them the best. We know there is a 99% probability it is a tension or viral headache and will go away. We can’t even consider the worst case scenario. So, in missionary medicine our minds are always operating in the realm of the most likely, not the most serious.
Some would say, “That’s horrible. Don’t these people deserve the same level of care that our US patients expect and deserve?”
The answer is three fold:
1. Maybe they do deserve it, but there is no way that can happen. Resources are not available;
2. They do not expect that same level of care. They are delighted for anything we can give them;
3. We give them a level of care that is far above what they had before we came, by addressing the “Most likely” instead
But, there is far more we can give our patients in these third world countries than what we can give them in the States. That is the personal touch and caring of a physician. They can experience the love of God, intervening on their behalf through a caring provider, in their hopeless world. We listen to them, we pray with them, we hug them and let them know they are loved by us and by God. That is the best medicine of all.
Most docs forgot or were never taught the basic rule. A middle-aged man with atypical chest pain (meaning you cannot 100% exclude it is angina) has a 50% probability of underlying coronary artery disease. Note the absence of risk factor review or troponins. It is age, sex and type of pain (cardiac, non-cardiac and do not know). It is a coin toss to determine if the patient has a lifelong disease. It is the job of ER doc and asleep cardiologist on call to determine if they will suffer damage or death if they are sent home. Negative Troponin and Normal ECG take care of the death part (not the damage part). A normal CTA should end the work up very effectively. In the past, the 50% rule meant keep in house to deal with death or damage, and do the stress test the next day. As the leading cause of death is still CAD, I would be very grateful if I left the hospital with neg troponins, no PE , CAD or Dissection. I would not need to beg someone to finish my cardiac work up as an outpatient.
I’m currently reeling from a case of pediatric brain tumor surprisingly found on MRI, done when patient lost the ability to walk, when the ballooning head circumference was available all along throughout life.
If you go to an “emergency room”…their job (an often incredibly busy and fairly thankless one) is to determine whether you actually have an emergent condition or not.
If not…they’ve done their bit. I don’t think it’s in their job description to necessarily make the diagnosis (of non emergent conditions).
That said, it seems the only prerequisite for having a troponin done is to have a (still beating) heart. So if you have any complaint that localizes above the knees in any ER, be prepared to sit through serial troponins.
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.
Used to be pride. Now I am in a group, and whoever does best chooses the next day's word. We seem to try to undermine the group with words like fuzzy or quaff.
What a marvelous teaching case for your students and residents. If I had been given that early in my medical training, it would be one that I would write down and review repeatedly to reinforce all the valuable lessons contained therein. Great antidote to the mechanistic and /or algorithmic systems in common use today.
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.
I touch every patient I see. (Granted, they are sick newborns in the hospital.) But I make sure to touch them in the presence of their mother, to demonstrate concern. Also, as I a wise attending taught me, I also sit down for every conversation with a parent. No matter how little time you have, sitting shows the parent that the time you do have is for them.
I imagine you are modeling that it's ok to touch these fragile beings, too. I agree about sitting down. Even if I've started leaving the room and the patient says "Oh, yeah, doc, I almost forgot," I plop myself down on the end of the exam table.
Absolutely agree with sitting. And taking the time to look them in the eye. It is the compassion that the parents and the patients need to know is there. Even when the outcome is poor, if that compassion is demonstrated it helps the healing process for after. People really need to know that the doctor cares about them and their loved ones.
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.
As an ER doctor with 60 years experience and a missionary to third world countries for decades, I relate to your encouragement to look for the most-likely cause of our patient's symptoms. This is exactly the dilemma of what we face in both extremes:
One of the differences missionary (and humanitarian) doctors must face when treating individual patients in Third World Countries is: how can we provide standard of care to our patients? Under the circumstances that we encounter, we cannot possibly provide the same level (Quality) of diagnostics or treatment that we are required to provide in the States. On the other hand, we provide something of much more value than we can provide in the States. This takes considerable re-orientation in our approach and re-adjustment in our thinking.
For me, as a board-certified emergency medicine specialist, I had to come to grips with this dichotomy. For example, when a patient comes into the emergency room complaining of a headache, we automatically shift into our modus operende to; what is the worst possible situation this could be? We think of subdural hematomas, hemorrhagic strokes, brain tumors, abscesses and temporal arteritis. It would be a critical mistake to miss any of these diagnoses. So, we order all kinds of tests, such as CT scans, MRI scans, a bevy of laboratory tests, and ultrasound. We may call in a specialist to help us on our quest to make a diagnosis. If we cannot make a definitive diagnosis at least we can reassure our patients that they do not have one of these sentinel events. The same goes for chest pain or abdominal pain. There is a list of “never-to-be-missed” diagnoses that we must always consider and rule out before admitting the patient to the hospital or discharging them to home. We cannot be lulled into deciding; What is the most likely diagnosis? Because that could be fatal for our patient and end our career.
One time a 21-year-old lady came to our emergency room complaining of chest pain. The ER doctor knowing that a myocardial infarct (heart attack) was a near impossibility for a young healthy female, looked for other causes and reassured the patient. She was sent home only to return in cardiac arrest an hour later and died of a heart attack. That doctor got caught by not ruling out the worst possible diagnosis and acted on his experience of the most likely. So, in US medicine our minds are always operating in the realm of the most serious, not the most likely.
In missionary medicine, we do not have the luxury of CT scans, ultrasound, or laboratory diagnostics. We have to depend solely on our experience, training, physical findings and prevailing diseases in the area. Besides, we do not have time to consider or rule out every possibility for their complaint. We may only have 5 minutes per patient, because of the sheer number of patients we have to see per hour. So, when a patient complains of a headache, we give them Tylenol (or whatever medicine we happen to have) and wish them the best. We know there is a 99% probability it is a tension or viral headache and will go away. We can’t even consider the worst case scenario. So, in missionary medicine our minds are always operating in the realm of the most likely, not the most serious.
Some would say, “That’s horrible. Don’t these people deserve the same level of care that our US patients expect and deserve?”
The answer is three fold:
1. Maybe they do deserve it, but there is no way that can happen. Resources are not available;
2. They do not expect that same level of care. They are delighted for anything we can give them;
3. We give them a level of care that is far above what they had before we came, by addressing the “Most likely” instead
But, there is far more we can give our patients in these third world countries than what we can give them in the States. That is the personal touch and caring of a physician. They can experience the love of God, intervening on their behalf through a caring provider, in their hopeless world. We listen to them, we pray with them, we hug them and let them know they are loved by us and by God. That is the best medicine of all.
Most docs forgot or were never taught the basic rule. A middle-aged man with atypical chest pain (meaning you cannot 100% exclude it is angina) has a 50% probability of underlying coronary artery disease. Note the absence of risk factor review or troponins. It is age, sex and type of pain (cardiac, non-cardiac and do not know). It is a coin toss to determine if the patient has a lifelong disease. It is the job of ER doc and asleep cardiologist on call to determine if they will suffer damage or death if they are sent home. Negative Troponin and Normal ECG take care of the death part (not the damage part). A normal CTA should end the work up very effectively. In the past, the 50% rule meant keep in house to deal with death or damage, and do the stress test the next day. As the leading cause of death is still CAD, I would be very grateful if I left the hospital with neg troponins, no PE , CAD or Dissection. I would not need to beg someone to finish my cardiac work up as an outpatient.
I’m currently reeling from a case of pediatric brain tumor surprisingly found on MRI, done when patient lost the ability to walk, when the ballooning head circumference was available all along throughout life.
I have to disagree a bit here.
If you go to an “emergency room”…their job (an often incredibly busy and fairly thankless one) is to determine whether you actually have an emergent condition or not.
If not…they’ve done their bit. I don’t think it’s in their job description to necessarily make the diagnosis (of non emergent conditions).
That said, it seems the only prerequisite for having a troponin done is to have a (still beating) heart. So if you have any complaint that localizes above the knees in any ER, be prepared to sit through serial troponins.
My response to another similar comment:
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.
Thoughts?
Doozy not woozy!
Radio or adieu. Yesterday's was a woozy. Thanks for the suggestions.
May I ask your go to wordle word or is that inappropriate?
Used to be pride. Now I am in a group, and whoever does best chooses the next day's word. We seem to try to undermine the group with words like fuzzy or quaff.
Yours?
What a marvelous teaching case for your students and residents. If I had been given that early in my medical training, it would be one that I would write down and review repeatedly to reinforce all the valuable lessons contained therein. Great antidote to the mechanistic and /or algorithmic systems in common use today.
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.
I’m in
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!
I touch every patient I see. (Granted, they are sick newborns in the hospital.) But I make sure to touch them in the presence of their mother, to demonstrate concern. Also, as I a wise attending taught me, I also sit down for every conversation with a parent. No matter how little time you have, sitting shows the parent that the time you do have is for them.
I imagine you are modeling that it's ok to touch these fragile beings, too. I agree about sitting down. Even if I've started leaving the room and the patient says "Oh, yeah, doc, I almost forgot," I plop myself down on the end of the exam table.
Absolutely agree with sitting. And taking the time to look them in the eye. It is the compassion that the parents and the patients need to know is there. Even when the outcome is poor, if that compassion is demonstrated it helps the healing process for after. People really need to know that the doctor cares about them and their loved ones.
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.