• Bad Specialist Medicine: A Guide for Beginners

    My objective is to teach you how to practice your medical specialty in the stupidest way possible. The most effective way of teaching is the case method. So let’s consider a patient. Call her Susan.

    Susan suddenly felt faint while walking through the lobby of her workplace. She sat down on a couch, then vomited. The vomit included perhaps 3/4s of a liter of blood. The paramedics brought Susan to an emergency department. She reported a history of chronic belly pain and that she had been taking ibuprofen for arthritis.

    A gastroenterologist was called in to determine the cause of these events. He performed an endoscopy. He discovered a large duodenal ulcer (that is, it was in the upper part of the small intestine), which he cauterized. He ordered a proton pump inhibitor (PPI) and a blood culture to check for heliobacter pylori infection.

    The doctor then had an opportunity to be stupid and capitalized on it. He told the patient that the ulcer had perforated a vein, leading to loss of blood. The mass of blood entering her gut made her vomit. All of which is true and all of which he should have told her. The problem — the first problem, actually — was the timing.

    Susan had been given midazolam to sedate her, so that the doctor could pass the scope down her throat. Even if the patient remains awake during the procedure, she’s likely to remember nothing — a good thing. But it also means that a patient who has just woken up from an endoscopy will, similarly, not remember what she’s been told. Hence you wait until the patient has recovered from the sedation before you convey important information. When a family member visited Susan a half hour after the procedure, she had no memory of the post-procedure conversation. Of course, the doctor hadn’t bothered to give the results to the nursing staff either.

    Repeated calls to the gastroenterology service brought the doctor back (the next day) to repeat the report of the results. Except that — here’s the second problem — he didn’t tell the patient all that he had found.

    Susan was discharged from the hospital, was prescribed more PPIs, and was told to stop taking ibuprofen. She turned out not to have a heliobacter pylori infection, which suggested that it had been the ibuprofen that had caused the ulcer. Nevertheless, her belly pains continued. Not wanting to be thought of as a complainer, she avoided seeking medical attention. Weeks later, the pain was growing worse. She went to her primary care provider and learned, for the first time, what else the gastroenterologist had seen.

    In his report, the doctor described not just the large ulcer that had perforated the vein, but also sores throughout the upper part of her small intestine. This could mean a number of things, none of them good, and it was information of considerable value to the patient. She would never have learned of this more extensive disease if, as patients sometimes do, she had not returned to her primary care provider.

    One can only speculate why this doctor was so stupid. My guess is that he understood his job as (a) discovering what had caused Susan to suddenly vomit so much blood and (b) doing what was needed to halt that bleeding. He did those jobs superbly. He hadn’t understood his job as — how to say it? Oh, I know — taking care of the patient.

    So, summing up, what are the two things you need to do to practice your specialty in the stupidest way possible? First, you should define your job as dealing only with the narrowly delimited problems that require your awesome skills. Second, whenever you can, avoid the open-ended tasks of caring for the patient, such as talking to her and taking responsibility to ensure she understands her illness. That’s a job for a primary care doctor. Or perhaps a nurse.

    @Bill_Gardner

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