Medical Discare

We’ve all heard of disinformation. By definition, it’s false information deliberately spread in order to influence public opinion or obscure the truth. I have to work hard to remember medical truths, to retain information around subject matter, to avoid anchoring, expand my differential diagnoses lists and to generally not screw up. I have to think. I have to worry. I have to care. I tell patients if I don’t know how to treat something, that I need a couple of days to figure something out, discuss with a specialist, obtain an econsult, bug an email network of providers, or simply just read, check a dose, review the risk of drug-drug interactions. I have to work at the practice of medicine. I sometimes wonder if that’s why it’s called practice. Even with our best efforts, none of us can get it all right. Information, recommendations, updates change. I’m constantly challenged by this and the seeming paucity of time. But still, I try. I want to practise well and I don’t want to hurt anyone. I want to be able to look back on my career and say without reservation that I did my best; that if a patient, one day long into the future, bumped into one of my kids, my child would be proud of what my patient had to say about me. It’s all about the ego, in the end, let’s just be honest. So, I care. This past month, a local specialist and I, through back and forth biopsies on a patient presenting with episodic painful ulcerations in her mouth and upper chest, zeroed in on my first ever case of pemphigoid. (Yes, I had to look that up.) The weird and wonderfuls are always enticing to try to nail—a race to the finish line often with a gaggle of care providers scratching their heads. It’s the more mundane symptoms that risk tripping us up, prompting us to anchor prematurely, encouraging dangerous complacency. Dizziness is one of my many clinical nemeses. I hate dizziness. The differential is so broad. Sometimes, as a measure of reverse psychology, I try to befriend my enemies. Secretly, without them knowing, I practice in my head saying nice things about them to make them less threatening. I did that with dizziness the other day. I looked it up, took out a beautifully laid out clinical learning tool for it, a group learning module put out by McMaster University, and I slated a small part of my cerebellum (the only real estate left in there) to a sensible three-part breakdown of dizzy’s etiologies. Neurgenic, cardiac and orthostatic. Within a week, as common things are common, a patient came in with this bugger of a condition. His age, 52, and the fact that he struggled just to get around a corner of our hallway, made me grateful for self-learning modules and the luxury of being able to easily re-book some of the phone assessments that day. I was grateful for the extra time I was going to need to figure this out. This is a man who does not misuse the healthcare system. But his symptoms got so bad over the weekend, he went to a walk-in clinic the Saturday before I was scheduled to see him. He was given a bottle full of betahistine and sent home. He tried a few. They made him worse. So he went back on Sunday. He relayed to me that the same doctor was working again and had convinced him it was important to finish the entire bottle before he would see a benefit. Mr. Mondor was visibly unwell on his visit. The issue had been going on for almost two weeks. He couldn’t work. It really wasn’t made especially worse by certain head positions. It was just always bad. He’d had this exact same presentation over a decade ago. It lasted months. Then it just resolved. His review of systems was otherwise unremarkable. His cerebellar testing, though carefully executed, was normal. His gait was not ataxic but gingerly demonstrated when asked. His neurological exam was normal. There was no nystagmus to note on watching his extraocular movements. His Romberg testing was positive as he almost fell over before opening his eyes in a panic. I made an urgent, physician-to-physician request for a head and spine MRI by calling the on-call radiologist who agreed to get the imaging done within days. Our office placed an urgent request, by phone, to a local neurologist. I carefully constructed the man’s story and findings in a consult letter. The part of his story that struck me most was this had happened before. The part of the physical that got me was the Romberg finding. I worried about spinally located MS. Mr. Mondor spent the next two weeks at home without any movement of the medical system on his behalf. My office and I repeatedly got on the phone with him, the imaging department and the neurologist’s office to push for his care. We re-sent faxes. We re-told the story. Mr. Mondor comes from a culture that respects authority. He needed convincing that what he’d been told at the walk-in clinic—finishing an arbitrary number of betahistine pills in order to notice symptom resolution—wasn’t proper and he could stop it if it was making him worse. But I had nothing more to offer, only my promise that we’d attempt to get to the bottom of this. As I write, my promise remains unfulfilled because he’s still waiting for his MRI, and the only neurologist in town still hasn’t called him. I’m the gatekeeper of a wanting system. As Mr. Mondor continues to suffer at home, the walk-in clinic doctor who ‘treated’ him has long forgotten about this man’s predicament. For all he knows, he’s gotten better since he hasn’t come back. A poor or absent exam, a prescription based on dangerous anchoring and an Oscar-winning impassioned ‘finish the pills’ suggestion when the patient came back telling the one-track doctor they weren’t working. This advice because thinking, caring and looking things up just all take too long and don’t pay for too-much-square-footage on a lake. But the next shift of 60 patients in an afternoon does. So while the general public is grappling with a worsening pandemic of mis- and disinformation largely disseminated by its lean on social media, medical discare is a frustratingly common variant of similar, too often delivered by operatives within our ranks. I have fashioned a list of examples of medical discare I reference whenever I feel the need to bang my head against a wall. The thickened, yellow toenail treated with polysporin; A blue puffer given for a case of croup so obvious a dog could have been in the room; An ultrasound ordered for a clinically obvious olecranon bursitis; Azithromycin given for a diagnosis of ‘pneumonia’ in an afebrile patient and no chest x-ray (wrong diagnosis, wrong treatment for said diagnosis); Congruent prescriptions for topical antibiotic AND antihistamine eye drops (let’s just do wrong twice) for a classic case of bilateral viral conjunctivitis (no itching, no watering, no crusting, no exudate, but a low grade fever and symmetric scleral injection); A sixteen-month old infant with a fever responsive to Tylenol and no other symptoms. “We’ll give him antibiotics because this is the way he presented the last time we gave him antibiotics.” OMG; A gentleman one week post-vasectomy performed by me, with minimally tender scrotal swelling. He could have called us, he could have emailed. Instead, like so many, he went to a walk-in. Quick care is misconstrued in this discare dystopia for good care. “It’s probably a hematoma, but we’ll give you antibiotics anyway.”; A lady familiar with our practice hasn’t called since the pandemic started. She’s been going to walk-in clinics. Along with a chest x-ray and a renal ultrasound, she’s been given antibiotics four times for her unilateral back pain. The only urine culture done during her first visit to one of these was negative for growth. She has neurfibromatosis. She has significant scoliosis. She is a cleaner. With her left arm and shoulder, she carries a heavy vacuum up and down four flights of stairs repeatedly five days a week. There is no elevator in the apartment building she tends to. It took me seven minutes to figure this out. Antibiotics don’t treat one’s vocation. But going to a walk-in clinic is quick, right? There’s a reason OHIP doesn’t cover naturopathic medicine, blood chelation, cupping and quack practices that get patients to stand on their heads for dementia prevention and treatment. There’s no evidence that they work. On days I spend half my time explaining to patients why their inappropriate treatment didn’t work, I wish to God the purse that pays us would audit the walk-in clinics for quality care. Wide world of walk-in medicine In the above small sampling of what’s happening out in the wild world of walk-in medicine, the doctor within has checked out, is sitting uselessly somewhere far removed from the once coveted role of healer, possibly lounging in a comfortable backyard next to one of our many blue-green algae-bloomed city-bound lakes of entitlement, audaciously using Family Medicine billing codes for discare-styled practice. Do we just let them continue to do this to medicine? Let them do it because they’re walk-in clinicians, that’s just the way the system is? Complacency is arguably the biggest perpetrator of most societal wayward shifts. Last week, a mother and infant duo came in for a postpartum visit and newborn exam. The infant was born weeks before with a large bilateral cephalhematoma. Interestingly, no instrumentation was required at delivery and the second stage was fairly short. I’d been her caregiver in pregnancy and managed her labour and the birth as well. The infant had a predictably protracted stay for jaundice. A recent visit at a walk-in clinic left this mother understanding that because of the scalp swelling, the infant’s birth weight may not have been accurate, and his current lack of weight gain may be over-exaggerated. Huh? Last time I checked, blood mass and scalp content all were part of a newborn’s anatomy, still part of the birth weight. Maybe it was a slip of the mind? Lord knows, I’ve had my share of saying stupid things to patients. In my intermediate years, I’m developing the skill of correcting myself and apologizing immediately. I respect myself more, find my interactions more fulfilling and honest when I do this. Patients value it too. Nonetheless, some of my burnout stems from this cheapening of medicine, but it’s not always the walk-in clinics. I have a lady, now 50, whom I suggested to go for a screening mammogram this past fall. Days after her milestone birthday, she received the much-feared diagnosis of invasive mammary duct cancer. Our breast cancer care program here in Sudbury is outstanding, responsive and efficient. This is one of the nerve-settling things we can tell patients when we break news like this. They’re in good hands, from the surgeons to the med and rad oncologists to nursing. So, I was a little disappointed when the initial consult report cited she had a history of remote oral contraceptive use but “no other identified risk factors for breast cancer.” This is a woman who’d come in years ago, aggressive and angry at her weight gain and my gentle suggestions for lifestyle changes. She wanted it to be her thyroid. At the time, she was easily 70 pounds over an ideal body weight. She had “no time” to exercise. Wine was a preferred evening ritualized beverage. And none of her three children were breastfed. Anti vaxxers are 420% more likely to believe conspiracy theories. We try, as a profession, to nip the voices of these passionately ill-informed mouthpieces so as not to damage societal strides previously made. But what if our own fears and time-limitations and the moral choices of those erroneously screened into this profession are also perpetuating medical disinformation? Speaking truth to power is monumentally hard and takes guts. Just so, it seems, is speaking truth to patients. Dr. Julie Connolly is a family physician and single mother of five, living and practising in Sudbury, Ont.

Medical Discare

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