White Coat Underground

Yes, this is a repost, sort of. I first put this up on denialism blog in December of 2008. For various reasons, I haven’t had a chance to crank out anything fresh this weekend, but this is still a good one, and I’ve edited it to freshen it up a bit, so don’t complain until you read it. –PalMD

It’s July again, and that means I have a crop of new interns.  I love new interns, because every topic is fresh, every moment a teaching moment.  I’m sobered by the statistic that predicts that only about 4% of American medical grads will chose primary care, but even when I work with  the subspecialty transitional interns, I get to give them a dose of medical education.  It’s interesting to watch this final class before the new ACGME rules take effect next July.  This weekend, they were busy, and they looked tired post-call.  That classic post-call look may turn out to be a thing of the past.

No matter what changes we ultimately make in the way we train internists, one of the lessons that residency teaches is to identify who is truly sick. I don’t mean who is faking it, I mean being able to look at someone briefly and decide whether or not they need your immediate attention. It may seem obvious, but it’s not. Objective factors can sometimes be deceiving. For example, an asthmatic may have perfectly normal vital signs, including a normal oxygen level, and yet be moments away from needing a breathing machine. For an asthmatic, a normal respiratory rate may indicate fatigue rather than health, and absence of wheezing my indicate such severe airway obstruction that wheezes aren’t even possible. The ability to recognize severe illness is one of the critical goals of residency.

This is one area in which the so-called alternative medicine folks can really be dangerous.

One time, we had a middle aged guy come into the clinic.  He looked like crap. He was too thin, too weak, too pale, and too breathless. To me, it was obvious that he was seriously ill. But at a brief glance, I’m not so sure a layperson would make that same judgment. None of the individual factors was really strong enough: yes, he was pale, but so are a lot of people; yes he was thin, but maybe that’s natural for him. But when my residents and I saw him, we were fairly certain that he had TB or AIDS or cancer and that he was approaching a crisis that might kill him. We immediately admitted him to the hospital.

But that’s not what his previous health care provider did. He saw a doctor (licensed DO or MD, not sure which) who told him something about his glands not working well, and gave him supplements. When the patient got sicker, the doctor changed him to some different supplements. This isn’t only a failure of an individual doctor to recognize an individual sick patient. It is a failure of a doctor to know how to think like a doctor.

One of my professors was fond of saying that the best internist on TV was Colombo, and while that dated him a bit, the point got through. A good internist can form an immediate impression of illness vs. health, but there’s obviously more.  First she meets a patient, takes a thorough history, does a complete physical, and develops what is called a “differential diagnosis”, or a list of potential explanations for the patient’s condition. The internist then uses the data she knows to guide her to further studies, and she will cross potential diagnoses off the list as the data come in. For example, the patient above was short of breath. Physical exam did not reveal any abnormal lung or heart sounds, so pneumonia and heart failure seemed unlikely. His oxygen level was good, so lack of oxygen reaching the blood (indicating a problem likely at the level of the alveoli) seemed unlikely. A blood test showed a very low blood count. This seemed likely to be the proximate cause of his breathlessness, but for a real doctor, that’s not good enough.

The type of anemia is very important—is it from blood loss, and if so, is it acute, sub-acute, or chronic? Is it hemolytic, meaning blood cells are being destroyed? Is it due to inhibition of normal blood cell production? A good look at a blood smear can help sort this out, as can a look at additional labs. A real internist will not be satisfied giving someone “Adrenal Max” or “Energy Boost Plus”, or some such nonsense.

The reason an internist wouldn’t just give a magic potion isn’t just because she doesn’t believe in magic. It’s because magic potions wouldn’t even cross her mind. It isn’t relevant to human health and disease. What is relevant is the patient, their illness, what science says is and isn’t plausible, and what medicine has found to be effective or ineffective. The doctor who gave the energy pills wasn’t right—he wasn’t even wrong. He was thinking so far outside the box, that he didn’t need to know anything about the patient or about medical science in order to prescribe the treatment. The thinking was a simplistic “energy low, give so-called energy pill”.

A friend of mine who is a lawyer was talking to me about a similar case recently and said, “why isn’t that fraud?” I didn’t have a good answer.

Comments

  1. #1 Pascale
    July 12, 2010

    Just as a reminder, the character of Sherlock Holmes was based on physicians that Doyle encountered during his training and practice. The Columbo analogy is pretty much on the spot.
    The creators of House actually twisted this around, thinking about a genius physician as socially irritating as Sherlock Holmes.
    I know a lot of physicians (especially me) who love to read mysteries. It gives me a rush to solve the case before the characters in the book, much the way I love to make a tricky diagnosis (all time favorite- pyloric stenosis from a metabolic panel over the phone). I suspect nephrologists may fall into this category more than other specialties.
    Of course, appreciating these skills does not protect you from wackaloonacy. Arthur Conan Doyle succumbed to a bunch of woo later in his life, even though he was a trained physician who obviously appreciated traditional medical skills.

  2. #2 symball
    July 12, 2010

    A friend of mine who is a lawyer was talking to me about a similar case recently and said, “why isn’t that fraud?” I didn’t have a good answer.

    I think the elephant in the room is that there is a good answer- it is fraud, but the majority of people would prefer to be defrauded than admit their beliefs are wrong/that they are ignorant of basic science.

    A real shame and certainly in the UK this is improving ever so slowly as more and more of the alt health myths are exposed as scams to the public. (e.g. Wakefield, mrs McKeith etc)

  3. #3 gaiainc
    July 13, 2010

    House drives me completely bonkers. I can’t watch without yelling at the TV because yet again they are doing it wrong. Gah!

    I liked to remind my interns and med students that patients come in with a story and whatever we decide is going on has to fit that story. It all has to make sense. If your gut is telling you someone is sick or something isn’t right, then listen. There may be a reason for that feeling. There also may not, but it’s never bad to try to think through.

  4. #4 Nathan Myers
    July 14, 2010

    My (now) sister in law presented in NYC with a severely painful, tightly swollen lower abdomen. The internist sent her home. Two days later she was taken in an ambulance for emergency surgery for (of course) ectopic pregnancy. The internist did not order a pregnancy test. Was it because he wasn’t “thinking like a doctor”? Or was he strung out on fatigue poisons? I wonder how many other people died unnecessarily on his shift. And why the majority of hospital deaths actually autopsied turn out to be caused by something other than the diagnosis signed by the attending physician.

    Before you excoriate promoters of alternatives to guild medicine, maybe you should work more on getting your own house in order. Where is the most real progress to be made?

  5. #5 Internment
    July 14, 2010

    “The reason an internist wouldn’t just give a magic potion isn’t just because she doesn’t believe in magic”

    Many doctors use SSRIs as their magic potion. Half the country are on SSRIs, even kids under the age of one(!), very often unnecessarily and I haven’t seen too many compelling studies showing they are effective or safe, and new studies are indicating the opposite is true. There is very little science-based evidence of a so-called “biochemical imbalance” in the brain that I can find that would warrant the hundreds of millions of prescriptions that are handed out on that premise. Patients are also at risk of developing serotonin syndrome, a very dangerous, and potentially fatal side effect as well. Mother’s little helper could be considered one of the first magic potions of the modern era couldn’t it? I’d love to see more commentary on this topic here.

  6. #6 PalMD
    July 14, 2010

    “kids under the age of one” are on SSRIs? Really?

    And Nathan, you have read critiques of medicine many times in this space. To say that “doctors make mistakes” does not lead a rational person to conclude, “therefore a bunch of quacks are right.”

  7. #7 Internment
    July 14, 2010

    “kids under the age of one” are on SSRIs? Really?

    Yes, really.

    Here is an article from Official Journal of the American Academy of Pediatrics regarding prescribing SSRIs to children:

    http://pediatrics.aappublications.org/cgi/content/abstract/105/6/e82

    An excerpt:

    “Only 6% of the respondents had ever prescribed an SSRI for a child younger than 6 years of age. In terms of SSRI prescriptions written for depression in the last 6 months, 32% of the physicians had recently prescribed SSRIs for adolescent patients and 6% for patients younger than 12 years of age.”

    As you can see 6% of doctors that responded to the survey have prescribed SSRIs to children under the age of 6. I can’t find the article I read regarding SSRIs for kids under one year at the moment but when I find it again I will post a link. Its not that uncommon as it seems some doctors use them for toddlers that have trouble sleeping.

  8. #8 Nathan Myers
    July 14, 2010

    If fatal pilot mistakes were treated in the cavalier way of physicians’, one might be well advised to consider train travel, or staying home. Nobody suggests that guild physicians’ mistakes imply anything about the merits of the alternatives, except relatively. Many of the quacks are guild physicians, honored colleagues you would not dream of excoriating in public.

    It’s one thing to make mistakes, another not to do anything to reduce the impact of the next one, and a third to actively resist doing any such thing.

    The question remains where improvements can have the greatest effect. Is effort better spent tarring those sought out by people whom guild medicine has failed, or in seeking not to fail them in the first place? There would be little market for quackery if guild medicine took its responsibility more seriously.

  9. #9 PalMD
    July 14, 2010

    Well, that’s a lot of logical fallacies in one comment, Nathan.

    It’s one thing to make mistakes, another not to do anything to reduce the impact of the next one, and a third to actively resist doing any such thing.

    That’s a huge strawman, considering the huge success of the Keystone program and the push by medicare to improve quality of care in hospitals by getting them in the wallet.

    Is effort better spent tarring those sought out by people whom guild medicine has failed, or in seeking not to fail them in the first place?

    That’s called a “false dichotomy”.

    There would be little market for quackery if guild medicine took its responsibility more seriously.

    That is simply a wacky assumption. There has been and always will be a market for quackery, regardless of the successes of medicine. These are relatively independent variables.

  10. #10 Nathan Myers
    July 14, 2010

    Resistance by physicians and hospitals to the Keystone Initiative, and its absurdly late inception, are excellent examples of the failure of guild medicine to put its house in order, but far from the only ones.

    Yes, there are dangerous quacks outside the guild who deserve immediate excoriation. My question is, why only those quacks? Why not guild quacks too? Surely you must encounter many more of them in any given month. Anyone who resists eliminating 36-hour shifts qualifies.

    It is probably true that quacks will always be sought out, especially by hypochondriacs. Homeopaths provide hypochondriacs the unique benefit of provably harmless, 100% placebo-based (not to say entirely ineffective) treatment. For the cost of the materials their prices might be exorbitant, but are less than guild medicine’s.

  11. #11 PalMD
    July 14, 2010

    Resistance by physicians and hospitals to the Keystone Initiative, and its absurdly late inception, are excellent examples of the failure of guild medicine to put its house in order, but far from the only ones.

    That one’s called “moving the goalposts”

  12. #12 Nathan Myers
    July 15, 2010

    And that one’s called “changing the subject”.

  13. #13 WcT
    July 15, 2010

    Guild medicine, incidentally, is one of the most irritating monikers I’ve seen handed out.

    “Yes let me find as clear a way as possible to link a science and evidence based high technology field to the dark ages!”

    Nathan – nothing you’ve said is an argument in FAVOR of anything you’re suggesting is a viable alternative to medicine.

    Yes, there are dangerous quacks outside the guild who deserve immediate excoriation. My question is, why only those quacks? Why not guild quacks too?

    … Pal has filleted licensed MDs and DOs on this site quite regularly.

    The problem you have here is that you’re equating individual physician quacks with the profession of physicians. Not acceptable, especially as a defense of quack medicine.

  14. #14 Nathan Myers
    July 15, 2010

    Who wants to defend quack medicine? By all means let’s have rational medical practice.

    The point is that guild physicians’ pretense of modern scientific rationality remains very thin indeed. The guild maintains heavy trappings of medieval habits and fetishes that interfere with patient care and, especially, with thinning the guild’s ranks of its most dangerously incompetent members. Pal’s pique at out-guilders’ success in taking income rightfully deserved by guild members (who often have done those patients no better for the money) does him no credit.

    Homeopaths are unprincipled hucksters, but there’s no way they can ever visit upon patients more than a tiny fraction of the harm incompetent or otherwise hapless guild members achieve every day, following guild norms to the letter.

  15. #15 j9
    July 15, 2010

    The organization that accredits residency programs referred to by PalMD above, the ACGME, is rightly obsessed with ensuring that newly minted physicians are trained to use evidence-based medicine:

    “Residents must know and apply the basic and clinically supportive sciences appropriate to their discipline:
    –pathophysiology and epidemiology of disease
    –clinical and laboratory findings
    –differential diagnosis and therapeutic options including —preventive measures
    –procedural knowledge

    Residents must critically assess and apply current medical information and scientific evidence to patient care:
    –apply principles of evidence-based medicine (EBM) to patient care (conscientious, explicit and judicious use of current best evidence in making decisions about the care of individuals in the clinical setting).”

    http://www.acgme.org/outcome/e-learn/introduction/medicalKowledge.html

    The profession has come along way from an apprenticeship model. Physician educators must document objective assessments of the competency of their trainees or risk losing the privilege of having training programs. Any “trappings of medieval habits and fetishes that interfere with patient care” run directly counter to the way in which today’s residency programs are structured.

  16. #16 Nathan Myers
    July 15, 2010

    Any “trappings of medieval habits and fetishes that interfere with patient care” run directly counter to the way in which today’s residency programs are structured.

    Really? Tell me about the role of nurses.

  17. #17 Vicki
    July 15, 2010

    I don’t know when, if, or how often it makes sense to prescribe SSRIs for children under six. But saying “here is evidence that children under six get SSRIs” as “evidence” that children under 1 year get them is nonsense. You might as well argue that because n% of doctors have prescribed them to people under 18, that percent of doctors have prescribed them to under-fives. Those are different sets, and different questions.

    Also, “6% have ever prescribed SSRIs to children under the age of six” doesn’t tell us anything about what percentage of children that age have ever been given an SSRI. Maybe there are some doctors that prescribe a lot; at least as likely, that’s one prescription a year, and some minuscule percentage of children that age getting the drug.

  18. #18 Internment
    July 15, 2010

    “But saying “here is evidence that children under six get SSRIs” as “evidence” that children under 1 year get them is nonsense. ”

    No one is making that argument.

    “Also, “6% have ever prescribed SSRIs to children under the age of six” doesn’t tell us anything about what percentage of children that age have ever been given an SSRI.”

    That’s correct, but no one is maintaining that it did. It does say that 6% of all doctors in one survey of physicians and pediatricians have prescribed SSRIs to children under six years. That’s a higher percentage than I would have thought considering prescribing SSRIs for children weren’t FDA approved until recently.

    “Maybe there are some doctors that prescribe a lot; at least as likely, that’s one prescription a year, and some minuscule percentage of children that age getting the drug.”

    SSRIs are generally never prescribed once. Rather, they are typically prescribed for long term use, often in combination with Ritalin. If a doctor is prescibing one SSRI prescription a year, then they are likely doing more harm than good.

  19. #19 gaiainc
    July 16, 2010

    Nathan, what about the role of nurses? And what does the role of nurses have or not have in residency training programs? You are insinuating something and I for one would really like you to spell it out.

    Internment, SSRI’s are not used “often in combination with Ritalin”, at least not in my practice. Also define “long-term”. The data I’ve seen recommends if you are starting someone on an SSRI or SNRI then to use that medication for 6 months before attempting to have the patient stop.

    As for the 6% of family physicians and pediatricians in North Carolina prescribing for the 6 and under crowd, what I’d like to know is how many of those were in rural North Carolina. Child psychiatrists are few and far between, particularly in rural areas. Primary care physicians often end up doing more psychiatry than people think or even that PCP’s want to do because doing otherwise leaves our patients without any psychiatric care at all. Ideal? Heck no. Reality? Uh, yeah.

  20. #20 DLC
    July 17, 2010

    “Guild” Medicine ?
    what, no “allopathic” or “slash poison and burn” meme ?
    Are sick people also afflicted with Dis-Ease ?
    are they members of This Guild ?

    (note: you may have to click through)

  21. #21 James Sweet
    July 19, 2010

    If fatal pilot mistakes were treated in the cavalier way of physicians’, one might be well advised to consider train travel, or staying home.

    Except what alternative health practitioners are pushing isn’t analogous to train travel. It’s analogous to hitching a ride on a griffin.

  22. #22 Nathan Myers
    July 19, 2010

    gaiainc: My comment about the role of nurses was in direct response to the assertion that guild hospitial policies “run directly counter to” medieval habits and fetishes.

    James Sweet: If the alternatives are as bad as you suggest, it makes guild members’ attitudes just that much less defensible.

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