The barbarous craft

One of the reasons I like my particular branch of medicine is that I occasionally get to do things which are 100% the right thing to do. If someone’s ear is full of wax, it’s never a mistake to remove it. Same goes for a kid with a bead up her nose. There are times, happily many times, when I know exactly what to do and then I do it and then I have a happy patient (or parent).

But like any doc, there are times when I don’t know what’s going on, when my best guess is probably no more accurate than a Magic Eight Ball, when my only asset is that semi-mystical laying-on-of-hands thing. When success depends upon my shine as a huckster, a salesman hawking something he really doesn’t believe in but knows that if his pitch is good, he’ll still have a happy client.

There are, for example, patients who have so many varied aches and pains and dysfunctions that I have to wonder if I’m either (A) missing something that only Dr. House could figure out (I know — it’s palladium poisoning!) or (B) dealing with a patient with a conversion disorder. That’s when the patient’s mental/emotional ailments “convert” into physical problems. Not terribly common, I’m afraid. I mean, I can remember one patient who developed a ball in the throat sensation the same week her husband died, and pointing out that “coincidence” was enough to cure her problem. But I have to think that conversion disorders are extremely uncommon.

Which leaves me in the dark, of course. If I’m not bright enough to apply Occam’s Razor and come up with the one brilliant diagnosis that knits it all together, and if I’m not willing to consider every stumper a psychological issue clad in physical symptoms, then I’m forced to admit ignorance. I do this most of the time, but I realize I’m not making anyone happy, least of all my patient. Some people want honesty. Most don’t.

Fortunately, no one else has been able to figure out my patient, either, and most of my predecessors haven’t even tried. So the first thing I discovered long ago is that trying matters. The mere fact that a doctor cares enough to want to figure things out is, pathetically, therapeutic. (Pathetically because it’s sad how often people are blown off by their other doctors.) And that’s step one of Good Hucksterism Good Doctoring. Step two is Doing Something. Doesn’t always have to be a prescription, and in fact I had one angry patient today who said his doctor “admitted he prescribed antibiotics for his patients because it made them feel better to get a prescription.” (Step three: the wizard never peeks out from behind the curtain. Never.)

Doing Something could mean framing the problem to make the patient realize that it truly is multifactorial. Your weight problem contributes to your sleep apnea, which exacerbates your nocturnal reflux (as does your smoking, by the way), which is giving you that cough (and the smoking doesn’t help your cough much either), and if you got a little more exercise you’d lose some weight and your apnea might improve and your fatigue would lessen etc. etc. Now, suddenly, all these disparate symptoms start making sense. It’s not so much that your body is falling apart and it’s not age. It’s your damned lifestyle.

Interestingly, my theory — the way I’ve framed the problem — need not be correct. It helps if I’m right, but it’s not essential. Because sometimes what people want is not so much relief of their symptoms as relief from worry. If I can exclude life-threatening illness (and yes, I can do that most of the time with imperfect certitude . . . but nothing is perfect . . .) and I can help them understand what’s going on, more often than not they’ll say they can live with their symptoms.

But getting back to the stumpers: it’s true, sometimes I play the Magic Eight Ball*. And if I make my pitch with verve and style, and if I make them think someone cares, and if I can sell them on the wisdom of this or that treatment strategy, well, the patient might get better. Often does.

And I’ll never know if I was right, or merely skilled at slinging the bull.

D.

*Mind you, I’m not so proud that I won’t send such patients to other specialists, or to other ENTs for a second opinion within the specialty. But what do I do about the patients who have seen all the other specialists and who are coming to ME for a second, third, fourth opinion? Do I tell them, “I’m as dense as everyone else you have seen,” or do I try to help, even if helping carries with it a dollop of dishonesty?

CME

Why is it that I complain about the heat constantly, but love to have the shower as hot as I can stand it?

Perhaps “a dry heat” isn’t all it’s cracked up to be.

We had a Continuing Medical Education activity tonight, a lecture on Valley Fever. Here in Kern County, we have the distinction of being a Valley Fever hot spot. It’s endemic throughout the Southwest, but here it’s big. We are the Valley in Valley Fever, after all.

What I learned tonight:

There’s no vaccine. Not even a glimmer of one on the horizon.

If you get it in your meninges (the tissue enclosing the brain), you’ve got it for life, and you’re in for a lifetime of treatment. But at least there is treatment. In the old days, most of these folks would die in the first year.

You can’t get it by working outside in your garden. Treated soil — soil that’s been watered, fertilized, etc. — does not harbor the fungus. So you’d think you’re safe as long as you don’t hang out in construction sites or go dirt-biking in the wilderness, right? Wrong. This shit can travel, wind-borne, for 35 miles or more.

You’re better off with a bad case of tuberculosis than with a bad case of Valley Fever.

As bad as the situation is with antimicrobials, what with the constant emergence of resistant organisms, the situation with antifungals is far worse. Our main fungicidal (fungus-killing) is Amphotericin B, a drug that punches holes in fungal cell membranes, allowing leakage of electrolytes and eventual death of the fungal cell. Unfortunately, it does the same thing to animal cells, hence the high toxicity of Amphotericin (AKA amphoterrible). Other anti-fungals are fungistatic, meaning they halt growth but don’t kill the organism.

Well, that’s all I can think of right now. I’m sure I learned more 🙂

D.

Hands-off medicine

Bend over, I need to check your doody.

My Sis was bemoaning the fact that all her new internist did was listen to her heart, look in her ears, and check her throat. Frankly, I’m surprised she did that much. My last three docs (always changing docs because we’re always MOVING, go figure) reviewed my meds, checked my BP, and asked what drugs I needed refilled. End of story. Do you think my wife, who actually has some trouble, gets a closer look? Not really. They like to tap out her reflexes.

Notwithstanding the countless texts written in the 19th and 20th centuries predicated on the value of physical diagnosis (Zachary Cope’s Early Diagnosis of the Acute Abdomen comes to mind, for one), one could make an argument that an internist’s job nowadays breaks down to algorithms crunching raw data: patient’s age? sex? family history? smoker y/n? drinker y/n? list of medications? and so forth. Turned fifty, let me send you for a colonoscopy. Eighteen months since your last mammogram, ooh, you’re overdue for another. Same goes for that pap smear. Not taking baby aspirin, well, take a baby aspirin.

I’m not an internist. I’m a surgeon. I practice physical examination and physical diagnosis with each and every patient I see. I’d be lost without my hands and eyes. Since I’m not an internist, you could argue I have no business criticizing them. And I don’t, and I’m not. What I want is to draw attention to the perception that internists are data crunchers who no longer practice the laying on of hands.

If we notice it, others will, too. Health care administrators, health insurance executives, health care policy wonks and politicians will notice. And what happens when these folks decide that the internist’s job can be replaced by a fairly unsophisticated computer program?

I do think that internists, most of them, bring a lot more to the exam table than would a computer program. I suspect they could argue very well for the necessity of their existence. But one thing I’ve learned in medicine these past 25 years: we doctors have little control over our own destinies. Bureaucrats have done a tidy job altering our professional lives to suit their fancies.

So doesn’t it seem logical that internists should strive to win the perception war before someone without an MD or DO after his name tries to debate them out of existence?

D.