Sunday, July 21, 2013

Asking For Help

Primary care physicians often refer their patients to specialists, say a cardiologist,  for what is simply known as a consultation.  If the doctor or patient is unsatisfied with the consultation, a second consultant might be  brought in for what is called a second opinion.  On rare occasions,  an internist might refer a patient to another internist for advice and consultation.

While the primary doctor usually orchestrates the referral, patients sometimes do it themselves.

A second opinion might be invoked when someone has been advised to have a major operation.  Or, it might be invoked in an unusually complicated case where the primary physician and his/her consultants are out of ideas.

The selection of the doctor to give a second opinion can be fraught with biases.

Consider the following.  If the patient makes the choice, it is often influenced by family and friends who can be easily moved by the celebrity of a consultant, or their personal experience with him/her,  rather than objective performance measurements such as post operative complication rates.  

When the primary doctor picks the consultant, it is often someone in their own group.  This introduces a financial bias where keeping the fees in house might trump inviting a consultant from another organization, who might be more qualified to weigh in on the case.   

If the ordering doctor picks a colleague from their own group, there are at least two more important concerns. The doctor giving the second opinion might be reluctant to disagree with care rendered by someone who is in their personal, clinical and financial orbits.  Additionally,  there is the matter of herd mentality (common in groups and hospitals) where physicians, with social and clinical ties, tend to manage certain problems uniformly, making it less likely that alternative approaches will be considered.

Surprisingly, internists almost never ask internal medicine colleagues for formal consultation.  This is unfortunate since another internist, with a panoramic view of medicine, might be of much greater service in mysterious or complicated cases than a squadron of sub-specialists who tend to look at cases through a single lens. 

My years in medicine have shown me that a consultation or second opinion, centered in knowledge and a wide ranging experience, is often, in tough cases, more valuable than endless testing, which tends to get more and more  incoherent as time goes on. 

Sound judgement is vastly superior to rampant testing, which once unleashed,  tends to generate more smoke than light.

In good hands the second opinion (a third opinion is almost never a good idea) is often clarifying and reassuring for both patients and doctors.  Bias should be kept to a minimum and doctors and patients should work together in picking a consultant.

Saturday, July 6, 2013

On Cleavage

It is almost inevitable that a physician will experience, over a long career, sexual arousal while seeing a patient.

In the vast majority of cases the feelings are rare, brief, without any violation of decency standards.

Many of us learned in our training that we might experience occasional erotic sensations  in the course of our clinical work.  We were assured that it was not abnormal to do so, though we were told we must never  act out any of those feelings.   To Wit, fleeting feelings were normal, prolonged feelings were a call for going on red alert.

Episodes of arousal are  usually biological, without emotional baggage, but they could indicate, presenting as a flirtation or seduction, a significant personality or psychological disorder.  

When the experience is anything more than ephemeral it becomes crucial to determine whether it is the doctor or patient launching Cupid's arrow.   In either case problems may go way beyond the exam room, permeating important relationships.  Psychiatric consultation can be of great benefit in sorting things out.

About twenty years into my practice I felt confident that sexual arousal in the exam room was not one of my problems.

But that changed one day when a new patient with a cough was brought into my office.  

Not only was she curvaceous but she had a full bosom with an an arresting cleavage.  Inchoate feelings of arousal started almost immediately and I found myself in a battle to not look at her chest, hoping my eyes would lock instead on to her eyes,  suggesting sincerity and caring rather than the embarrassing and over heated feelings I was struggling against.

Alas, my defenses crumbled when I examined her.

It was my habit to tell  patients what I was doing as I examined them: now I'm going to look at your throat, now I'm going to listen to your lungs.  Disaster struck when I came to listen to this patient's heart when I heard myself say, quite clearly and audibly - and now I'm going to listen to your breasts.

She gave no signal that she heard me though I felt certain she had.  Since she said nothing I decided not to open a can of worms and,  feeling exposed  and mortified, said nothing.

For the next twenty-two years, when coming to a  heart exam 

I would faithfully say, "and now I'm going to listen to your (pause, pause, pause, get it right) heart.

What did I learn?

I learned that  I was human and not always as in command of my feelings as I had imagined.  Moreover, I learned that patients can be generous in forgiving our frailties.  

Whatever feelings of attraction  I had for the patient were extinguished by the experience and our doctor patient relationship took an ordinary trajectory.

Monday, July 1, 2013


Dear Reader -

I sent out my last post, Televised Snake Oil, on 6/13/13.  I've since learned that some of you never received the post or had to go through some tricky gymnastics to view it.

It's not clear to me why this happened.

I will resend hoping the problem somehow auto corrects.