The thread where we are physicians (and/or surgeons)

My first post ever was in the medical school thread like 5 years ago when I was going to apply to medical school, and so now I guess it is appropriate to make a new thread that I am now living the glamorous life of medicine.

Also it permits me to put this disclaimer up front: possibly I can answer some questions about medical things, but I am a dude who you have not met before (except for one dude on this board who mostly posts to I Love Games), so any advice about diseases or medicines or whatever is literally just the advice of a random dude from the internet.

can you take a look at my knee

Depends on yr insurance dude

What is this rock-solid Conventional Wisdom about "second opinions"? You can't get a second opinion on EVERYTHING. Why not get a third and fourth?

(ie if my internist and a hematologist both agree on what I have, isn't it incredibly unlikely that another hematologist is going to disagree?)

btw you guys are really rockin' my crisis w/ some of these threads this week...

(also my insurance seems only to cover second SURGICAL opinions, wtf)

Without knowing details (which sound crappy! hematologists usually do not mean something fun is happening) I would guess one of two things:

1) Internist and hematologist both have the same data to work from and both feel compelled to say "most likely it is this thing" but have no definitive way to know for certain, to the point where they feel like maybe giving someone else the same information will lead to a different synthesis. The corpus of medicine is vast and basically infinite and so people who see certain presentations infrequently are going to be less comfortable proceeding than someone who is like "Oh yeah that's nbd". For realsies, Plasmon and I are going to do the exact same thing once I actually get to start doing that thing, but I would wager that fairly frequently we would encounter a diagnostic mystery with our different sets of training and patient experiences and come up with different potential diagnoses.

2) Internist and hematologist both feel compelled to say "most likely it is this thing" but feel that you are unsatisfied and/or concerned enough about their diagnostic opinion that they're basically giving the equivalent of "I dunno I am just one dude, there are smarter dudes than me".

oh, noooo, those 2 docs are not urging me to get a second opinion. Primarily it's a family member with an academic-medical background who gives me 20 questions to ask in every email. When/why should I be skeptical is what I'm asking?

and you are right, nothing fun is happening.

the diagnosis of the hemat should be finalized next week, and I believe he'll be certain. So is that good enough?

You have the right to be skeptical basically for as long as there is not a definitive diagnosis (i.e., until there is tissue saying "it is definitely this thing" or a diagnostic test with 100% accuracy or a trial of therapy has been successful). When you exercise that right is basically a personality thing (some people will continue to demand another answer even when the diagnosis is fully known, because they just don't like the implications of that diagnosis, and some other people will defer everything to the doctor), but basically if you feel OK with the explanations you've been given by the internist and hematologist for why it is this thing, you are not obligated to find the dude who will tell you otherwise. (Note: this dude absolutely will exist, and sometimes it is because he has the right answer, and sometimes it is because he is a crazy person who believes all illness is secondary to toxins or bad thoughts or insufficient prayer or whatevs.)

Involving family people with medical advice is a whole other kettle of fish; we are strongly discouraged (though not officially 100% banned) from providing medical services to family because of the concern for emotional judgments clouding rational thought, because enough studies have shown that people do that.

Most heme diagnoses are rock solid, based on pathology / immunohistochemistry. AFAIK there's not much room for interpretation in most cases. Though path can sometimes be ambiguous or misleading (sampling errors etc). Hematologists tend to have little patience for ambiguity, which is one reason why they choose that field (and typically, hate neurology).

Second opinions are probably most useful when there's more than one thing wrong at the same time (could this funny rash be related to my nerve disease?) or when you have symptoms that are being given a syndromic or non-specific diagnosis (do you agree with the first doctor that my fatigue and achiness are due to a "viral illness"?).

There's an art to enlisting your doctor(s) to engage more thoughtfully with your case. I recommend Jerome Groopman's "How Doctors Think" if you're interested. He suggests several specific open-ended questions designed to trigger your doctor to brainstorm about other possible diagnoses (from memory, it's something like "what other problem could produce symptoms like this?" or "what other structures are nearby the affected area?").

I like that approach better than the patients who openly challenge my judgment. Some of them demand a second opinion before I've even managed to explain the first one. Many bring well-researched but usually ill-founded theories about their own cases. I try to be patient but there's not much time in my clinic to listen to someone cite facts from an website about mycotoxins or chronic Lyme disease.

I dictate all my clinic letters, usually saving the complex/frustrating cases for the end of the day (part of that is good old fashioned procrastination). I read and revise before sending, which is my cue to revisit of my own initiative those Groopman-like questions in order to give a full accounting to the possibilities and uncertainties in the case, even (especially) in the cases when my emotional reaction to the patient's approach is negative / defensive, so I'm giving them the benefit of my own doubts.

Hahaha chronic lyme noooooo

Anyway yeah if there are results coming next week from Heme I assume that basically means they have cells of yours and are running them through whatever tests they are going to run through. And if the results come back and say that there is This Definitive Thing, the only people who would argue with that are the aforementioned quacks. If the results come back equivocal and the doctor says "Well we didn't find anything specifically, but I still think it is this because x-y-z" and you don't quite buy it then basically that'd be the only reasonable reason to go find another guy to look at the exact same information. If the tissue says what it says and your family member is still trying to make you ask a million questions about what else it might be, that's his own pathology talkin'.

Oh, "her" pathology. Definitely her.

I am not relishing the prospect of an open-ended struggle with a serious illness while coping with someone who sees the absence of a crisis as a vacuum to be filled.

However, her questions are skewed more toward treatment -- what about harvesting stem cells, let's see someone at a leading center in Manhattan, etc.

man morbs you are in my thoughts, dude

Treatment stuff can be tricky because there probably will be A Specific Recommended Therapy, but there may also be Exciting Clinical Trials afoot. The best defense (what I would give to a patient's family member if they were pressing me) is that we go with A Specific Recommended Therapy because we have the most data available to say that we have a 40% or 90% or 98% chance of treating that thing, which is higher than anything else anyone has studied,and a 1% or 4% or 15% risk of adverse reactions, which we know about and can generally manage, and are considered either safer than other treatments or justified given the efficacy of the treatment. Exciting Clinical Trials are being undertaken specifically to see if they can meet or exceed the efficacy benchmark without a significant enough risk of adverse events to not make it worth pursuing; if we knew it was the most effective and safest treatment, it would already be A Specific Recommended Therapy.

I swear I am not using this analogy to play to you specifically, but basically the amount of treating with probabilities that goes on in medicine was a thing I always kind of approached like sabermetrics in baseball. There is very, very often no absolutely certain way to make sure you win, but there are enough metrics to help you figure out what gives you the best chance to win in any given situation and hope the probabilities play out in your favor. (I guess if I wanted to start torturing the metaphor I could go on to describe experimental therapies as promising minor leaguers, and sometimes you will get Mike Trout, but sometimes you get like, Travis Snider or Justin Smoak, and sometimes you get like, Matt Bush.)

thx dude

getting an ethics lecture from a neurologist that testified before the Senate about the Schiavo case. Holy buckets, I hadn't fully appreciated what an awful, cynical bit of political theater that was.

That woman's parents were as awful as any I have seen exposing themselves repeatedly in the media.

Ugh, I hate thinking about that case, but I have no doubt that I will end up writing at least one paper about it at some point :(

I was in med school when Bill Frist started his telehealth neurology consultation practice. Wrote an essay about PVS vs MCS for an ethics class.

http://upload.wikimedia.org/wikipedia/en/9/98/Schiavo_catscan.jpg
CT head: Normal 25 year old :: Schiavo

Wikipedia on the autopsy results: The brain itself weighed only 615 g (21.7 oz), only half the weight expected for a female of her age, height, and weight, an effect caused by the loss of a massive number of neurons. Microscopic examination revealed extensive damage to nearly all brain regions, including the cerebral cortex, the thalami, the basal ganglia, the hippocampus, the cerebellum, and the midbrain. The neuropathologic changes in her brain were precisely of the type seen in patients who enter a PVS following cardiac arrest. Throughout the cerebral cortex, the large pyramidal neurons that comprise some 70% of cortical cells – critical to the functioning of the cortex – were completely lost. The pattern of damage to the cortex, with injury tending to worsen from the front of the cortex to the back, was also typical. There was marked damage to important relay circuits deep in the brain (the thalami) – another common pathologic finding in cases of PVS. The damage was, in the words of Thogmartin, "irreversible, and no amount of therapy or treatment would have regenerated the massive loss of neurons."

I'm going to have to work through some personal ethical challenges re: what *I* think is the best course of action and what the family thinks is the best course of action; when these two are irreconcilable, ultimately I need to support them, because the "unit of care" in my world is both the patient and the family unit (which may include non-blood relatives as well). I mean, who am I to tell Schiavo's parents they are (were) wrong? That's not my job. They were not wrong, they just had different values and perspectives, but I can't imagine how I would have handled being the social worker in this case.

Anyhow, I am such a huge huge huge advocate for advance planning and legal support for advance planning; so much heartache and, frankly, medical nonsense can be prevented. Or should be. It's tough stuff.

The problem with the ethics of the Schiavo case is that it got hung up on the metaphysics of consciousness and brain states -- persistent vegetative vs minimally conscious vs coma -- instead of the ethics of decision making. The political shitstorm was a proxy for the usual right-to-life tactic around abortion, where the goal is to recast a discussion about choice into one about the subtle, unknowable gradations between being and non-being -- life and when it begins instead of choices and who should have the power to make them. Exactly how minimally conscious Terri Schiavo was is an interesting neurological question (and religious and philosophical and biological etc), but the debate about what to do in her case shouldn't have depended on that. Her husband was obviously the correct substitute decision maker. Once he said that she wouldn't want to kept alive in that situation, that statement spoke with the force of her own voice, or should have.

...

IME in neurology, living wills often don't match up well with the situations as they play out in real life.

Most people imagine one of two scenarios:
-- progressive fatal disease (say, ALS or advanced cancer), should they be resuscitated? should they go onto a ventilator?
-- sudden nearly fatal catastrophe (stroke, aneurysmal rupture, MVA) in which they're left on life support in ICU, should that be continued indefinitely?

Far more common are cases where the person's life can be extended with fairly simple techniques but where the quality of life in that situation is debatable. These are mainly strokes, but also post-arrest hypoxic-ischemic encephalopathy like the Schiavo case. In many of those situations, ongoing care is not as dramatic or technological as most people imagine when they hear the phrase "life support". It's basic nursing care, a feeding tube running a milkshake 3-4 times per day, and antibiotics for the inevitable pneumonias. Transfer to long term nursing care outside the hospital is quite realistic (and often could be done within a couple of weeks, but is held up by a lack of available beds, not by medical necessity). But many of the patients are left with little or no ability to communicate, no ability to care for themselves, and no realistic hope for significant recovery.

The question always comes up: would the patient want to be kept alive under those circumstances? The particular circumstances are definitely relevant: if someone has said "no life support" in a living will, but wouldn't have thought Shady Pines nursing home with a PGJ is "life support", you can fairly think the question is unanswered. Similarly, if the will says "no hope of recovery" and you have to admit that you're not entirely sure how the case will play out over the long run (I've seen post-stroke patients who recover more than I expected, and also those who do worse), it's fair to say that that might imply that we should prolong the situation long enough to make sure.

When there's a question to be answered, or even just a reasonable doubt about how to apply the living will to this particular situation, you have to ask the patient what s/he wants us to do (or not do). When the patient can't answer (can't understand the question, can't communicate a reasonably complex idea etc), we look for a substitute decision maker.

There are rules at least in Canada for who shall be chosen as an SDM, given multiple potentially competing options (spouse, parents, siblings, kids, etc). I always work to establish consensus with the family, but when consensus is not possible, I follow those rules (and also get a consultation from the clinical ethicist).

After we talk at some length about the diagnosis and prognosis and treatment options, I frame the question for the family something like this:

"I don't want you to tell me what you think should be done here, or what you think is right and wrong, or what you would want to be done if you were him, I want you to tell me what he wants, if he were able to tell me right now. I need to ask you because I can't ask him. Even if he never told you clearly anything that would cover this situation, I want you think of what kind of person he is, and what you think he would want us to do now. I've seen people who say, "he'd want us to do everything possible to keep him going, to give him a chance" and I've seen people who say "he'd never want to be kept alive like this". Either one is fine with me, my job is to do what he wants, but not to do what he doesn't want. It's a strange comparison, but it's a little like buying a birthday present for someone you don't know all that well. You don't want to spoil the surprise but you don't want to come up with the wrong present, so you ask someone who knows him well what kinds of things he likes. You could show me a little snow globe with a rabbit in it and ask me if that would make a good present for my wife, and I'd tell you yeah, she loves that kind of thing, our shelves are full of clever and artsy little statues of animals. Now maybe I like that kind of thing myself or maybe I don't, but even if I don't, I can tell you honestly that she'll love it, even if she's never seen that particular little gift before, because I know her, and I know that's the kind of thing she likes. And that's what I want you to tell me: what kinds of things would he like his doctors to do for him, in this situation. Should we continue doing everything and see how it goes [I've always made it clear to them that full medical care is no guarantee of long-term success] or should we back off and just keep him comfortable without prolonging his life?

That's not quite word for word but I do a version of the "present for my wife" comparison almost every time.

I also make it clear that the underlying disease (the stroke etc) is the ultimate cause of death if withdraw active treatment, using a comparison to a ship taking on water after hitting an iceberg: you can keep the pumps running or turn them off, but if the pumps fail the real reason the boat sinks is because of the hole the iceberg torn in its hull.

Almost every time, the family unanimously agree on one choice or the other. I take dissent among the family as a warning sign, because by my analogy of the SDM role as a gift concierge, they should be able to agree on what the patient would want, assuming they know him well.

I am not lying when I say I am willing to do whatever the patient wants. I steadfastly keep my own opinions out of those conversations.

Plas, I really appreciate the thought and skill you put into your posts, apropos of nothing else.

Yes Plas, thank you for that, lots of good stuff there and lots of things for discussion (after I finish my stats homework). But for starters, what are the "typical" (I realize there is really no typical here) reactions of the family? I don't mean do they decide to withdraw support or not, but does it prompt certain questions or thought processes or discussions or ???

Thanks Trayce, just trying to put my own thoughts in order.

Quincie, the family usually react pretty well to the conversation, seems to help them make a clear decision (in either direction).

The main trick of my framing is to take the decision away from them, in a sense, and give it to the patient. This is the correct view of the SDM in my opinion. The little detour about my wife's animal statue collection is meant to put a folksy low-stakes spin on a similar type of decision-making-by-proxy. I usually roll my eyes and shake my head a bit at that point, so they get the idea that the gift isn't my preference at all but that my love and respect for my wife allows me to accurately gauge what she would want and relay that to someone else.

That's the same flexibility I want them to have: the commonest stumbling block for an SDM IME is the family member who knows that Mom or Grandpa would never want to be kept alive in a nursing home, but is unwilling to say that to us because they fear the repercussions (in their own mind, not necessarily any external pressure) of being the one to make a life-and-death decision. If I can show them that the decision was already made, by the patient in question, years ago in an ongoing fashion by character and personality and other similar stated wishes, it takes the decision away from them just like my gently amused husband character beholding another addition to the collection of clever owl figurines (true story, we have a ceramic moose head sticking out of our living room wall).

In fact, once they admit that Mom would never want to go on like this, but that they are uncomfortable saying so themselves, I can say that I have to take what they just said as evidence of the patient's prior wishes, and can only therefore continue care if someone can convince affirmatively if that's what the patient wants instead.

With the bad strokes, bad prognoses, and older or worse-off (limited functional status), most families decide the patient wouldn't want to have their life extended. It might be a 60-40 or 70-30 split. With milder deficits, younger and healthier patients, most families want to prolong the situation to see how it goes. I've seen exceptions at both ends of the spectrum, including fairly young patients who families (citing patient's prior wishes) strongly object to tube-feeding despite a decent chance of long-term survival in a nursing home, and old and severely demented patients with terrible prognoses whose families (citing patient's prior wishes) want everything done for them, including being full code in hospital. It takes all kinds.

For each family going through the process, it's the first time, they need some teaching and instruction. I always stress that our decisions are open to review and they're welcome to contact me (through the nurses or residents) to revisit the question. Meanwhile I've been having conversations like this several times a month for over 10 years, going back to med school. The initial explanation is pretty much shtick for me at this point, well rehearsed. Sometimes the conversation takes an unusual turn after that, depends on the family and the situation.

Wait, it's a rhino head in the living room, not a moose. Something like this:

http://static.achica.com/Media/Product/Main/0/0/008170_1.jpg

This BBC programme is just extraordinary, humbling stuff

what are u on about

BBC documentary cameras during surgery at major Birmingham hospital, hour long covers two patients back story, prep, surgeons approach, the operation (in full horrific but inspiring detail), outcome and aftermath.

They do terrible things to ppl I wonder do they tell them the half of it

how yall doing

do we have any nurses on ILX? medical assistants? PAs/NPs? pharmacists? other hospital or health care workers? curious how everyone else's experience has been

I did my first social work school internship in the ICU of a major urban hospital and good god I can't imagine what it is like there now.

Volunteered for my city's medical reserve corps (they need SW for screening and intakes and general SW stuff) but as of yet have not been called in.

What's your sitch?

quincie I did a double take even tho I know what your training is in bc I usually see “sw” standing for something else

I’m an MD, a diagnostic radiologist, after a 30 year career I retired recently. I’ve renewed my license as ‘voluntary’, which in california means my continuing medical education is up to date and I can practice but I cannot accept compensation. It seems like a good time to volunteer.

interesting, dan. keep yourself safe first. we on the other end of the career spectrum would welcome you in the fight against this thing *fist bump*

I'm a first year IM resident, and apart from an overnight I did earlier in the week I have this week off, so I'm using that to rest up and read as much as I can. my friends from medical school who are training in NYC have given me their accounts and it's painful to imagine experiencing: like a particularly stressful night in the ICU, but every. day. and here in boston we're at least a couple of weeks behind, which on the one hand is relieving but on the other hand coincides with my ER rotation...

quincie, sorry I forgot to shout out the social workers! you guys fucking rule. have you been doing any work over the phone? last week is my usual clinic week, and I did most of my visits by phone. I also had an appointment with my own therapist over the phone. serious shout out to people whose clinical work involves a lot of mental health care

wish you the best k3vin, I did an IM internship before my radiology residency and it was the most stressful year of my life, I can’t imagine going through that now

Ended up in an esoteric subsubspecialty where I already was working from home, which on a purely selfish level has been extremely nice (the volume of work I do is down enough to make my days a bit shorter and often easier, but not down enough to where I'm gonna get furloughed or laid off, at least not yet) but does make you feel insanely useless sometimes. I can be a pretty OK hospitalist (neurohospitalist, but still) at this point, but I went from being a mostly in-hospital person during training to a 25% hospital person my first year or so out of training, to now doing occasional weekends, mostly to make sure I don't end up forgetting how to do everything. I might end up getting surged back into the hospital but the recent numbers from my area aren't that bad so we might just not get surged on this wave. (Who even knows what's going to happen once the stay-at-home orders get lifted, for all I know this may not be the worst wave out here).

Also strong agree that intern year was traumatic, even pre-pandemic. thoughts and prayers to you

intern year was miserable. friend of mine is starting his in july, in california, i cannot imagine

i'm doing primarily outpt psychiatry now, after two years of entirely inpt consultation. we've been doing telephone visits for the last three weeks or so, and i'm currently working from home because i had a covid r/o test last week (just resulted negative). our hospital group is finding out today (or so i've been tipped) that we're taking temporary 10-15% pay cuts across the board because of the collapse in elective procedures and clinic no-shows, which is honestly fine if it means we stay afloat and i still have a job

funnily enough, our clinic (behavioral health) typically posts a lot of no-shows but since we've moved to phone visits (video not yet possible) the rate has gone down. ppl that would have otherwise forgotten/avoided/been too disorganized to make their appointment are much more apt to "show up" if you just give a ring ten minutes ahead of time, turns out

thus far NM is a few weeks behind the curve in terms of covid cases and thus far our resources have not yet been strained. which is a huge relief because northern new mexico isn't exactly minneapolis or boston, let's just say

also if i can do one wisdom, kev: for the love of god learn to use dragon if it's available to you and if you haven't already. i foolishly thought that my mavis beacon typing skills meant it wasn't necessary but holy cow in retrospect i think, over the course of residency/fellowship, i could've gotten back like 1000+ hours of my life if i'd just dictated instead

wishing you well too gbx!

I couldn’t have done my job if not for dragon speech software

I don’t think we have the dragon thingies, but EPIC is a lot better than the other EMRs I’ve used

in the midst of an ED stint, and I have to say one of the worst things about this shit is having to swab people. as if dyspnea weren’t bad enough, let me stick a 6 inch q-tip down both your nostrils