Scary Patients

My Quora Answer to:
As a doctor, have you ever been in danger from your patient?

Yes. Just one.

I was working in the ER at Waupun Hospital when the EMT's brought in a patient from a local prison. Waupun, Wisconsin is home to three prisons and close to a few others. The local economy thrives off of kidnapping and caging people.

Before I entered the bay, my nurse pulled me aside and warned me not to get close to the patient. He explained that the prisoner had permanently disabled a nurse at another hospital by attacking her physically during her intake exam. It was the only time in my career when I saw and treated a patient without doing a physical exam.

NB: I always did physical exams even with my psych patients. In addition, a physician can learn a lot just by observation. In medspeech, we document this with “A, A, Ox3, in NAD” which is shorthand for Awake, Alert, Oriented to person, place, and time, and in No Acute Distress. With ambulatory patients we also observe gait and lower body strength but the prisoner was shackled to a gurney and I was NOT going to unchain him just to observe his gait. That's how scared I was.

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Bedside Manners

Answer to Why do doctors often have poor bedside manners, and what as a patient could I do to make their say better?

Because physicians are humans.

You will find the arrogant, rude, inconsiderate, and uncompassionate among us just as in society at large.

However, you will also find the sensitive, caring, loving, and compassionate among us, too. Just like society at large.

I'm not sure about others, but we learned about good bedside manners in med school. My teachers were professors in the Psychiatry Department at the then North Chicago VA. The training was excellent, and I internalized a lot of it. Among other components, we learned which words and phrases not to say, what body language puts patients at ease, and even to change the rate of speech under different conditions. Good stuff.

As for your second question, what can YOU do? Plenty, starting with just letting your doc know how you feel. Try not to make it confrontational. Just simple and honest. This may change how they interact with you, but I doubt you'll make much of a change in their character.

If that doesn't work, write a letter and mail it to the clinic manager/hospital CEO. Snail mail makes a bigger impact than email. That should make some difference. Especially if many others complain.

Then there's always Yelp, or Google Reviews, and so on. Permit me to give you a personal anecdote. I had to change family docs at the end of last year because my insurance changed. My first visit with my new one was February 2nd of this year. The encounter was humiliating.

Last Fall I fell into a manic episode that lasted 6 weeks. During that time I apparently drank. Which is not what I normally do. At one point I fell and kissed the concrete. I was taken by ambulance to an ER where, of course they obtained a blood alcohol level which was just above the legal intoxication level.

Anyway, the new doc walks into the room, introduces himself, then says, “so you are an alcoholic.” Then proceeds to grill me about drinking and abusing drugs, which I have never done. No physical exam, no history taking, nada. On the way out, he says, “see you in 6 months.”

I posted a negative review on Yelp. Someone in the hospital system must have read it and talked to him because at my follow-up visit August 2nd (just last Friday), he was as nice and attentive as can be!

If none of this helps, change docs. It's your right. Good luck.

http://bit.ly/2ML3mXI

Antibiotics and Viral Illnesses

Quora Answer to
Have you ever had a patient refuse to believe the diagnosis you gave them?

Yes. But it was through his wife, a Registered Nurse who should have known better.

I was working in an Immediate Care and Occupational Medicine clinic in Burlington, Wisconsin one night during an influenza outbreak. A very sick man came in with typical influenza symptoms: fever, chills, body aches, non-productive cough, sore throat, and nasal congestion/clear nasal discharge. On presentation, he was a well-nourished, poorly hydrated, middle aged White male, ill-appearing, in mild distress. Eyes were white, sclera non-injected, extraocular muscles intact. Pupils equally round and reactive to light and accommodation.

Neck was supple with a full range of motion. He had tender bilateral submandibular lymph nodes (no anterior cervical lymphadenopathy which is important). Nasal mucous membranes were injected (red) and hyperemic (congested) bilaterally with a clear discharge. Oral mucous membranes were dry, his pharynx was injected, but without exudate (pus).

He had a cough and auscultation of his lungs revealed bilateral wheezing but no rales, crackles, or rhonchi. There was good air movement despite the wheezes.

Vital Signs: Heart rate regular at 98 beats per minute; temperature 100.5 degrees F; respiratory rate 15/minute; and oxygen saturation 96%.

The rest of the exam was unremarkable.

Based on my findings and the fact that there was a statewide outbreak, I felt he had influenza, a viral illness. He was also dehydrated so we started an IV to give him fluids. I added dexamethasone (a corticosteroid) for two reasons: to decrease or eliminate the wheezing, and help alleviate his body aches. I added IV Toradol for the same reason. It also brought down his temperature, which really wasn't alarmingly high.

He responded well to treatment. While we were rehydrating him, his wife tracked me down and wanted to know why I didn't order a strep test and chest x-ray. I explained again why I thought he had a viral infection. She wouldn't buy it and demanded I order them. Both are relatively cheap so I did, mainly to placate her. Both came back negative: no strep pharyngitis; no pneumonia.

She wouldn't buy that either, explaining to me that the rapid strep assay was “only 90% accurate.” More precisely, I explained that it is both highly specific and sensitive, with a predictive value (at that time) of almost 95%. Besides, there is also a clinical algorithm that has a negative predictive value of almost 85%. Basically, in the presence of a cough, the abscence of tonsillar exudate, and no anterior cervical lymph nodes, it is highly likely NOT strep. I explained that to his wife, too. Then I asked her what she thought he had. No kidding, this was her answer: “acute sinusitis, strep throat, and pneumonia.” So of course he needed antibiotics. In fact, she demanded them.

First of all, treating a viral infection with antibiotics is poor medicine. Secondly, and if you've read some of my previous Answers you should understand, what she thought were the causes of his illness violates Occam's Razor. As it pertains to medicine, it means that the preferred diagnosis is the ONE that most precisely explains most if not all, of the signs, symptoms, and test results.

Despite accomadating her about the RSA and chest x-ray, I refused to treat him with antibiotics. Soooo… she called the clinic administrator and complained. The administrator drove all the way from Janesville, WI to Burlington to “please, please give him an antibiotic.” I explained to her why I felt that was not medically necessary. She then went to the other doc working that night and he was more than happy to prescribe one. For a patient he didn't even see.

Later, I asked him why and he said that he always prescribed an antibiotic for every patient who presents with a sore throat. Why? His reasoning was that he would rather prescribe incorrectly than miss a strep pharyngitis. I call that “CYA Medicine.”

Remember that clinic because it's central to another much more tragic story of mine.

https://www.quora.com/Have-you-ever-had-a-patient-refuse-to-believe-the-diagnosis-you-gave-them/answer/Michael-Mangold-4?ch=99&share=1154ff98&srid=TCJzj