February 12, 2010

Occam's Razor

I've been accused of being an arrogant know-it-all so I try my best to keep it in check. No one likes an A-hole, myself included. But when I'm right, and I know it, I struggle to keep it check. And one of the concepts I've wrestled with is, if med students are so smart, why are there so many stupid doctors out there??? I thought my experience was an anomaly, but in talking to others, it doesn't seem to be. But here's a brief history of where I'm coming from. Family member, hereby known as Patient, had an episode of unexplained syncope. While driving. And didn't tell me until well after a family reunion because Patient knew I'd give them the riot act. Fortunately, no one was hurt during the episode. Confounding factor, Patient had some sort of unidentified nasty infection beforehand and had been on Levaquin, which in rare cases may induce Torsades. No doctor visit (patients can be somewhat stupid, too, I think it's the human condition) except to Family Care Doc #1 who thinks it's Prostatitis based on age and some now resolved infection. Ooookkkkaaayyyy, not sure how that explains syncope. Next Family Doc #2 says "you must've been dehydrated, that's it." Ooookkkkaaayyyyy. Finally, I convince Patient to go to a specialist, whom we shall dub Cardiologist #1. He's internal medicine and not a surgeon so ostensibly, Cardiologist #1 should have some diagnostic skills. He recommends that with the new ablation therapies, they can cure, yes cure arrhythmias right up. Warning bells begin to go off. In my job, we avoided the field of arrhythmia because we deemed it too friggin' difficult for drug development. So surely, it must be easy to clear right up. So off we go to Cardiologist #2, an Electrophysiologist. His Fellow, Cardiologist #2.5 (Fellows don't really count as real docs, do they?) takes the case history and relays it to Cardiologist #2. His first recommendation, let's run some tests. So after the whole battery (echo, nuclear stress test, EKG), only two things come up - enlarged atria and mild atrial fibrillation (hereby dubbed A-fib). Cardiologist #2 says, let's throw Patient on the table and see what makes his heart tick. Seems a bit rash to me, but then a surgeon's first recommendation usually is the knife. Patient opts for a more conservative approach. Cardiologist #2 then prescribes a beta blocker which IS the standard front line therapy for arrhythmias, including A-fib. But, um, did you happen to look at Patient's chart? Patient's pulse is in the 60s and bp is 120-125 over 60-65. I told Patient, do NOT take that medicine unless you'd like to fall back down after climbing a flight of stairs. Good grief. I do a bit of homework on nodal ablation and the long term outcome trials are in process. No one knows how this procedure works long term but Cardiologist #2 and #3 were both telling me it's great. Did I mention that we're in the largest medical center in the world and home to some of the greats in heart disease? I tell Patient to ignore witch doctor, I mean Cardiologist #2. We go to another electrophysiologist, Cardiologist #3 and his Fellow, Cardiologist #3.5. More tests, lots of EKG testing over 24 hours and an event monitor for a month. Nothing more enlightening. He does honestly reply that the long term outcomes for nodal ablation aren't know so at least he's honest with me. He also states that nodal ablation doesn't work very well in patients with atrial enlargement so just go ahead and scratch that pipe dream. So he finally prescribes a Tilt Table Test. Real simple assessment of the baroflex response. Patient FAILS horribly. Cardiologist #4 performing the test prescribes an alpha agonist. Is that a good idea for someone with atrial enlargement and A-fib? Cardiologist #3 basically leaves it at, learn to live with it. Fast forward to my second semester of my first year of med school. I'm reviewing the cranial nerves (really fun mnemonics to learn them! just google 'dirty mnemonic cranial nerve') and for each one (there are 12) I need to associate the clinical deficit if that nerve runs into problems. I get to good ol' Cranial Nerve X (I knew the roman numerals I learned in grade school would come in handy at some point in my life) - the Vagus Nerve. It does all manner of different things but one of the biggies when it comes to problems is the vasovagal response, basically a failed Tilt Table Test. You've gotta be kidding me. Quick search on google confirmed by some legitimate medical journals. Vasovagal Syncope is THE most COMMON form of loss of consciousness. Started reading the Prodrome description and it read a LOT like Patient's initial description right before Patient lost consciousness. Read a bit further and in Circulation was a trial that showed that crossing one's legs and squeezing prevented syncope over 95% of the time. Long term outcomes on drugs were equivocal with no demonstrable benefit. So why were some pushing drugs? So there's even a simple way to manage this condition? Good grief, you're telling me that 2 family practitioners, 4 cardiologists and 2 fellows couldn't think that maybe, just maybe, THE most COMMON form of loss of consciousness might be a good place to start to explain loss of consciousness? Occam must be looking for his razor at the prospect that this is where Western enlightenment has descended to. Like I said, I thought, nay hoped, that this was an anomaly, but I've heard too many other people relate similar stories. I'm getting all worked up again at the remembrance of missed diagnoses past. And depending on whom you believe, medical errors may account for a LOT of preventable deaths in our country (A lot of deaths or overestimation). Wherever the number may fall, given my experience, I'd wager that it's higher than we should be comfortable with. Don't get me wrong. There are some very good doctors out there. I know firsthand. My son's birth was a difficult one and I am thankful to this day that the OB we had knew her stuff backwards and forwards and backwards again. But this is still disturbing. So during my training, I'm keeping my ears and eyes open for why our country might be training some obviously very intelligent students to be dangerously incompetent. Any thoughts?

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