March 28, 2014

horse sense

     "So tell me about your 18 month well child checkup," the attending told me.

     I paused a moment and then said in my best Texas accent, "You'll see why in a minute, but something ain't right with this kid."

     The attending laughed and interrupted me saying that's actually quite an important observation.  To have seen enough of the usual suspects to know when something much more dangerous crosses your path is very important.  And to see it within the first few seconds of walking through the door is critical.  It's horse sense, really.  Yes, we have to know libraries of information, but the application of it is really quite simple.  Use your powers of observation and then feed that into a Sherlockian mode of deduction.  I still remember my brother's oncologist saying, "you'll find that the majority of medicine is just common sense."  And he was right.  My common sense told me something wasn't right.  I then began to rattle all the minor things I noticed that if they were by themselves, wouldn't amount to much.  But when you see the big picture and put them altogether, warning bells should start sounding.  And loudly.  This is when I knew I had earned the attending's trust and was going to get a good evaluation.  While I'm still presenting, he starts ordering tests based solely on my presentation as he hadn't even seen the kid yet.  This kid should've had these tests 6-8 months ago but had somehow managed to pass a couple of physicians who missed the boat royally.  We took a shotgun approach since it had been going on so long - genetic screening, early intervention, surgical consult for testes that had not descended (they are supposed to descend by 12 months and the poor kid had physicals which said they were descended at 9 and 12 months, which they most certainly were not), autism screening, cystic fibrosis confirmatory testing, etc.  On the one hand, I felt very proud of myself.  On the other, I felt very sorry for the family.  They were in shock, and deservedly so as no one had told them this before.  And it was only the beginning for them.  Their life was not going to get easier, only harder.  Such is the way of our training.  We learn on the "interesting" patients.  But you never, ever want to be interesting to a doctor.

March 21, 2014

things rarely present like they do in the textbook

The following is not FACTUALLY accurate. Details have been changed, things deleted, stuff made up, all to protect identity. But it is 100% absolutely true.

     I came home from working at the pediatrics clinic all day and told my wife, "If you get syphilis, this is why.  But don't worry.  It's really easy to treat."

     Needless to say, she was not amused.  A rather precocious teenaged patient had come with a rash that was rather widespread.  And the rash didn't look like anything I'd seen before.  Common sense says to wear gloves, which I fortunately I remembered to do.  I went out and presented to my attending.  When he asked me what I wanted to do, I honestly replied, "I've got nothing."

     We both walked in and he looked at the rash in a similar fashion.  I could tell he was just as perplexed as I was.  We went and got the Nurse Practioner.  The NP came in, shrugged her shoulders in uncertainty and thought it might, maybe, just possibly, I don't know be an atypical case of a staph infection, emphasis on the word 'might'.  So the patient got amoxicillin and sent on their way with a follow up in three days because honestly, we were anything but sure.  In the back of everyone's mind lingered the thought, "is this syphilis?"

     Sir William Osler, the founding father of modern 20th century of medicine said, "He who knows syphilis, knows medicine."  The rationale of that statement is because syphilis can pretty much do whatever it damned well wants to do - rash, fever, muscle aches, joint pain, heart disease, brain disease, psychiatric symptoms, etc.  But we rarely see it anymore because it's highly susceptible to antibiotics.  Most people in the western world have had a dose of penicillin or a z-pack for a respiratory infection or sinusitis.  That antibiotic would've knocked out any syphilis hanging around.  So much like rheumatic fever, it's becoming a thing of the past, which is a good thing.

     The patient returns three days later.  I walk in and it's clear the rash hasn't improved at all.  In fact, it's gotten worse.  Again, I smartly put on gloves but now notice that the rash has spread to the palms of the patient's hands.  In the immortal words of Scooby Doo, "Ruh-roh".  There are only a handful of rashes that go to the palms, syphilis being one of them.  It also means that at that stage of syphilis, the lesions are teaming with the parasites.  Even a simple handshake can spread millions of the little buggers.  I've never washed my hands so thoroughly as after that visit. 

     But the patient was already on antibiotics.  Was this a resistant form of syphilis?  Gonorrhea is making a strong comeback with resistance to our usual armamentarium.  So why not syphilis?  We ran the blood tests of syphilis but in the meantime, tried another approach.  We kept her on the antibiotics but treated her as if it might be scabies.  Or, bed bugs.  Hell, it really didn't matter in the end.  It didn't look like either but hey, this is the art of educated guesses.  Again, another three days pass and the patient returns.  This time the rash is subsiding so it must have been an atypical presentation of scabies rather than an atypical case of syphilis.  Who knows?  My wife was only mildly relieved.  She threatened to have me start stripping in the garage before coming home and heading straight to the shower.

     So the next time you hear some politician talking about how medicine can be just algorithms and essentially a cookbook, please, please, please don't vote for that person if you want to help me.  Sure, the algorithm will help about 80% of the patients but removing any concept of actually thinking and relying on our decade of training is going to hurt the other 20%.  It is MUCH more subtle and complex.  There's a reason our training is so long and education continues lifelong.

March 14, 2014


     My pediatrics grade is essentially divided equally between three parts - first month evaluation, second month evaluation, and the exam.  For the first time in my life, I received a "Pass" as an written evaluation for my performance.  Now, I've gotten "pass" on plenty of tests.  I know I'm not the strongest test take.  But in the real world?  Never.  I felt a lot of things but pissed off was probably the strongest one.  I was told to be happy for it given all of the stress I've been under for....I can't even recall anymore.  First my brother, then my dad, and finally my son.  Somewhere in there, I went to medical school but I'm not quite sure I recall it.  So I was supposed to be grateful that I passed given the circumstances.  Pardon my language but $*%^ that.

     So the second month of pediatrics rolled around in February.  Different location, different attending, different everything.  And the stars aligned just right for me to be in the type of situations where I do best in.  Lots of work, an attending willing to let me take on as much responsibility as I wanted (and actually listened to my plans), and it was outpatient.  I was going to be damned if I let another month of "Pass" come across my ego.  I put my head down and plowed on handling things as simple as well baby checks to rather complex patients.  And my performance was not undervalued.  I redeemed myself and got "Honors" with rather good comments on the written part.  Those are actually probably the most important part.  At the end of your med school career when you apply to residency programs, probably one of the biggest thing besides your first licensing exam score, is the Dean's Letter.  On the letter goes ALL of your comments from Every.  Single.  Rotation.  I've known a few students who apparently didn't play up the resident's ego enough and got a bad comment on the review, despite passing the class.  I knew the students.  They were not slackers.  But doctors can be assholes just like any other profession.  And that one comment can tank your application.  No one wants to have to explain in an interview the comment "student was disinterested" or "lackadaisical in their approach" even though the rest of the comments were good.  You want to spend your limited interview time talking about other things because your letter has line after line after line reiterating "hard worker", "will make an excellent clinician", "was able to handle the most complex of patients", or my personal favorite "functioned at the level of a resident."  And then there's that one that matters more in Family Medicine than other specialties, "great at developing relationship with patients."

March 9, 2014


A happy belated birthday to my dad.  It was two years ago yesterday that he received his stem cell transplant.  It's a birthday that means much more to him than his classic birthday.

chief complaint

     Whenever one makes an appointment with a doctor, they ask for a reason for the appointment.  Everybody's done it.  The person then booking appointment, enters into the electronic medical record what the patient is being seen for.  This is supposed to help us.  Before we go into the room, we like to know what we're walking into, at least I do.  But on my last rotation - pediatrics - the chief complaints were written as if the person entering them had no medical training whatsoever.  Rather than get irritated, I started keeping a running tally of them so I could laugh at them.  But really it is a sign of driving down the cost of healthcare with foreseeable consequences.  Less trained people are replacing those with more training.  PAs are replacing doctors.  LVNs are replacing RNs.  Psychologists are replacing psychiatrists.  But I'm not going to get into that right now.  I'm just going to use my list to laugh.

  1. Thrash in mouth - I think you meant thrush in mouth.  Thrashing in the mouth would be quite a terribly different thing.  And I wouldn't know how to treat it either.
  2. Swollen right tisticle - Seriously?  We can't get testicle spelled correctly either?  And it was the left tisticle, by the way, but I figured it out.
  3. Lump near head - Do you mean the neck?  That thing that the head is connected to?
  4. Rash on bottom - Bottom of what?  Bottom of the hands, feet, etc?  It is appropriate to use buttocks in the medical field.
  5. Rash in private area -  Oh, good grief.  Can't you use at least the diaper area?  Or, groin?  Or, God forbid, the anatomically correct term of perianal area?
  6. Pain - Help me out here.  Pain where?????  Believe it or not, it makes a BIG difference where the pain is.
  7. Fever - Again, help me out here.  Fever in and of itself is not a reason to bring someone in (unless it's a newborn).  Fever and what?  Cough?  Abdominal pain?  Those are very different things.
So if ever your doctor walks in and has no clue why you're there or they are running late, it may not be their fault.  They may have quick tried to see a patient with a run-of-the-mill headache and it turned out that the kid could hardly breathe for the wheezing and obvious new diagnosis of asthma.  We can't exactly just let that go.  We've got to try to get the kid stabilized and then decide whether they need to go to the ER.  So the next time you're making an appointment, do everyone a favor and be as specific as possible.  If you have three separate problems, tell them that.  Don't do the infamous, "oh by the way..." as we're trying to walk out the door having solved one problem.