Monday, July 31, 2006

What Your Doctor Didn't Learn in School

Several years ago, my mother-in-law gave me a book called "What Your Doctor Didn't Learn in Medical School," which contained all of the usual arrows shot at doctors and hospitals with salvation offered in the form of nutrition (of course, what is not included in the book is how there seems to be an endless supply of these cure-everything diets; the author even has --- I know you'll be shocked -- published two different diet books; which one do we follow?). I'll leave it up to Orac to debunk all of that stuff.

It remains true, however, that there is a whole range of things your doctor didn't learn in medical school --- or residency, for that matter. That is why every physician must see himself/herself as a perpetual student. Many times, the education we get does not come in the form of Continuing Medical Education courses, lectures, or journals --- it's good old-fashioned learnin' on the job! Sort of makes one feel a bit like Jethro Bodine in his quest to be a brain surgeon.

The problem is that when a physician sees patients with a lot of chronic medical problems, sorting out the best way to care for them is not always straightforward, and there are no treatment algorithms available in textbooks for them. As an illustration, here are a few patient scenarios I have seen in the past week:

  • >> 65 year old man with a very symptomatic hernia. Pretty simple? Actually, he smokes 2 packs a day, has had 4 (yes, four) MIs, had a coronary bypass with porcine aortic valve replacement and is therefore chronically anticoagulated....Avoid him like the plague, you say? Operate on him on the day before Armageddon, so the postop complications can be avoided? Hey, the guy has symptoms with his hernia, and although he's not a great surgical risk, we can mitigate many of his risks with appropriate perioperative care (for which Medicare does not reimburse) and get him through this without too much difficulty.
  • >> Morbidly obese (>300 lbs) man with recurrent diverticulitis and a recurrent incisional hernia; somebody in some other state did his initial colon resection and initial (soon to fail) hernia repair. Add a dash of sleep apnea and a pinch of hypertension into the mixture. Hopefully he will not need emergent surgery, as bringing up a stoma in someone with his abdominal girth is an exercise in frustration, and repairing his hernia is an exercise in futility.
  • >> 60 year old lady from Mexico who gets some of her care there and some here; some from regular physicians, some from "alternative" therapy providers. Presents with profound anemia and a sigmoid colon tumor, and a prior history of a hysterectomy for "cancer" in Mexico --- despite the lack of HIPAA laws in Mexico, there are no available records. Undergoes surgery and then chemotherapy......and then disappears to pursue what I don't exactly know. Shows back up two years later with a tumor in the pelvis, seen on studies done in Mexico ---- is this recurrent colon cancer or recurrence of the still-unnamed GYN malignancy? Should it be surgically removed, radiated, or treated with chemotherapy? Going through the options is difficult when dealing with translators.
  • >> Healthy middle-aged man who undergoes a "shave" biopsy of a skin lesion by his primary care physician. It shows melanoma, but because the excision is incomplete, the margins of the lesion are positive for melanoma ---- what is the stage of this tumor? That is a question that will nag both the patient and I, as there is now no longer a way to determine the stage.
  • >> Middle-aged man with oh-my-God worsening pulmonary insufficiency and pretty severe gastroesophageal reflux. It's pretty clear that his reflux is contributing to his lung situation with silent aspiration, but how much improvement will he see if he undergoes an antireflux procedure? 10%? 50%? Zero, with only maintenance of his current level of disease and no improvement? Anybody's guess.
  • >> Older gentleman with such severe COPD that he was turned down for cataract surgery (that's pretty darn bad) who shows up in the ED with a perforated viscus. He needs emergency surgery, but he's not a good candidate for a haircut, much less a laparotomy.

And so it goes. These are the types of patients who continue to teach me, to push me to think long and hard about the best way to care for them. The lessons learned are not always easy for the student or teacher. While there are lots of patients who see me with straightforward problems who have an uncomplicated operation and move on, the other ones are the patients that give me plenty of fodder for thinkin' and learnin'.