Reality Stories of Medicine - Things About Patient Care You Don't Learn at School

Part One

In The Office or Hospital: Patient Observations

The “laundry list” office visit

This is a classic issue in the office setting. The patient comes in for a routine physical examination. He or she has neatly compiled a written list of their problems to discuss with you. Usually it’s on one of those yellow tablets of paper that you used in math class while in high school. I have seen these lists 3 or 4 pages long, single spaced! From the patient's perspective, they just don't want to forget anything. One can’t blame them.

If you let the patient review each problem, the exam might take over an hour or longer. But does the patient care? He doesn't know that you are likely behind already. Maybe a half hour or an hour even before you started with them. Now it’s their time.

These lists are often generated by patients who may have OCD (obsessive compulsive disorder), are journalists, have forgetfulness, or they are engineers.

Do yourself a favor and gently get the list out of the hands of the patient. Review each problem that they have expeditiously. I have found that if you let them keep it, they will go through their list slowly and methodically. You should kindly take the list, review it briefly and thoroughly, and bring the patient back for additional exams if need be.

The practitioner needs to be in control of the exam, or they will be lost for the day, and this will bring much consternation. There is an art to doing this. Take care of all the patient problems and do it with grace. Have them come back if you can’t finish.

I am all for lists of problems and communication, but there has to be a balance.

What about the second opinion?

The desire of a second opinion can be nothing more than a lack of trust in your treatment or diagnosis. Call it what it is. Patients will demand it at times, but more so, their family members will do it. They will probably be careful not to “hurt your feelings”, but often they will get them without your knowledge.

I don’t have any problem in obtaining second opinions on difficult cases or in cases when the diagnosis of the patient’s problem is not known. We have to know our limitations.

But there are many superfluous second opinions obtained because of non-trusting family members. Case in point: a recent healthy, 80 year old male was in the hospital with a SBO. He got better after 3-4 days and went home. He had had gallbladder surgery a year before. Thorough work- up now with CT abdomen/pelvis, blood work showed no other problems. We were up-to-date on colonoscopy. Our diagnosis was adhesion-causing-SBO, like many SBOs are.

This didn’t satisfy the family. They opted to have their father go see a gastroenterologist in a local larger city to get his opinion so he could agree nothing else needed to be done. The wife of my patient told me, “We trust you completely, but you know, my kids, well they wanted us to get a second opinion.” Did they find anything? No. But thousands of extra dollars certainly were spent!

Second opinions can be a “rubber stamp” and only serve to increase the cost of health care. But we still live in America, and people are free to seek out second opinions. Now if Medicare or other insurances wouldn’t pay for the second opinion, then certainly there would be a money issue in getting them. But remember that places like the Mayo Clinic thrive on them.

The patient with newspaper article clippings from their favorite “newspaper MD”

Dr. G*** is kind of like a Marcus Welby MD type doctor from the 1960s-1970s. Marcus Welby was not only a compassion old GP from years back, but also a great guy, and everyone loved him. Dr. G*** has been our "newspaper MD" for years; last page in the front section. He’s a throwback to the old General Practitioner. He has a daily, syndicated newspaper article published in the local pap (and 100s of others) where he answers the public’s questions on health issues from bladder infections to low back pain to onychomycosis to restless leg syndrome. The article is found on the last page of the front section of the paper.

For nail fungus, his solution is rubbing Vick’s Vapo-rub into the nails daily. For restless leg syndrome, but a bar of ivory soap under one’s bedsheet at night. Nothing backed up by scientific studies. But patients swear by him. Often, our patients will bring clippings of his article in to share with me a particular answer that Dr. G*** has for a medical problem that they have had. “And that smelly ointment for my toenail fungus really works” they are sure to tell me.

One patient came in telling me that “Dr. G*** recommended Neurontin for pain after shingles. Why didn’t you suggest that for me when I had that awful condition a couple years back, doctor?” “Mrs. Smith, I did suggest it. And we did put you on it, and it was called gabapentin. That’s why you don’t remember; we called it by its generic name! And remember you couldn’t take the drug because of the prominent side effects of fatigue and dizziness from it?” “Oh, that’s right, doctor, I didn’t realize that gabapentin was Neurontin.”

Sometimes, it appears that patients want Dr. G***'s opinion about a medical problem they have. You’ll have to figure out how to deal with this.

The “internet search” patient who wants to direct their medical care

It has been said that the internet’s number one use is in health questions for the masses of people out there with access to it. You got a hang nail? Look it up on how to treat it. You got a sore throat? Look it up. Hemorrhoids? Look it up. Sarcoidosis? Look it up. Cough? Look it up! The layman is looking up the “answers to their medical problems” on countless healthcare websites. Nothing wrong with that, you say. It helps to educate people. Absolutely.

The problem however, becomes “sorting” the information and knowing what is important and what might not be as important.

Let me give you an example. Typically, I will walk into a room to see a new consultation. The chief complaint of the patient might be, “I have chronic fatigue syndrome”, or “I think that I have Lyme’s disease”, or “I have a disseminated yeast infection”. There may be others. Accompanying the patient is reams of internet searches (maybe 2 or 3 inches thick) on their associated topics. We are talking about hundreds of pages. The patient is trying to academically prove to me, the physician, that they have a particular medical condition based on their internet search. “All the symptoms that I am experiencing are just like this particular disease,” they say.

Frequently, after a thorough history and physical examination, and review of x-rays and labs, I will “burst their bubble” and tell them that they do not have so and so a diagnosis that they thought they did, and actually their diagnosis is something quite different. (And maybe it is all in their head.)

Sometimes they leave the room disappointed that I haven’t supported their research, and then it’s off to another doctor to see if they can find someone to support them. I remember a particular patient who thought that he knew that he had a new diagnosis of Lyme’s disease. He didn’t have it clinically. But he thought that he did. He found a website on the internet of some laboratory company in Virginia who prided themselves as the only company available who can make an accurate laboratory diagnosis of Lyme disease. “Any other technology was behind the times, and would give a false negative result. Send your blood to us for definitive testing”, they said! He was adamant that his blood be sent to this laboratory in Virginia for “definitive testing”. What a sham. But there are many companies out there that take advantage of people.

Conclusion: Kindly set the patient straight early on in the visit. Help them sort out their internet search. The internet has them confused.

The Family Leave scammer

President Clinton and congress passed the Family Leave Act back in the 1990s. It seemed like a good thing to do; giving family members a chance to take care of their loved ones when they were sick. They could then miss time from work without repercussions.

There are the governmental, paperwork forms to fill out that the family member must submit to their employer. Though you are not the family member’s doctor, it is your responsibility to fill these out as you are the doctor of the patient. (“Doctor, would mind filling out these forms for me?”) Of course not, because more forms to fill out brighten our day. It's only going to get worse.

As usual, good things get taken advantage of. Fortunately, most people are reasonable about family leave time. But you will see over time that there are those who don’t really need the family leave time off because their loved one “is really not that sick”. But they will apply for the time anyway, so that they can have time off from work for a while. Yes, this is true. I have seen this numerous times over the years. It is difficult to “police” this as a doctor, as you want to give people the benefit of the doubt.

I had a middle aged daughter of a patient of mine that wanted time off from work to take care of her ailing 75 year old widowed father who had fallen and broken a rib. Sure, he had pain that would continue for a few weeks, but he was...