Lesson#6 The Consultant is Not Always Right

One of the most valuable lessons I learned from a patient, unfortunately, happened after she died. Lots of doctors could not figure her out and she had the audacity to keep getting worse, in spite of our efforts to save her.

All the clues were there to make a correct diagnosis and she had a fixable problem. Nonetheless, we were not creative enough to help her.

The Case

Mrs. Piecemeal was a previously healthy pleasant 80 year old white woman who presented to my partner complaining of several weeks of fatigue, generalized achiness and low grade fever. Her Past Medical History was only significant for remote pericarditis and diverticulosis. Her Family Medical History was not helpful. Her only medication was Tylenol for an occasional headache.

On Physical Exam she looks tired, T 99F BP 110/60 slightly pale, with mild tenderness to her temporal scalp, otherwise negative.

Lab tests showed WBC 11,000(slight elevation), Hg 10.1 (moderate anemia), ESR 98 (Inflammation is high).

We then made a series of mistakes. A presumptive diagnosis of temporal arteritis was made and she was placed on Prednisone 60 mg daily. She felt worse and the steroids were stopped but she developed brisk rectal bleeding. Her colonoscopy showed blood throughout the colon but no bleeding sites. Upper scope was negative as were 2 bleeding scans. She required multiple transfusions and the surgeons decided to remove her colon. The bleeding continued, however and she developed high fevers and blood cultures grew out a strange strep species normally found in the mouth from every bottle.

We consulted ID, consulted CV Surgery, did an 2d Echo but no one had any good suggestions. The CV Surgeon told me there was nothing he could do. We started antibiotics but she continued to bleed.

We had one last chance to save her life. If you were her doctor, what would you do?

Diagnoses are elusive things sometimes. The fact is they are very important.Residents ask me all the time, “What should we do?”, and my answer is often,“First, let’s make a correct diagnosis”. One of my teachers, Gerald Bowling, MD, once made the observation when we were dancing around a difficulty diagnosis.“It’s in the lung, it’s in the lung, it’s in THE LUNG”! he implored us to not overlook the obvious or mis-connect the dots. So many things can color your thinking or send you down the wrong path.Remember Rule #2 is Don’t only Listen to the Patient. Well consultants might be very smart, they might know much more about an area than you, but consultants are not always right. Their advice is another VERY IMPORTANT data point, but as the Family Doctor, YOU need to put everything together sometimes to make the diagnosis.

In this case the CV Surgeon missed a chance to be the hero and told us nothing could be done. In fact, he was the only one who could have saved her, and I was not smart enough to figure the case out so I could convince him.

So…..What are the relevant fact of the case?

  1. Brisk GI bleeding
  2. Mouth organisms found in the blood
  3. History of Pericarditis
  4. Negative Upper Endoscopy
  5. Still bleeding after colectomy

STOP and Think for a minute

  1. She eventually died of an air embolism to the brain

This patient as it turned out had developed a small, positional cardio-gastric fistula (from her heart to her stomach). Infection from the mouth (and eventually the air that killed her) spread from the stomach into the heart and blood stream and blood streamed out from the heart into the stomach. When she lay on her left side, however, for the upper endoscopy, the fistula would close so no blood would be seen.

So many lessons in this one case!

First, don’t treat with steroids in Temporal Arteritis without confirming the diagnosis (preferable with a biopsy). Second, and sadly, the consultant is not always right. It would be easier for the primary care doctor if they were.

Thirdly, one must often be a detective to make a correct diagnosis. Fourthly, treatment is mostly folly without a correct diagnosis, at least when the condition is life threatening.

There are probably more lessons here, do you seen them? I have a hard time seeing them, perhaps, because I keep seeing Mrs. Piecemeal’s sweet face, and it reminds me that I failed her in a way, but if you learn from my mistakes, her death will not have been in vain.

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Lesson #5 How did you see that?

Yogi Berra once famously remarked, “You can observe a lot by watching”. What is true about opposing pitchers and Hollywood starlets is also true about patients and families.
Medical observing can be divided into a variety of important categories all the way from assessing family dynamics at a home visit, to looking at a rash (called inspection) to examining a tiny skin lesion under magnification. The key is always the same –PAY CLOSE ATTENTION.
Let me give you a few examples:
On a house call once I noticed that the gas on the stove had been left on and realized my older patient’s memory loss was much worse than I thought. The body language between a teenager and her mother can give me important clues to how well they are communicating.
Once by playing close attention I was able to make an important diagnosis and impress a resident all at the same time – not an easy feat.
The Case:
Matt was a 29 year old accountant with a slightly itchy red rash on his right lower leg. The resident, I’ll call her Dr. Shah, thought it might be a contact dermatitis (an allergy) and asked me to look at the rash. She was right about the rash but missed something important. Below the rash, on Matt’s ankle were hundreds of tiny red dots. They did not hurt, itch or blanch (turn white when pressed upon), and Matt did not even know they were there. They were petechiae – tiny little tattoos of blood that indicated a potentially serious blood disorder. I checked the other ankle – it looked just the same. I asked Matt a few questions and examined the rest of him.
Blood tests confirmed he had a dangerously low platelet count. Platelets are the cell like structures in blood that help it clot and normally run 140,000-400,000 platelets/dL. Matt’s count was 18,000 or 13% of normal. He had a condition called Idiopathic (we don’t know why) Thrombocytopenic (low platelet count) Purpura (bruising) or ITP. With proper treatment, he made a full recovery.
The resident was incredulous. “How did you see that”? Well, it certainly helped that I had seen petechiae before, and I tried not to sound glib but the only answer I could honestly give was, “I looked carefully”.
Once I witnessed a smart British doctor diagnose a man’s hip pain by looking at his shoes. By the way the heel was wearing, he could tell his foot was turned a certain way by a hip deformity. Who would have thought?
You CAN “Observe a lot by watching”. Yogi was right. So in your interaction with your patients, pay close attention to what they say and how they say it. Watch their body language and the family dynamics in the room. When doing your physical exam, keep your eyes peeled for any and all findings as the patient may not always complain and often an important diagnosis will be staring you right in the face.

And listen to Dr Yogi because he has a lot of great advice. Like the next time you are on your way to a house call,  “when you get to a fork in the road, take it”!

Lesson #4 Your Words Matter

Young doctors sometimes fear that their patients don’t take them seriously enough. Take my word for it, YOUR WORDS MATTER, more than you might think.
When I was a young med student I met a man I will call Joe. He was 70ish, frail, malnourished and tremulous. He was in the hospital with pneumonia and when I met with him to explain his diagnosis and treatment; he exhibited the most bizarre behavior. When I spoke, his lips moved. When I stopped speaking, his lips stopped moving. I repeated the exercise multiple times.
Perhaps it was a habit or a form of synesthesia where 2 senses are interconnected and blurred but it taught me how my words could impact another person.
I learned this lesson another time and felt amazingly empowered. A 60 year old man came into our office with a lacerated finger from work. He smelled of tobacco and I listened to his lungs and remarked that his lungs did not sound too good. I asked if he smoked.
“2 packs a day for 40 years”, he said.
“You should quit” I shot back, “That would be the best thing you could do for your health”
I sewed up his finger and sent him on his way.
3 months later he came back in for another unrelated injury. We chatted some more and I asked him about the smoking.
“I quit”! He said.
“That is great”, I remarked. “When did you quit”?
“Right after you told me to. No doctor had ever told me to quit before”.
I congratulated him and smiled to myself, not quite believing what my words had accomplished.
To this day, getting people to quit smoking is one of my favorite doctoring things to do and usually it is not nearly this easy. But sometime people are ready for the message.

Several years later, I learned a similar but less happy lesson in the power of my words.

Malka was a 70ish, heavy smoker with emphysema who lived at a local nursing home. She was a bit cranky and refused to give up smoking even though her lungs were slowly failing. I watched her getting weaker and weaker and decided to have a discussion with her about Advanced Directives. It was my view that people should think about these things ahead of time so we can be sure their wishes are honored.
Malka listened to me explain that her emphysema was getting worse and that I wanted to know what she wanted us to do if her heart should stop. We had a nice detailed discussion and I came away feeling better that I knew who her durable power of attorney for health care would be and that she wanted to be resuscitated in case her heart should stop but she did not want to linger on a respirator. Pretty reasonable discussion leading to pretty reasonable decisions, or so I thought.
I was surprised when I overheard her say to one of her friends,
“My doctor told me I am going to die today”.
Malka was a bit dramatic, a bit of a complainer, so I did not pay much attention to her remark.
I was shocked to learn that later that day she suddenly did die, just as she had predicted.
Of course, I don’t know for sure that my words were the thing that made the difference and brought on an earlier demise for Malka. I am sure her emphysema and endless smoking had a lot to do with it too. But I learned the lesson again that day that my words were powerful and needed to be handled with the greatest of care.
So, whether you are a doctor, or a parent, or a friend, don’t underestimate the power of your words to lift up or tear down, to inspire or to discourage, to heal or to love. It is a power that is within each of us.

Lesson #3 Style and Substance

What is more important, to know what you are doing, or look like you know what you are doing? To have style or substance? When it comes to doctoring, one needs both. If you have book smarts alone, but don’t act convincing, patients won’t listen to you. If you look the part but don’t know your stuff, you will be downright dangerous.

I tell residents in family medicine and medical students all the time that they have to be more than a bit of a salesman. Each time they meet a new patient they need to convince this person that they are a medical professional, they know what they are doing, they care about them as a person and they have their best interests at heart. The resident/student needs to know how to “sell themselves” and in today’s world patients are skeptical.
Many patients have been burned by doctors that don’t listen, make dumb mistakes or just don’t seem to care. The default position is that any new doctor is going to be just the same. To be successful, the doctor in training needs to be aware that in every interaction they themselves are under the microscope.

So how does a new doctor connect with a patient, put them at ease and gain their confidence. Here are a few lessons I have learned along the way.

1. Look the part. Professional dress is key. If you don’t have a white coat, you better be 100% on the rest of your game.
2. Listen hard. See rule#1 Listen to the patient. This is why they call an advanced physician an attending. They attend! Ask appropriate questions and pay attention to the answers. Ask questions that build on their answers.
3. Actually touch the patient. Shake their hand (after cleaning yours), and do a careful exam. If they ask for a diagnosis prematurely, ask them to wait until you have finished your evaluation. Patients don’t want a doctor who jumps to conclusions. I recently heard of a patient that went to an emergency department three times before one of the doctors actually touched them. Their diagnosis was delayed too.
4. Carefully explain in plain language the results of your evaluation. Explain your thinking and your plan and what they patient can expect.
5. Make sure you follow up on any promises you have made. Nothing will undermine a patient’s confidence more quickly than breaking your word to write a letter or call a consultant or check on a lab result.
6. Make note of special event in the patient’s life that you can ask them about at the next visit. An upcoming trip, a new grandchild, a new sport or hobby are good options. They will appreciate you showing some interest beyond their symptoms and medications.
7. Share something about yourself. Patients want to know what sort of doctor they have. Remember though this visit is about them not you. Your parenting advice cred will rise if you can speak from real world experience. When you empathize about how hard it is to be up with a child with an earache, it resonates.

Even if you look perfect, the best way to get trust is still to earn it. Listen closely, make careful diagnoses and prescribe correct treatments. The more your patients feel better, the more the trust will come.

Lesson#2 Don’t Only Listen to the Patient

The second key to getting a good history is a bit paradoxical, “Don’t only listen to the patient”. There have been times when I was too accepting of what the patient told me. Patients may be stoic or malingering or serial embellishers or just too scared to tell you how they really feel. This is why the great diagnostician William Osler once said “It is much more important to know what sort of patient has a disease than what sort of disease the patient has”. You have to be a bit of a detective sometimes to sort out all the information. What the patient tells you is very important but it is only part of what you need to make a correct diagnosis. Find out enough about the patient to see him and his illness in context with his family, his job, his worries and his history. Add to the history a careful physical exam and appropriate labs and other testing. I made the mistake early in my career of putting too much stock in a patient’s self-diagnosis and it led to a true disaster.

The Case

Farmer George was a healthy 75 year old WM. He had frequent heartburn and used Rolaids. One day he developed “severe heartburn” and diaphoresis (sweatiness) and came to a small ER in rural Ohio by squad. Staffing the ER was a somewhat scared, somewhat clueless, newly licensed 2nd year Family Medicine resident half way through a 60 hour moonlighting shift. I took a careful history, and gave George a GI cocktail (Maalox, a numbing medicine and an antispasmodic). “My wife made me come”. He said. “I get this heartburn all the time”, he said. “The only reason I got this sweat is that I got this flu bug I been having sweats all week”, he said. “ I’ve never been sick a day in my life”, he boasted. His eyes were wrinkled by years of smoking and sun, but sure looked sincere to me. “I am fine Doc, the milky stuff took all the pain away”. His family history was fine, no history of heart trouble. He took no chronic medication, had no allergies.

I did a careful physical exam and listened to his heart for a long time. It was steady and strong at 72 beats/minute. His Blood Pressure was excellent at 124/82.

He begged me to let him go home and I naively accepted his version. I did not do an EKG and he happily left feeling well, but 2 hours later he was dead, likely from a myocardial infarction. Let that be a lesson to you…no one will ever thank you for not doing an EKG!! The patient’s history and perception were only part of what I needed to understand his condition. I overestimated his opinion and it led to a disaster.

I will never know if his EKG would have been abnormal because I did not do one. I kicked myself and wallowed in guilt and self-loathing. I then made another mistake, one that I think too many doctors make. I kept it to myself. I told none of my friends or fellow residents or teachers. I was too embarrassed. I had always thought of myself as bright, caring, wanting to help people. Well, good education and good intentions are not enough. One also needs good training and good judgment and I did not have enough of either at that point in my career. George had taught me another valuable lesson and I was not sure it was worth the price but was determined not to make the same mistake again. Yes, I would listen to the patient, but in the future, I would get whatever more information I need and I would make up my own mind. Trust But Verify is good not only in negotiating with adversaries but also in making a correct diagnosis.

Lesson 1 : Listen to the patient

If the first rule of treatment is “Do no harm”, the first words of diagnosing ought to be “Listen to the patient”. We all know there can be no effective treatment until a correct diagnosis is made. I do not know how many teachers have told me over and over again, “Listen to the patient and they will tell you the diagnosis”. However, many times I see evidence that this is not done well or even attempted. Patients tell me that the doctors they have seen have not listened to them or brushed aside their concerns and seemed to have an agenda wholly different than the person in front of them.

Studies have shown that doctors routinely interrupt patients in less than 20 seconds with questions or comments that serve to confuse and not clarify the condition. I have learned that by listening carefully to the patient I can learn more than any test. If I hear the patient and understand their story, then my questions can be more targeted, the tests I order more focused. The treatment is often correctly tailored and effective.

I learned this lesson early in my career and it has been repeated many times since. I started practicing family medicine in my home town of Dayton, Ohio in July, 1985.

One of the first Sundays that I was “on call”, my associate called me to ask me to make a house call on a VIP (Very Important Patient). This was someone who I knew well and who had terrified me in my youth. This was the Cantor who led the singing group I had sung with for 3 years (ages 11-14) with an iron hand. He had expected the best of us and molded 50 mediocre voices into a top notch synagogue chorale that had toured Israel and much of the Midwest.
The case
Cantor K was a 40 year old WM ((White, Man) who was healthy except for mild anxiety, which was worse every year before the High Holy Days when he was in front of the largest crowds of the year. Four days before Yom Kippur he awoke with a severe pain in his chest. He rushed to his Family Doctor, my partner, who did an EKG which was normal, and ordered a stat stress test which was also normal. He went home without feeling any better. Two days later he was beside himself, because every time he tried to sing the pain was like a knife. Nothing could be more frightening to a Cantor two days before Yom Kippur. It was Sunday, who ya gonna call? The junior partner, of course. Here I was, fresh from residency, a former student of the demanding Cantor, and not normally afraid of a house call. It was thirty years ago and I remember it like it was last week.

His wife, the sweet and soft spoken teacher, met me at the door. She ushered me into his private study. Surrounded by his sacred books, sacraments and mahogany shelves we sat and I asked him some open questions.
“Tell me how the pain started”.
“Two days ago, I just woke up with it, a terrible pain in the middle of my chest”.
We traded short questions and answers. He had never had a pain like this before. He had no associated symptoms of nausea, shortness of breath or sweating, or pain down the arm. There was no increased pain with walking, but the pain did worsen if he tried to sing, which terrified him.
“What am I going to do, its two days before Kol Nidre (the famous Yom Kippur plaintive liturgy) and I can’t sing. This is my worst nightmare”!
“Ok”, I said, “Let’s take a step back”. “The night before, when you went to bed, did you feel well”?
“Yes, but I had a scratchy throat”.
“Did you take anything for your throat’?
Sheepishly, he admitted, “Well, I was so afraid of getting sick, I took an antibiotic”.
“What was it called”?
“Doxycycline”.
“You took it with a full glass of water, right”?
“No, I never take water with my pills. I swallowed it dry”.
“What did you do then”?
“I went right to bed”.
He had just told me the diagnosis!
All medications can cause side effects. Some drugs can irritate the esophagus. The number one drug that causes esophageal ulceration is none other than doxycycline. The best way to get an ulceration is to take a medication dry and then lay down. The pill sits in the esophagus all night and causes an ulceration. In his anxiety to stay healthy, the Cantor had inadvertently given himself an esophageal ulceration. He had also given me enough information to make a correct diagnosis. I did not need an Upper GI xray or an esophgo-gastro-duodenoscopy (EGD) because his answers to a few simple questions had given me all the information I needed to help him.

I started him on some Tagamet to lower his stomach acid (that was the best antacid in those days) and Carafate to coat the ulcer and help it heal. I prayed that there was enough time for his ulcer to heal before his biggest day of the year began.

I was proud of making a diagnosis that I was convinced was correct. Not as confident of my treatment plan, for Kol Nidre services, I decided to attend his synagogue instead of my own to see the fruits of my labor in action.
He bounded onto the Bima and looked his usual robust self. He was much better and no longer had the pain. When he sang that night his voice had never sounded sweeter to me. The pathos was deeper and the intonation was stronger. I smiled to myself, and had to repent for the sin of pride that night but also marveled at what I had learned. “I listened to him and he gave me the diagnosis”!
As I told students being inducted into Alpha Omega Alpha, the Honor Medical Society in 2009, “Part of listening to the patient is more than receiving information. It is about showing you care and giving your full attention. What good lovers and skilled politicians know is how to focus on another “like a laser beam”. Whether you are looking for love or votes or just building a therapeutic relationship, active attentive listening is absolutely essential. Could this be why after residency they call you an attending physician? This is how you understand your patient, how you build trust and how you plan your care. Because if your patient does not trust you, nothing else matters as they will not respect your opinion or listen to your advice”.
Another part of listening to the patient is also listening to the family and friends. They can often supplement with some very valuable information. In 1990 a 17 year old girl came to see me in the office, with her mother, complaining of an unusual rash. Not immediately recognizing the condition, I asked the Mom what she thought it was. “I think it is measles”. That would have been easy to discount, because measles was very rare even then. “Why do you think it is measles?” Well she visited a friend at Ohio State last weekend and she was diagnosed with the first case of measles in the state this year and it looked like this.” Well, that is a pretty good reason, so I consulted a Derm text and sure enough she had it all right down to the Koplik spots in her inner cheek. The state had us confirm it with titers but that was the second confirmed case of measles that year and only the second case I had ever recognized. Thanks goodness I had asked Mom for her insight.
I enjoy listening to other people. It is a natural curiosity that I consider a gift that I take after my Mom who “never met a stranger.” Every person has a story, something to teach me. The key is to pay attention.

The Greatest Lesson

Life is full of lessons. I learned this the hard way at the age of 14. My Dad, a respected and loved man, a pillar of our community, died suddenly at the age of 47 from his first heart attack. My childhood world of innocence came crashing down and nothing seemed to make sense. My mother was left a widow in her early 40s, with six children ranging in age from 8 to 20 years old. Why should this good man, beloved by all, be taken from his friends and family at a time when he was needed most? I was confused, angry and hurt. The security and serenity that marked my prior life was gone. It would have been easy to become bitter and lose myself in drugs or self absorption. But this is not what happened.

Two powerful forces came together to bring our family through this tragedy. There was a tremendous outpouring of love and support from our extended family and the small but cohesive local Jewish community. There were three main synagogues in Dayton, Ohio that cold January day in 1973 and three very different rabbis with unique approaches to Judaism. Each spoke at my father’s funeral, creating a united front that showed me and my 5 siblings that we would get through this together. The Jewish tradition has a very detailed and regimented way of dealing with death and this was very comforting to me. We sat shiva, the week of mourning, in our home, constantly attended by friends and family. We stayed home and had services in our home for that week and spent 30 days focusing on our loss by avoiding movies and parties and any boisterous activities. My two brothers and I went to the synagogue every day for one full year to lead services and chant the mourner’s Kaddish which praises God’s name in spite of our loss, championing the idea that life is precious and God is good.

Even as I sometimes disdained the words that thanked God for being so great, I was comforted knowing that I was doing something to honor my father’s memory just as he had done for his father all the way back to ancient times. Soon I was an integral part of the minyan, the group of 10 parishioners needed to make a quorum. We could not say the Kaddish and have it be valid if we fell short. Any kaddish left unsaid could never be recouped and I was determined to say each one. If we needed one or two to complete our group, I would be on the phone to some nearby helpers to pitch in. Soon I was comforting other mourners and explaining the order of the prayers and the special rules. This daily exercise made me feel part of the community, help me feel closer to my father and my brothers, and surprisingly it helped soothe my confused soul.

The second powerful force that brought our family through this heartbreak was my mother. Always the optimist, this disaster deeply tested her resolve and natural sunny approach to life. To her the cup of life was always half full, not half empty. She was devastated but refused to allow the dream that she and my father so lovingly built to be destroyed. Through the power of her will and the great expectations she had for each of us to not give in to this loss, she was determined to see our family continue to thrive. She had no time for self pity but had 6 children to raise. Her goal was “to make each of you independent of me”.
She succeeded. Five of us became physicians and one an engineer. We all married and had children of our own. My Mom died a few weeks ago in November, 2015, at the age of 86, blessed with 24 grandchildren and 23 great-grandchildren with 2 on the way. Her legacy remains to love life, love your family and spread that love around as much as you can.
Four of my sibs specialized (Psychiatry, Physiatry, Preventive Cardiology and Medical Research) but I chose to be a family doctor. I like keeping patients and families healthy and wanted to help families avoid the kind of tragedy that hit my family. I wanted to give my Dad’s death meaning and vowed that he would not have died in vain. I would dedicate my life to being the best family doctor that I could be and spare as many families as possible the suffering that my family had faced.

When my Father died I learned that life is not fair, that good people sometimes suffer needlessly. But, I also learned that when something awful happens to you, you can choose how you will respond. You can withdraw into defeat or you can rededicate yourself to make something good come out of it. With my Dad’s memory to inspire me and my Mom’s Churchillian tenacity to encourage me, I set out to learn how to heal people and hoped perhaps to heal myself.