White Coat Underground

I’ve been teaching internal medicine for a number of years now. The practice of internal medicine falls into two broad categories; inpatient medicine, and outpatient medicine. Because of certain historical imperatives, internal medicine training is heavily biased toward inpatient education, and these days, inpatients are sick. To qualify for hospital care a patient must be receiving care that cannot be given outside the hospital; they must meet criteria for intensity of service and severity of illness. Ask any old-timer doc and they will tell you that hospitalized patients are much sicker than they used to be.

This makes hospital-based medicine very interesting. The acuity, the excitement, and the challenge are much different than primary care medicine. There is a real thrill in becoming competent at running a code or putting in a central line. In some ways, inpatient medicine is easier than outpatient medicine. Primary care requires a high tolerance for uncertainty—you can’t run stat labs in the office, you can’t monitor vital signs every six hours. The hospital feels safe to medical residents, while the office can seem simultaneously boring and confusing.

With that knowledge we can better understand a common complaint of patients, what we can call the “Why are you bothering me” problem. When residents rotate through the outpatient clinic with me, they often wonder aloud to me why people bother to come in with “silly” problems, like the common cold. That’s when it’s time to put the pen and stethoscope down and have a chat.

People come to the doctor because they want to feel better. Most doctors want to help them achieve that goal, but healing isn’t all about ripping out an appendix or performing CPR. Leaving aside the fact that a lay person cannot always distinguish a bad cold from strep throat—an important distinction—people want a little healing, even the intangible kind. People come to my office and pay me in order to hear my opinion, to get advice about feeling better, and to be reassured. The fact that they are not always happy with my advice is a natural and important part of this interaction.

It is important for all of us who are physicians to remember that there is no such thing as a stupid appointment. If nothing else, the time can be spent getting to know someone new—-misanthropy is not a good trait for a clinician. And building that rapport can lead to more gravid revelations in the future. Once you get a complete stranger to trust you, you start to experience “door-knobbing”, where a patient, holding the doorknob on the way out says, “By the way doc…”. That “by the way” is often the most significant part of the visit. The cold they came in for becomes the mole on their leg that is getting bigger, or the heart burn that only bugs them when they climb the stairs.

Once you have decided that a visit is a waste of time, the patient will share that conclusion, and will have no reason to tell you anything of consequence. And that’s not good medicine.

Comments

#1 Dan J
June 16, 2010

I’m glad my oncologist doesn’t ever think I’m wasting her time. She’s got a great sense of humor, too.

Love the “door-knobbing” reference. I’m going to file that for future use.
#2 k8
June 16, 2010

This is why I love my family doctor. He never makes me feel stupid for coming in. Actually, I’ve had more lectures about waiting too LONG to come in when there’s something wrong. We have a relationship. And that’s what makes me so pleased to have him as a doctor. And when I had meningitis, the fact that he came to the hospital every day to make sure I was getting the care I needed meant the world to me. I knew that the people treating me ultimately had to answer to him. The person that knew me and my body the best.
#3 JustaTech
June 16, 2010

And sometimes what we want is to hear “Oh, I don’t think that’s anything serious” or “I don’t know what that is, but it doesn’t sound like anything I’d be worried about”.

I wish I could say that I have a good relationship with my doctor, but so far she’s been someone I’ve seen once a year for two years and then she graduated. Twice this has happened. I guess I can’t win at “Young, woman, and going to be here for a while”. Maybe next time I’ll ask for “Not-about-to-retire woman doctor”.
#4 LadyDay
June 16, 2010

Well said, PalMD!
#5 Liz
June 16, 2010

Great post. I hope all residents have someone like you to explain these things.
#6 george.w
June 16, 2010

Awesome post, I wish the doctors in our HMO would read it.

Leaving aside the fact that a lay person cannot always distinguish a bad cold from strep throat

Exactly. Having chronic pain means that trivial stuff and important stuff both hurt and you can’t tell which is which. Once I know something is harmless, I can try to ignore it or manage it.
#7 Dianne
June 16, 2010

Part of the problem with the “why are you bothering me with this” problems is that, possibly counterintuitively, they are often the hardest to solve. What do you have to make someone feel better from a common cold? Reassurance, maybe, but is reassurance worth a $20 copay and a 30 minute wait? Or that 20 year duration probably somatic stomach ache: dozens of internists before you have failed to make the patient feel better, what’s the chance that you’re going to succeed (once in a while you might find the lactose intolerance or celiac disease that others missed, but mostly…not because it’s not there)? It’s hard to deal with these patients because their problems are both easy (if you’ve had a stomach ache for 20 years it’s pretty clearly not something that’s going to kill you) and very hard (nor is it going away any time soon.) Frustration, sympathy, anger, and guilt are all hard emotions to deal with. Put them all together in one situation and they’re a huge mess.
#8 medrecgal
June 16, 2010

A corollary to this comes a little later in a visit when you see situations where the physician asks the same question in your title after realizing that whatever advice (s)he has dispensed in the last 15-30 minutes isn’t going to be heeded at all by the patient. Sometimes I see this so clearly in a provider’s notes in the medical record that it just boggles my mind. If I were in the physician’s shoes (which I wanted to be, but it didn’t happen that way), it would frustrate me far more if a patient came in for serious stuff and ignored my expert advice than if that patient came in for something that turned out to be trivial. (Because as we all know, sometimes serious issues can present in seemingly trivial ways.) Unless it was something really off the wall obvious like a hangnail or a pimple, I’d tend to err on the side of caution (based upon plenty of experience as a patient and a boatload of medical knowledge). The key here is exercising enough reason, i.e., weighing the potential significance of the symptom(s) against experience, knowledge, and other factors before rushing off to the doctor’s office. I have also seen too many cases where what a patient really needs is just someone willing to listen when no one else seems to care. Sad commentary on our society is in all of these circumstances.
#9 OleanderTea
June 16, 2010

Beautifully put, Pal. As a professional patient, I vote that your post be required reading for all doctors!
#10 Nathan Myers
June 17, 2010

This sounds like competent doctoring. What refereed peer-reviewed journal papers support it? Or is this something you would label “alternative” if somebody outside the guild did it?
#11 PalMD
June 17, 2010

Nathan, at least try not to be an idiotic skid mark. Seriously, you do see the flaw in your idiotic blathering, don’t you?
#12 Vicki
June 17, 2010

Yes. Sometimes a person (*waves*) goes through a few rounds of tests, and winds up with “we don’t know what’s wrong but your heart is okay, try wrapping a scarf around your face when it’s cold.” Or with instructions to just rest and get plenty of fluids.

But sometimes that odd pain turns out to be a badly inflamed gall bladder. People die of “it’s probably nothing, I don’t want to bother the doctor.”
#13 Dianne
June 17, 2010

But sometimes that odd pain turns out to be a badly inflamed gall bladder. People die of “it’s probably nothing, I don’t want to bother the doctor.”

I sometimes semi-joke that the ideal patient is just slightly hypochondriacal. That is, the patient who presents occasionally for the odd cold or lower back pain is probably not going to sit at home and ignore that little chest pain or rectal bleeding.

Another thing that occurs to me with the “it’s nothing” visits is to look for the secondary agenda. For example, did the patient come because s/he needs a note or his/her employer will call staying home with a cold a “vacation” day rather than a “sick” day? Does s/he want a prescription for Sudafed, even though it’s over the counter, because otherwise the pharmacist will look at him/her like s/he is a drug dealer looking for raw materials? Could there be some underlying depression (anxiety, phobia of illness or a specific illness, boredom, etc) that is making the patient feel bad even when s/he appears perfectly healthy?
#14 gaiainc
June 17, 2010

What I tend to find with the “it’s probably nothing, I don’t want to bother the doctor” POV is that deep-down the patient does know/think something really bad is going on and that the patient doesn’t want to have such suspicions confirmed. My most recent case was my 70 yo woman who had a breast lump, didn’t tell me about it, didn’t want her breasts examined, but did get her mammmogram that was sufficiently abnormal that she was biopsied that day and has moderately invasive ductal carcinoma. Denial is not just a river in Egypt.

I also have had instances where patients come in, I truly wonder why they are seeing me, we have a protracted discussion about options, and in the end they get testing that shows something horrible. I diagnosed one patient’s metastatic lung cancer that way, because his chiropracter wasn’t helping his back pain and he wanted an MRI. Yeah, that was a fun phone call.

I also have a lot of cases that show the flip side of above, where the symptoms weren’t a harbringer of anything terrible and the testing showed nothing horrible. There is still a lot of art to medicine, though we have definitely have science. I think that the art is in getting the information I need from the patient to figure out where to go and what to do. Sometimes it is just a sense that something isn’t right about a patient. I also have patients that we just agree that I’ll see them regularly, so we can keep working on their chronic issues that I’m unlikely to “fix”, we both know that I’m not going to fix the problems, but the regular contact keeps the problems manageable. That is the challenge and the joy of primary care, that long-term relationship.
#15 Amy
June 17, 2010

This is extremely timely for me. Yesterday I saw the doctor because I’m having trouble breathing, feeling like my throat’s closing up and wheezing, particularly when I exercise (I’m about a dress size overweight and I’m trying to change that). To me not being able to breathe is something to worry about (particularly given I’m not yet 25!). But she told me because I had a cold about six weeks ago that was probably it and told me this was more likely to happen if I was unfit- it was like she was telling me off for that (and it’s not like I hadn’t mentioned trying to get fit 30 seconds before!).

Needless to say I’m going to seek out another doctor.
#16 kishin
June 17, 2010

Hats off to PalMD for his patience with his patients. My primary care doc (probably someone Pal knows locally!) is great but he’s busy and I hate to go in for something stupid like a (non-strep) throat infection that the doc can do nothing for. Is it really true that a lot of people can’t recognize strep? My recollection is that it hurts really bad. Even when I’ve gone in with a bit of rectal bleeding, it’s just been ordinary (not familial) polyps that again, not much can be done for. Being “a little bit of a hypochondriac” is probably a good thing, but I worry more about people wasting doctors’ time with frivolous complaints than with people waiting too long to be seen. I wonder if this has been studied at all?
#17 Nathan Myers
June 17, 2010

OK, then, “holistic”.
#18 PalMD
June 17, 2010

Here ya go.
#19 Nathan Myers
June 17, 2010

Still waiting for those papers, though.
#20 PalMD
June 17, 2010

Srsly, Nathan, to ask for “evidence” that behaving like a human being is a good thing is pretty fucking idiotic.
#21 Arnold T. Pants
June 17, 2010

1. It’s definitely better to see dozens of people with chest pain that turns out to be heartburn than to see one patient who is in a severely bad way because they ignored a heart attack.

2. Nathan Myers, you’re relying on a common altie fallacy, that only alt med quacks are compassionate and try to treat the whole patient. Just because we don’t read from magic books doesn’t mean that we don’t care about the patient. Just because we don’t dilute our medicines beyond Avogadro’s number doesn’t mean that we don’t think that the emotional context of the patient is important. Just because we don’t poke at imaginary meridians doesn’t mean that we don’t work very hard to do what we can to benefit the patient. In fact, this is where the whole evidence thing comes in to play. We want evidence precisely because we care about our patients and don’t want to subject them to useless remedies like homeopathy and acupuncture, no matter how profitable they might be. We want to know what actually works, and it’s not anything you’re selling.
#22 Arnold T. Pants
June 17, 2010

Oh, and here’s your paper Nathan.
http://www.ncbi.nlm.nih.gov/pubmed/7992984
#23 Nathan Myers
June 18, 2010

Behaving like a human being is not always anything to be proud of. Lack of scruples about one’s definition of “alternative”, for example, is very typically human. (Likewise, Mr. Pants’s disconnected ranting.) Competence and compassion, like honesty, are all too rare, and their presence correlates rather poorly with guild membership.

Having found a way to maintain competence and compassion toward your patients, at least, wouldn’t you be proud to add scruples? It might seem like it would make writing your blog less fun, but it is typical of humans to be very bad at predicting how we will feel about changes. Dangerous quacks are no less worthy of scorn without the unwarranted generalizations. Maybe you will even find greater satisfaction in writing what would be defensible without childish name-calling.
#24 Arnold T. Pants
June 18, 2010

Nathan, now you’re just all over the place. First you want evidence that being compassionate is good, now you’re complaining about tone. If you want to troll, at least pick something consistent to argue about. At this point I will stop feeding you.
#25 Comrade PhysioProf
June 18, 2010

The hospital feels safe to medical residents, while the office can seem simultaneously boring and confusing.

Do you fear that you’ll send a reassured patient home from an office and they’ll drop fucking dead?
#26 PalMD
June 18, 2010

Yes, sort of. If, for example, someone has some ankle swelling, it sets off a line of thinking and the differential diagnosis is fairly broad. In the hospital it would be simple to run some tests and observe the patient, but in the office not only do you have to think through all that, but you have to decide how likely the patient is to be OK or not if they go home.

That’s part of it, anyway.
#27 Zuska
June 18, 2010

Pal, thanks so much for writing this.

On one of my visits with my fabulous PCP, she asked me casually, “So, how’s your heartburn?” while writing in my chart. I wasn’t having any problems with heartburn – at that time. But because she had asked, when I started having trouble, I felt okay to bring it up with her, didn’t feel like it was too trivial to mention.

At the end of every visit with her, after we’ve gone over whatever I’m officially there for, she always asks, “so, anything else on your mind? anything else worrying you?” She always gives you the opportunity to put out those little things you are concerned about but think might be a “waste of time”.
#28 Pascale
June 18, 2010

I believe our training paradigm and feelings about inpatient and outpatient medicine have driven the rise in hospitalist care. Yes, in-house hospitalists provide excellent care and shorten stays, but I must admit this career path would have been attractive to me. Take care of interesting acute stuff without the pressure of a waiting office full of outpatients who you have to turn out every 15 minutes or the practice loses money? Hmmmmm…..

As a subspecialist, my question is not why the patient is wasting my time; it’s why the primary care physician is referring them! Bedwetting, orthostatic proteinuria, and asymptomatic microscopic hematuria should be managed perfectly well by primary care physicians; however, these are things that won’t be seen every day. Recent management recommendations must be reviewed, and there probably isn’t a template in the MR system. Much faster to refer to a subspecialist, and the extra cost isn’t coming out of the PCP’s pocket…

Primary care is not about “making people better,” really; it is about relationships with people over the long-haul and being there for them. If you are a resident, and that doesn’t appeal to you, then you really should consider a different career path. We need some specialists (almost anything in pediatrics is understaffed)…
#29 James Pannozzi
June 19, 2010

NATHAN MYERS IS QUITE CORRECT in certain aspects of what he is saying.

I have no doubts about PalMD’s compassion, but the system of medicine to which he has given his allegiance has aspects which are well known to be dehumanizing and reductionistic in their approach. Diagnose the illness, identify the disease, follow the “evidence” based treatments… one size fits all, unless, of course, the test results are equivocal or confusing, the disease cannot be explicitly identified or the condition is chronic and identified but not responding to conventional treatments. In which case palliation, or worse, sending the patient home “to die” are all that is left.

This brings us to the second aspect of what Myers is implying and on which he again hits the mark exactly spot on. A number of scientistic (not scientific) conventionalist apologists have set up the aluminium foil covered straw man of “evidence” based medicine with the implicit assumption being that everything that so called “standard” medicine does is based on the evidence of peer reviewed supposedly scientific double blinded placebo controlled studies.
That anyone could believe the nonsense that a method of testing of pharmaceuticals, and not a very good method at that (Vioxx or Avandia anyone?) would be used to give standard medicine the veneer of a logico-deductive scientific credibility is astounding to me.
A good number of drugs prescribed by PalMD still do not even have their mechanism explained. Not so long ago, aspirin was one of them.

How does any system of medicine proceed? In reality, it is by the case studies, journal articles, and, most importantly, the praxis of dedicated practitioners like PalMD – communicated to their peers in various ways, and taught in the medical schools. It is the same with the Homeopaths, with the Acupuncturists, with the Chiropractors and Osteopaths.

Attacking Myers does not change any of this. He has merely pointed out that the emperor has no clothes. Accept this and follow the conclusions of its logic. Or, deny it and worsen the morass into which our health care has sunk because special interests find it profitable to maintain a fiction.
#30 JP
June 19, 2010

James Pannozzi, you state “That anyone could believe the nonsense that a method of testing of pharmaceuticals, and not a very good method at that (Vioxx or Avandia anyone?) would be used to give standard medicine the veneer of a logico-deductive scientific credibility is astounding to me.”

How would you improve the method of testing pharmaceuticals?
#31 Chris
June 19, 2010

JP, perhaps something better than the “provings” used in homeopathy!
#32 Dianne
June 20, 2010

That anyone could believe the nonsense that a method of testing of pharmaceuticals, and not a very good method at that (Vioxx or Avandia anyone?) would be used to give standard medicine the veneer of a logico-deductive scientific credibility is astounding to me.

How do we know that Vioxx is dangerous? Because a large scale clinical trial showed that there was an increased risk of heart disease in those using it. How many “natural” remedies have been discovered to be dangerous and taken off the market by naturopaths? Were the dangers of kava root, ephedrin, shou wu wan, and so on discovered by naturopaths? No. To the best of my knowledge, no seller of naturopathic medications has ever removed a product from the market because it was shown to be ineffective or dangerous. Is this the model you want all medicine to follow? Really?
#33 Nathan Myers
June 21, 2010

For the record, Mr. Pannozzi does not speak for me. In particular, I do not believe, for example, that homeopaths have anything of value to communicate to one another, or that even observant and expressive chiropractors succeed in communicating what they discover to other chiropractors or to their teaching institutions.

I do agree with Mr. Pannozzi that, as I hinted earlier, the majority of what a competent medical professional like Pal does over the course of a day that benefits his patients has no basis in randomized controlled trials, or even in peer-reviewed research. Objectively, those activities qualify for what he brands as “alternative”. The only difference, in other words, between what Pal excoriates by name, and what he does, is who does them. I will repeat that I do not believe this makes Pal a quack. However, his own definition indicates otherwise.
#34 PalMD
June 21, 2010

See, now that’s interesting Nathan. I’m wondering what data lead you to your conclusions.
#35 Nathan Myers
June 22, 2010

You can try to change the subject, but you won’t get any insight from doing that.
#36 PalMD
June 22, 2010

Asking you to elaborate is pretty much the rhetorical opposite of changing the topic.
#37 Dacks
June 22, 2010

It helps to remember that every patient goes to the doctor for a reason – they might have a relative with a serious illness, and it sparks worries about their own health, they might have anxieties that are causing psychosomatic symptoms, they might be lonely. Or they may have a more easily diagnosed and treatable problem. But knowing that they came to you for a reason should help a doctor treat all patients with respect.
#38 Cara
June 22, 2010

Great post, Pal.