The Elephant In The Room

This past week I had an patient encounter that left me beyond angry at our own medical profession. While evaluating a patient, I inquired as to her last GYN visit. The patient matter of factly told me she had never been to a GYN doctor and that her primary care physician told her she did not require that until she was twenty one years old. I struggled to maintain my usual poker face when hearing such absurd things and asked my patient to repeat it so that I heard her correctly. She again stated her physician’s twenty one year old criteria to start seeing a GYN doctor. I felt that boring headache starting. The one I get when someone is doing something less than intelligent. Figuring she left out that she was sexually active, I asked if she made that clear to her doctor. Not only had she made it clear, but she advised me that she inquired with per PCP about birth control, specifically the IUD and was told she could not have one because she had not had children yet. Now, I know some of your are thinking “well, sometimes patients aren’t reliable historians”. While this is sometimes true, trust me when I say her attention to detail and her reaction to the very treatable diagnosis left no doubt that her doctor had done her wrong. Not only did he give her gross misinformation regarding women’s care and birth control, he barely addressed birth control at all. To say my blood was boiling is an understatement.

The fact is, most of us have encountered these types of practitioners, usually through their patients. Their misdeeds range in severity from unnecessary x-rays that make us raise an eyebrow, to patient’s literally diagnosed with “the Flu” or “Viral Syndrome” then prescribed a Z-pack (seemingly the panacea of choice patients ask for these days) thereby contributing to antibiotic resistance, to more negligent actions such as my example above. There are practitioners providing poor care, some to the level of being potentially, though not immediately, dangerous. Is it age, ignorance, apathy? A discussion of the why is a bit too broad to address here. I’m more interested in what we do about it when we encounter it and from my experience, it seems very little.

With the exception of fitness for duty exams when practitioners are suspected of working under the influence, I can say I’ve rarely seen a provider’s actions addressed. I’ve heard colleagues and co-workers complain to each other about another practitioner’s actions. I’ve heard people laugh it off and I’ve even heard others make excuses for it. I’ve rarely heard anyone called to the carpet for it. There exists an underlying air that it is improper for one practitioner to ever question another practitioner’s actions. That it is a big professional faux pas. I would think there are many other reasons why. Perhaps the proper channels for addressing an issue are too laborious? Some don’t want to get involved at all, some don’t want to get listed a troublemaker, some are afraid to challenge a fellow practitioner / don’t want to deal the with overbearing egos that are so prevalent in medicine, some don’t want to ruin working relationships, and I’m sure there is a whole host of other reasons I’m not aware of.

The fact is, just treating another practitioner’s patient correctly is sometimes not enough. In doing nothing to address the practitioner’s shortcomings we are just as accountable as the practitioner who errors. Perhaps not legally, but ethically. When we do nothing, WE ARE ENABLERS. We are presented with a situation that if addressed, could prevent numerous other medical issues but instead we do nothing and wait for the the issue to worsen, boil over in it’s respective way, or worse still for the patients, just fade away. When we do this, we become responsible for weakening our own medical system as well as doing a disservice to patients.

Please do not read this and think I’m coming off all high and mighty. I’m not. I’m sure I’ve managed some patient’s incorrectly that no one has ever brought to my attention. Hopefully, it has been very minor things. Regardless, I can honestly say I would rather someone bring this to my attention so I do not continue doing the same thing over and over rather than find out 15 years later or worse yet at the end of my career. If we really care about our patients, we have to care enough to routinely ponder if we are doing right by our patients, be able to set ego aside, avoid hubris, and be open to criticism when it is due. If one cannot, then one should really reassess why they continue to practice medicine.


Psychiatric Patients In The ER

Patients with psychiatric emergencies increasingly use the ER for their care. While the ER can initially assess and address acute psychiatric conditions, these patients ultimately need dedicated psychiatric services to finish out that care. Unfortunately, these services have become scarce leading to psychiatric patients to be boarded in ER’s, sometimes for days. During this time, the patients do not get the care they need, utilize resources that could be used for other ER patients, and contribute to ED workplace violence. While many hospitals don’t acknowledge this issue, one state is trying to find a solution…

Your opinion is wanted…

Surgery Clinic

This is a gallbladder. Specifically this is my gallbladder (lovely, isn’t it?) after it was removed laparoscopically this past February and as is routine, sent for pathology. As you can see, there was a lot going on in my gallbladder at the time. While gallbladder disease and surgical treatment is pretty much routine medicine, I thought this was a good example to illustrate that the pathophysiology behind it can be varied in nature.

The simple explanation for what causes gallbladder disease is an over concentration or saturation of a particular substance. What causes the saturation is not always known and there are a couple of substances involved. When it comes to explaining to my patients the concept of concentration, I like to describe to them a very simple example. I use the example of putting sugar into water or iced tea. I remind them that when you put in a little sugar, it dissolves very easily but if you put in too much, the sugar precipitates out and you can see it. In much the same way, this is what happens with gallstones.

  • Pigment stones (1): Pigment stones are composed of Bilirubin, which is the result of the breakdown of red blood cells. Certain conditions cause the liver to make too much bilirubin such as cirrhosis, biliary tract infections, and some blood dyscrasias. Again, the end result is a hyper concentration of, in this case, bilirubin that precipitation out. Pigment stones make up about 20% of gallstones, are black or brown in color, and have smoother (but not completely smooth) edges than their cholesterol counterparts.
  • Cholesterol stones (2): Your liver excretes cholesterol and normally the bile in your gallbladder can dissolve this. However, in some people, the liver excretes more cholesterol than the bile can handle. The cholesterol eventually precipitates out, crystallizes, and eventually forms a stone or stones. These stones are typically yellow in color with jagged edges and account for about 80% of gallstones. Of note, one does not need to have high cholesterol for this to occur.
  • Impaired Emptying: Sometimes, the saturation of cholesterol and/or bilirubin can be due to impaired emptying of the gallbladder and not increased excretion / production from the liver. Impaired emptying can be due to pathology of the smooth muscles and epithelial cells of the gallbladder wall, contractile dyscoordination of the gallbladder wall and cystic duct, cystic duct resistance, and gallbladder polyps near the opening of the cystic duct. The net result is a slower and/or irregular emptying of bile. The longer the bile pools in the gallbladder without moving, the more risk of bilirubin or cholesterol precipitating out. This can lead to stones or gallbladder sludge.
  • Sludge: This is a mixture of particulate solids that have precipitated from bile. Such sediment consists of cholesterol crystals, calcium bilirubinate pigment, and other calcium salts. The precipitates cause the bile to become thicker, more viscous in nature but not yet concentrated enough to form stones. Many patients may be asymptomatic but some may develop biliary colic symptoms as is seen with gallstones.
  • Polyps (present but not seen in the picture): These are growths that arise from the inner wall of the gallbladder. About 95% of polyps are benign in nature with cancer’s being rare. In addition, a majority cause no symptoms and in most cases are monitored with serial ultrasounds to make sure they don’t increase to a size concerning for malignancy. Sometimes, the polyp can arise near the opening of the cystic duct (as in my case) and cause an outflow obstruction leading to sludge and/or stone formation resulting in biliary colic symptoms.