Sunday, October 11, 2009

The phone call

New experiences don't end with residency. I love that about medicine. Another feature of medicine that makes it uncommon among professions is the human drama that goes with it.

I had seen a late 30-something for a complete physical last week. She looked down and through the course of the interview, I found out she had just finalised her divorce. To make matters worse, her 4 year old daughter had come away from her first visit with her father with bruises on her body. This brave woman fought back tears as she told me these things between looking in her eyes and ears. I felt a bit uncomfortable as a male provider doing this complete physical exam during a stage of her life when surely she must think all men are pigs.

Introducing the pelvic exam, as sensitively as I could, I offered her a complete sexually transmitted disease testing panel. At first she declined, but when I pointed out that in the context of the setting of the divorce, she might consider it, she agreed.

The results came back this morning.

I picked up the phone to call her. I pointed out that the Chlamydia test was positive. As if this was not bad enough news to give, I had to point out that as a notifiable disease, our lab had directly contacted the county healthy department. She asked if her name had been given. Honestly, I did not know, but I found out quickly. Not only was her name passed on, but a county health nurse would be contacting her.

Besides the devastation of getting a sexually transmitted disease from someone who had betrayed her in so many other ways as well, she was not concerned about her privacy and reputation. My heart was in knots as I tried to reassure her that even in a small town like ours, her information would be confidential. However, more and more people seemed involved in the loop: my medical assistant who receives the result from the lab, the lab personnel in charge of notification, the county health department and its share of employees that would be doing following up. I could see her point. I felt helpless and frustrated but that must be nothing compared to what she felt.

I'll follow her closely. I hope she's okay.

Sunday, October 04, 2009

Aloepecia totalis

It was a busy afternoon. The student working with me came out of the room and told me that next patient -- a 53 year old male was a caucasian male here for a physical. As busy as we were, I went into the room with her quickly. The patient had wanted us to see his 1 month old in the same visit and Mom came along as well, so there were quite a few people in the room. He took his cap off as I began my physical and I noted he was bald. I asked him when he lost his hair and he said when he was 39. I looked up at his face ready to begin the HEENT (Head, Eyes, Ears, Nose, Throat) part of my exam when I noticed, hello? He has no eyebrows. Wait! He also has no eyelashes and... no nose hair, no hair in his ears, no facial hair, no hair on his arms and legs. He smiled and said 'Aloepecia totalis'. Cool!

I have seen one such case before and it is in this blog. In that case however, it was the side-effect of a drug. In this case, it seems, the patient denied any exposure to that drug and any other for that matter. No-one else in his family has this.

Moral of the story: just when you think the physical exam is a routine...

Saturday, October 03, 2009

Is the generalist a relic of the past?

The other day I was talking to my brother. He told me casually in the course of conversation that he had got his physical for the year. He then mentioned that he had had his yearly appointment with the urologist to check his prostate. That got my attention. What's wrong? Nothing. He just sees a urologist once a year to check his prostate. He has no medical history of urinary or reproductive problems. He has never had urological surgery.

I was at a medical meeting and during a break talking with someone about how there isn't enough training in procedures during residency training. The person I was talking to turned out to be a subspecialist. He disagreed with me regarding training primary care doctors-to-be in procedures. He quoted papers that reported better outcomes when these procedures were performed by specialists.

So, should you go to a cardiologist to have a heart exam and evaluation? Should you see a nephrologist to manage your blood pressures? How about an endocrinologist or a diabetes specialist to manage your diabetes? Should a gynecologist manage your post-menopausal symptoms or a rheumatologist manage your osteoporosis or arthritis? Should you see psychiatrist for stress coping with changes in life or depression?

What is the role of the primary care provider? Is he or she to be a triage person, directing the flow of medical traffic to different specialist-destinations?

I am a primary care doctor. I don't treat a single organ or organ system. I don't wear blinders and only want to hear about your medical problems or complaints pertaining to just your heart or just your kidney or skin or mind or bones.

Are we emasculating primary care doctors when we deny them the right to be doctors and treat patients, rather than just refer them to specialists?

Of course, on the other side of the line is the recognition of the limitations of one's scope of practice. I won't do neurosurgery or try to remove your gall bladder or even do an angiogramon your heart. Some things are clear. But what about managing blood pressure in a diabetic, or abdominal pain in a pregnant, depressed young woman? Is that outside the scope of my practice? Who decides that? Me? The specialist? Some regulatory body? The public?

Of course, I have my own answers to these questions. And of course, as Einstein pointed out, the observer affects the observed phenomena. I am biased.

Fortunately, on a personal level, I am not legally limited in my scope of practice in any but the broadest ways.


Being a primary care doctor is a privilege in many ways. It is also a sacred position of trust. What is said in a doctor's office is, very few legal exceptions, never to leave the room. Of course, in the day of the electronic medical record, that is not entirely true, or is it? How much of what a patient tells you belongs in their medical record? Most would argue, effectively I think, that personal information divulged in the course of the encounter may not always belong in the record. Such information might be a personal event -- a child winning a ribbon at a competition, or a vacation story. The electronic medical record is accessed by numerous healthcare providers that care for a patient in the course of time. With the HITECH and HIPAA laws, accessing this information without a direct clinical context is a breach of law. However, what if a primary care provider records information divulged in conversation during the physical or during the office visit with their doctor? What if they record this information as part of the documentation?

Okay, this is a long preamble to what I really want to say in this piece. I have a couple of patients in my (young) practice that have varied medical complaints for which I have not been able to find an organic cause. I may add, it is not for want of looking. Healthcare dollars have been spent in procedures, tests and consults, all with no fruit. In both cases however, each patient has something they have done that they seem guilty about. They don't say they feel guilty. But their body language, the looking down, the averting the gaze, the downturning of the corners of their mouth, the sudden change of expression all say it.

There are numerous stories in literature about guilt affecting peopel in different ways, including symptoms of physical illness. Is this what is wrong here?

I have another patient who was abused as a child and is dealing with multiple phantom pains. I sometimes wonder if forgiveness is the 'cure' rather than the years of continued pain medications and periodic absences from work with physical therapy to achieve recovery.

I shall not leave myself out of this equation: I have guilt too. At the end of an exhausting day of planned and unplanned clinical encounters, phone calls, nurse notes, impromptu meetings with colleagues, residents, allied health providers and teaching, I am spent. I leave my office guiltily, leaving a desktop full of notes to be dictated, phone calls to be returned, requests from colleagues, students and residents for this or that -- things I am too tired to do. Did I do right by my patients that day? What about the one that left frustrated because I was running late and she couldn't wait anymore? Did I miss something? Did I miss the right decision in sending this one home? Should I not have admitted that one?


Is treating this root of medical problems within the scope of my practice? Should it be?