My long time primary care MD had brushed off my repeated concerns. Ignoring his scorn and listening to a relative's MD instead, I ended up in the ER just in time (with sepsis).
As your footnote states, you have colleagues who need checking. Many, in my experience.
I am a nurse and when people ask.me, I often encourage them to call their provider .Many patients are reluctant to ask questions. I let them know that I think their questions are good and try to build their relationship . If a provider will not answer questions, I find that to be a red flag
Thanks Susan. I have spent months inpatient for a long series of cancer treatments. Nurses are terrific for many reasons… one is that they are not haughty as many specialists are. You mention another: they listen to patients and in my experience, never counter the clinician’s or attending’s actions. That said, nurses provide a safe team member with whom patients can share their doubts and anxieties.
Patients have doubts and anxieties when receiving long term clinical care. Maybe a big dose of humility from the doctor would be helpful.
Given the behavior of the patient (forgetting to take pills and failing to apprise the physician friend of her PCP's advice), the liklihood of cognitive impairment is high. A formal test (e.g., a MOCA) is in order. If positive a review of possible medical causes is in order.
As an oncologist, I feel this daily — patients come in with outside recommendations, and it adds a whole new layer of complexity. You put it perfectly.
And I know that I, too, have been guilty of making other doctors' lives harder by suggesting "Just ask them about XYZ." When one does not have the whole picture, things can look different, but when one's loved one is getting what seems like less than ideal care, it is difficult to stand by and watch.
Being a doctor is a really hard job.
Being a loved one is a really hard job, too.
Thank you for this essay, which, as usual, perfectly articulates what is in my heart.
My personal curbside consulting... Over a half hour in depth discussion with a senior psychiatrist about my daughter's manic symptoms.. we hatched a medication management plan (I have a hate on Olanzapine, the standard first line med here), using a less well known antipsychotic, sold it to my daughter's treating psychiatrist... She then went on holiday, and we got seen by the senior psychiatrist in the practice (incidentally in the same year at medical school as my curbside advisor, and not in his 'happy for a member of my family to see' cohort) who frankly bullshit us (being unaware I was a medical student very familiar with mania in multiple family members) - started with 'she's not on a mood stabiliser, she needs to be on a mood stabiliser...' Suggested "mood stabiliser" was Olanzapine... (But the antipsychotic she was on apparently didn't count as a mood stabiliser)... Wanted an ECG before prescribing propranolol to an otherwise healthy young woman for akathisia (heck, my GP has prescribed it to me for migraines and hasn't even taken a BP)... Oh yeah, and described Risperidone as a sedating antipsychotic...
I know you acknowledged there are less conscientious doctors than you out there, but also, some of us getting curbside consults as patients are more responsible than others. I've also had a curbside consult from a neurologist at the hospital I'm a med student at, which confirmed I was eligible for subsidised injectables for migraine prevention, and concluded with a next-week official consult to prescribe them (skipping his 6 month waiting list)... So personally I'm very grateful for them. Used wisely, I think those of us who can access curbside consults from specialists are fortunate.
Totally agree. Both things are true: doctors’ egos are “hurt” when patients use curbside consults. They feel undermined and there is a tacit message that the clinical team has missed something. At the same, patients have freedom to discuss their health and seek alternative perspectives about their health problem. I frankly do not care if the doctor’s feelings are hurt.
My health is my concern; not protecting the doctor’s ego or self-image.
My former oncology specialist took me down verbally in the infusion center because inhales her more experienced colleague about some of her decisions. She raised her voice and carried on that she was my doctor and I had to stop talking with her esteemed colleague (higher up the chain at a top academic medical center)
Under her less than optimal care, I experienced a relapse. Maybe a coincidence, maybe not.
I am a general internist practicing in Ottawa and I can completely relate to every aspect of this beautifully articulated essay. I have seen it from both sides. I have been pressured to order unnecessary tests and to prescribe unnecessary medications by advice given to patients from well meaning colleagues leading to over diagnosis and over treatment. I have also seen friends and relatives who are clearly not being well treated by their physicians. It's a delicate road to navigate. However, one thing that I have learned the hard way is not to become directly involved in the care of friends and relatives. While it sometimes works out, it often leads to both bad medical care and loss of friendship.
Wonderful; thank you. I just had such a situation, causing my doctor to burst out, "Everybody's a doctor!" The question, raised by an assistant in another medical office, was whether in splitting an tablet that is not scored, one risks getting zero active ingredients in one of the halves. I for one appreciated that outburst, regardless of the actual facts of the matter.
"rant about what I see as poor clinical reasoning leading to overuse" -- Having repeatedly encountered poor clinical reasoning as a patient, I wish more physicians would do this, publicly. In every profession, half the practitioners are below average, and the average for medicine should be increased.
My long time primary care MD had brushed off my repeated concerns. Ignoring his scorn and listening to a relative's MD instead, I ended up in the ER just in time (with sepsis).
As your footnote states, you have colleagues who need checking. Many, in my experience.
As per usual, I agree with Adam, and it is a frustrating scenario to say the least.
My only addition to this excellent article is that most of these unwanted consults don’t come from the curbside,they come from “Dr. Google“
Ben Hourani MDMBA
I am a nurse and when people ask.me, I often encourage them to call their provider .Many patients are reluctant to ask questions. I let them know that I think their questions are good and try to build their relationship . If a provider will not answer questions, I find that to be a red flag
Thanks Susan. I have spent months inpatient for a long series of cancer treatments. Nurses are terrific for many reasons… one is that they are not haughty as many specialists are. You mention another: they listen to patients and in my experience, never counter the clinician’s or attending’s actions. That said, nurses provide a safe team member with whom patients can share their doubts and anxieties.
Patients have doubts and anxieties when receiving long term clinical care. Maybe a big dose of humility from the doctor would be helpful.
“Those of us in healthcare should be cautious about the recommendations we make when we are outside the clinical setting…”
Yes - and the advice with which you finish this paragraph is essentially what I have always strived to follow!
And - yes - I tend to get a little worked up about coronary artery calcium scans.
Given the behavior of the patient (forgetting to take pills and failing to apprise the physician friend of her PCP's advice), the liklihood of cognitive impairment is high. A formal test (e.g., a MOCA) is in order. If positive a review of possible medical causes is in order.
As an oncologist, I feel this daily — patients come in with outside recommendations, and it adds a whole new layer of complexity. You put it perfectly.
This is just a really hard job.
It is.
And I know that I, too, have been guilty of making other doctors' lives harder by suggesting "Just ask them about XYZ." When one does not have the whole picture, things can look different, but when one's loved one is getting what seems like less than ideal care, it is difficult to stand by and watch.
Being a doctor is a really hard job.
Being a loved one is a really hard job, too.
Thank you for this essay, which, as usual, perfectly articulates what is in my heart.
This must have deep meaning-your rants are about calcium scans while a lot of my "extra-clinical" consults involve recommending said scans.
😂
My personal curbside consulting... Over a half hour in depth discussion with a senior psychiatrist about my daughter's manic symptoms.. we hatched a medication management plan (I have a hate on Olanzapine, the standard first line med here), using a less well known antipsychotic, sold it to my daughter's treating psychiatrist... She then went on holiday, and we got seen by the senior psychiatrist in the practice (incidentally in the same year at medical school as my curbside advisor, and not in his 'happy for a member of my family to see' cohort) who frankly bullshit us (being unaware I was a medical student very familiar with mania in multiple family members) - started with 'she's not on a mood stabiliser, she needs to be on a mood stabiliser...' Suggested "mood stabiliser" was Olanzapine... (But the antipsychotic she was on apparently didn't count as a mood stabiliser)... Wanted an ECG before prescribing propranolol to an otherwise healthy young woman for akathisia (heck, my GP has prescribed it to me for migraines and hasn't even taken a BP)... Oh yeah, and described Risperidone as a sedating antipsychotic...
I know you acknowledged there are less conscientious doctors than you out there, but also, some of us getting curbside consults as patients are more responsible than others. I've also had a curbside consult from a neurologist at the hospital I'm a med student at, which confirmed I was eligible for subsidised injectables for migraine prevention, and concluded with a next-week official consult to prescribe them (skipping his 6 month waiting list)... So personally I'm very grateful for them. Used wisely, I think those of us who can access curbside consults from specialists are fortunate.
Totally agree. Both things are true: doctors’ egos are “hurt” when patients use curbside consults. They feel undermined and there is a tacit message that the clinical team has missed something. At the same, patients have freedom to discuss their health and seek alternative perspectives about their health problem. I frankly do not care if the doctor’s feelings are hurt.
My health is my concern; not protecting the doctor’s ego or self-image.
My former oncology specialist took me down verbally in the infusion center because inhales her more experienced colleague about some of her decisions. She raised her voice and carried on that she was my doctor and I had to stop talking with her esteemed colleague (higher up the chain at a top academic medical center)
Under her less than optimal care, I experienced a relapse. Maybe a coincidence, maybe not.
I am a general internist practicing in Ottawa and I can completely relate to every aspect of this beautifully articulated essay. I have seen it from both sides. I have been pressured to order unnecessary tests and to prescribe unnecessary medications by advice given to patients from well meaning colleagues leading to over diagnosis and over treatment. I have also seen friends and relatives who are clearly not being well treated by their physicians. It's a delicate road to navigate. However, one thing that I have learned the hard way is not to become directly involved in the care of friends and relatives. While it sometimes works out, it often leads to both bad medical care and loss of friendship.
Wonderful; thank you. I just had such a situation, causing my doctor to burst out, "Everybody's a doctor!" The question, raised by an assistant in another medical office, was whether in splitting an tablet that is not scored, one risks getting zero active ingredients in one of the halves. I for one appreciated that outburst, regardless of the actual facts of the matter.
"rant about what I see as poor clinical reasoning leading to overuse" -- Having repeatedly encountered poor clinical reasoning as a patient, I wish more physicians would do this, publicly. In every profession, half the practitioners are below average, and the average for medicine should be increased.