Sunday, November 24, 2019

Thanksgiving 2019

Behold the denizen who has bravely entered our property so close to Thanksgiving!

Wishing all of you a great holiday.

Sunday, November 17, 2019

Why I Won't Prescribe You Antibiotics

At least a few times a year I am asked to prescribe antibiotics to people who are not my patients.  From my point of view, there is only one answer that makes sense here – no.   I have the same reaction when patients call me for a refill or advice when I have not seen them in a year or two.  The patient may feel that I will refill their heartburn medicine indefinitely without an office visit, but I won’t.  Once I hit the refill button, I am now totally responsible as the doctor. 

Patient Gets Medication Refill in 14th Century

The Patient’s Perspective
  • I’ve been on the same medicine for 10 years and all I need is a refill.  I feel fine.
  • I do not want to take time off work for an unnecessary appointment.
  • Why should pay a copay when all I need is a refill?  Sounds like a rip off.

The Physician’s Perspective
  • No refill until I verify that there are no concerning symptoms. A routine ‘heartburn patient’ may have developed some swallowing difficulties which could signal a serious medical condition.
  • Pt may not need the same dosage of the medicine.
  • Pt may not need the medicine at all.
  • Pt may be on new medications which might impact on the decision to refill the heartburn drug.
  • Pt may be overdue for a screening colonoscopy.
  • Pt may have general medical issues and needs to be encouraged to follow up with the primary care physician.

It might be tempting for one of our staff to ask me for antibiotics because ‘I have another UTI’.  My secretary might hope that with one phone call, I can save her time and money.  While she may be an able secretary, she may be a lackluster diagnostician.  Many of my own patients come to my office ‘because their diverticulitis is back’.  While their symptoms may remind them of their first episode of ‘diverticulitis’ last year, often the actual medical evidence supporting the original diagnosis is rather thin.  I can’t count how many of these patients have never had diverticulitis. 

Prescribing you medication is a serious responsibility.  It’s not an act that should be casually done with a stroke of a pen, or these days, with a stroke of a key.  Wouldn’t you want all the odds to be in your favor? 

Sunday, November 10, 2019

Why Doctors Won't Give Medical Advice

Doctors dispense medical advice.  That’s what we do.  Folks come to our office with various medical issues.  We talk to them.  We poke around some of their body parts.  Then, we exercise our medical judgement.  We might order a CAT scan.  We might prescribe stuff.  We might simply reassure them and send them on their way. This is a typical ‘day in the life’ of a health care provider, formerly known as a doctor. 

From time to time, folks solicit my advice under different circumstances.  Despite my efforts to keep my medical specialty stealth, sometimes the secret seeps out when I am in a social setting.

“Oh, you’re a gastro guy?  Would you mind if I asked you quick question about my husband?  He has a gas problem…”

I get questions like this all the time, and I do my best to respond in way that sounds authoritative, yet dispenses no legitimate medical advice.  Here are some examples of how I might respond to the above inquiry on spousal flatulence.
  • “Yeah, if I had a dollar for every time someone asked me about their gas…”
  • “Hmmm.  Sounds interesting.  Do you have any corks at home?”
  • “Call the gas company.  When we had a gas leak in our house, they simply fixed the pipe with a blowtorch.  Maybe your husband has the same problem.”
  • “I would call your husband’s doctor.  I suggest around midnight when you know he’ll be available.  Much better than calling during office hours and dealing with that office rat race.”
  • “Are you sure it’s gas?  Have you heard about the light-a-match gas test?”
  • “Your say your husband has gas?   You should hear what he told me about you!”
Cows pass methane orally and rectally

The point is that physicians generally defer from giving medical advice to folks who are not our patients.  Even a seemingly innocent query can have serious ramifications.  I would not want to give casual advice to non-patients who have questions about last month’s chest pain or if it’s safe to travel to South America before a cardiac stress test next month. 

This is not just true for doctors.  Try asking a financial planner you meet at a party if you should unload your stocks based on the market’s behavior that day.  Ask an attorney who does not represent you if he thinks you are better off settling your case or proceeding to trial. 

Professionals cannot be flip about rendering advice, particularly to strangers.  Consider this hypothetical.  I’m out to dinner and my friend’s wife, who is not my patient, asks if she should double up on her Nexium because she’s still getting heartburn.  I say yes.  But what she thinks is heartburn is really angina.  My casual remark may make me an accomplice to a catastrophe. 

So, don’t ask me about your husband’s flatulence if he’s not my patient.  Bring him and his gas to my office and we will do our best to deflate the situation.

Sunday, November 3, 2019

What Makes a Good Doctor. You Be The Judge

I’ve delved into the issue of medical judgment more than once on this blog.  I have argued that sound judgment is more important than medical knowledge.  If one has a knowledge deficit, assuming he is aware of this, it is easily remedied.  A judgment deficiency, per contra, is more difficult to fix.  Who doesn’t think he has good judgment?

For example, if a physician cannot recall if generalized itchiness can be a sign of serious liver disease, he can look this up.  If, however, a doctor is deciding if surgery for a patient is necessary, and when the operation should occur, this is not as easily determined.  Medical judgment is a murky issue and often creates controversies in patient care.  Competent physicians who are presented with the same set of medical facts may offer divergent recommendations because they judge the situation differently.  Each of their recommendations may be rationale and defensible, which can be bewildering for patients and their families.  This is one of the dangers of seeking a second opinion, as this opinion may be different, but not superior to the first one.  Patients have a bias favoring second opinions as they harbor dissatisfaction, or at least skepticism, with the original medical advice.  

Whose Advice Carries More Weight?

Here are some scenarios which should be governed by medical judgment.
  • A 60-year-old woman with severe emphysema uses an oxygen tank.  She has never had a screening colonoscopy.  Professional guidelines suggest that screening begin at age 50.  Does a screening colonoscopy make sense for her considering her impaired health?
  • A 40-year-old man has had 1 week of stomach pain.  This started 10 days after he took daily ibuprofen for a sprained knee.  The physician suspects that he might have an ulcer.  Should this patient undergo a scope examination to make a definite diagnosis?  Should the doctor prescribe anti-ulcer medication without determining if an ulcer is present?  Should the ibuprofen be stopped if the patient states he has significant pain if he does not take it? 
  • An 80-year-old woman had some recent dizziness and nearly fainted.  The doctor sees her in the office two days later and questions her carefully.  He suspects that the patient was simply dehydrated.  Should the doctor simply reassure the patient or arrange for a neurologic evaluation to make sure that a more serious condition is lurking? 
Of course, you want your doctor to know a lot of stuff.  More importantly, you need a physician who can give you sound and sober advice.  Knowledge and scholarship are important physician attributes, but practicing medicine demands more.  At least, that’s my judgment.  What do you think?