Also, her lack of curiosity also revealed her ageism, willing to accept these symptoms just because her patient was older instead of questioning him about his baseline state.
Hubs is 83. DM II well controlled. S/P CABG 2002. Very smart but a bit scattered engineer (like many). He works out, walks the dog, reads constantly, wins at poker. I always tell them that stuff so they know he’s a good 83. Had chest pain/?belly?symptoms so went to ER. Resident, long-term cardio, long-term internists and I all thought it was GI, but they kept him anyway b/c he’s a pretty good 83 and we’re worried little. Retired RN. Always tell them.
Many doctors have failed art class when it comes to listening and the laying on of hands. They order labs and imaging before even seeing patients and examining, which wastes money and time and can be dangerous. They don't provide adequate histories to the doctors who interpret imaging because they don't know the history or they don't like elaborating. They duplicate tests because they skim charts to see what's already been done. Sometimes, they withhold histories to see if some specialist can figure it out on their own. They pooh-pooh the suggestions of their subordinates who might propose an alternative to their diagnosis or treatment plan. They don't answer questions adequately or in a way that people can understand. They are not willing to admit when they're wrong or when they forget to address something. They propose solutions that aren't realistic for their patient or don't follow up on how those solutions are going. They also don't supervise their PA's, who sometimes have no clue and also do things that aren't necessary or could be harmful. I've seen it all. I think you're on your own these days in the medical arena. I give thanks when I actually encounter a good doctor, one who listens and has good sense. They seem to be rarer these days.
I've done the first one. If someone calls with a cough and fever, I might say, "Tell them to get a chest xray on the way in so we have that" as an attempt to make everything more efficient. Sometimes it's not helpful. I'm especially likely to do that if the xray will be closed when after their appointment. I do try to make it clear when I do that and why. If a patient said, "I want you to listen to my lungs first," I'd be fine with that.
Pooh-poohing the suggestion of a subordinate is something that is 100% guaranteed to get a doc in trouble. If a nurse feels they have something that is important enough to go against all of their training that tells them to do what the doctor says, I want to hear it and ignore it at my own (and the patient's) peril. I cannot stress this point strongly enough.
When I was a younger doc, I felt terrible about admitting mistakes and was probably defensive about everything. Now that I'm older, I readily admit: "Sorry; I got distracted and forgot to send your medication in." We were taught in med school to always admit and apologize for mistakes and I do and have been amazed at the grace my patients give me, but especially if it's a more serious mistake, it requires a lot of courage.
Proposing non-realistic solutions! Don't get me started on that one! hooboy! sometimes people will come out of the hospital with a discharge plan and I'll wonder if the discharging doc knows anything about who the patient is besides "a 79 year old male with urosepsis."
Retired Ob/Gyn-my husband would not have been so nice and might have made things very bad for the PA. He thinks because he is married to an MD he might as well be an MD himself.
I find there is very little relationship building left in medicine, especially at the urgent care level. Reminded me of my physician father who practiced in rural Maine and would be so appalled at our current system.
I'm not sure I could have stayed incognito. Yet I applaud your ability for doing so. At a certain point, when someone is as incurious as the PA was in your story, to raise your voice to try to make yourself heard is pointless because the level of incuriosity means they won't hear you anyway, and you have wasted your breath and energy. In this case, you got what you wanted, a chest x-ray, and it came back clear. Sometimes we don't need a name to put to our condition as we just need to know and trust that the human body can heal itself if you provide it the right circumstances and nourishment.
I read my hubs your line "When Mister I-don’t-need-no-doctor asks about going to the clinic, you know it’s bad." and he chucked. He said that if I ever asked about going to a clinic he would know it's serious, drop everything, and put on his advocate voice.
Yes, really all I wanted was prednisone and a chest xray and not to feel like I was supposed to be my husband’s doctor. She was able to give me those things (barely, but still).
I felt that I had nothing to offer the poor PA, really. If I worked with her, over time, I might be able to help her see why the human tableau in front of us is interesting and entertaining instead of just something that is standing in between her and going home at the end of the day, but as a patient spouse, I didn’t see that I could do anything helpful for her.
Enjoyed reading your article Mary- thank you 🙏 I love how you went incognito so you could experience the 'other side' of care.
Unfortunately, it seems like too many young doctors are already jaded before they even fully get into their careers.
We had many hair raising experiences in the ER with residents and my autistic disabled son,until they finally put a Careplan in place. Now it's mostly smooth sailing from the time EMS picks him up to being settled in the ER. Of course I realize that they only do this for 'frequent flyers'.
I am constantly shocked at how incurious people have become in general - my kids and I talk about their challenges with their teachers not asking questions or encouraging children or teenagers to think but rather just be passive recipients of information. Made worse because so much information is provided without context or shaping, there's little nuance. I am so sad that it has become this prevalent in medicine too
I think a vicious cycle gets set up where we are trying to see more and more patients and noticing less and less about who these patients actually are or what diseases have them and then the people are less interesting to us and so we are comfortable rushing through their visit ever faster and the faster we go, the less interesting the patients are! This is one of the things I’m trying to point out to the world.
Patients (and doctors) and diseases are charming and interesting and have quirks and crannies that are worth knowing, for the beauty of knowing them, for their own intrinsic interest, *and* for the usefulness of knowing them.
Sigh, my grandson is probably going to go to medical school. I think I should have him read your blog.
I have no one medical in my family, and I was/always will be a nurse. I know how much paid attention to what was going on with my dad. Oh dear, who will advocate for me? My son does have a Family Practitioner/pediatrician as one of his best friends, so I am going to tell him if we get sick (we are 77 and 79), to please not simply rely on "the Dr. knows best." and to consult with his friend for us. My husband will be worthless if I am sick:) He's lucky he has me is all I can say!
Thank you for the nice compliment! I would love for people in training to read it; that's part of the point!
It is so important to talk with your loved ones who will be your decision makers about what your wishes are! My planned articles keep getting pushed out of the way because more pressing articles come forward, and this has perhaps just pushed to the front.
Wow. Had an ear infection which cleared up with antibiotics so went to visit a friend who had a terrible sinus infection. A couple of days later, I had a horrible headache, a bit of fever. Slept all day and headed back home the next day (2 day trip). Once home, I worked out and by the next day, I had the worse cough and couldn’t believe the amount of snot. Bad cough for a few weeks. Never went back to the doctor but I think I may have had whooping cough based on this post. It was horrible. I see my provider next week and I will ask them what vaccines I need.
You are a better person than I am. I tried to go incognito to the urgent care a few weeks ago. After 2 and ½ hours of waiting in a waiting room with only a few people, then a med tech incorrectly taking my blood pressure, followed by a dismissive, distracted NP doing a non-exam diagnosis, I blew my cover. I hope to not need “urgent care” again because what I experienced was neither urgently conducted nor careful care.
That sounds awful! I hope you are getting better. It definitely helped that really all I wanted for my husband was prednisone and a chest xray. If she had refused those, it would have been a very different article.
Your story made me smile. I have an Extensivist clinic where I stabilize patients outpatient after discharge. One of my mantras is NEVER go to Urgent Care without consulting me first. Usually, I squeeze them in if it’s a weekday. If it is in the weekend and it’s not a bladder infection, I direct them to ER.
I am sure some good urgent care mid levels and docs exist.. but the pressure to triage 10 patients an hour makes it difficult.
And what is this trend of listening to hearts and lungs over clothing? Or taking blood pressure over sweaters ?!
Are healthcare workers supposed to take blood pressure on a bare arm and listen to hearts and lungs on bare skin? What a novel concept! I routinely get my blood pressure checked over my sweatshirt and my heart and lungs checked over my clothes. I guess if the readings are more serious, I should say something?
I have more than once had my GP note that I had surprisingly high blood pressure on a visit, only to tell her that the nurse took it through my clothing, and...surprise, it always drops back to normal when I roll up my sleeve.
And, to be completely correct, rolling up your sleeve can affect the measurement too if it's tight. I have people pull their arm out of the shirt. It stretches the neckline out a little bit briefly, but only a few patients complain about that. Also, you are supposed to be at rest for at least five and, ideally, more minutes. Ha! Ain't no way that can happen in a clinic! If I don't like the initial number, I recheck at the end of the visit. People's blood pressure often goes down at the end of the visit, I think, because they can relax that I'm not going to say something terrible. I think even when people are coming in for a simple follow up, they worry that I'm going to find something bad.
I remember when I was in training in Minnesota, I would see immigrant patients from Africa frequently. I would say, "I'm going to lift your shirt" and I would and there would be another shirt underneath. "I'm going to lift your undershirt" and I would and this would go on for four or five shirts because Minnesota was so shockingly cold for them. In the summer!
But, yes, if it is important that they listen to your heart or lungs, you can say, "Oh, I don't mind pulling my shirt out for you." and that is a non-confrontational way of saying, "I would like a minimal accurate exam"
When they approach you with the blood pressure cuff, you can already be pulling your arm out of the sleeve. Don't push the sleeve up bc that can be constricting too. Wear stuff with a stretchy neck and have one arm in and one arm out. With your feet flat on the floor, and your back supported. And being silent. And not having to pee. And after having sat still for at least five minutes.
The simple logistics of the clnic make it almost impossible to do a blood pressure correctly in a clinic.
In terms of tangibles: CXR, prednisone, the outcome would have been the same. I would have understood my patient and his wife better, I would have done a better exam, I *think* my patient would have felt connected with (never underestimate the healing value of the healer's presence and attention), and would have had more instructions for when to call back, call his PCP, what else he might get at the pharmacy, etc.
Lol. It's always a dillema to divulge or not. I like to know when the grandson MD from California comes to my patient's appointment, but I also like to think that I treat everyone with the same courtesy, interest, and attention, regardless.
Informative- like the incognoto observations. it seems the "medical system " has levels of filters, like the medical assistant ( did you mean a PA?) who becomes the filter for the Doctor who may or may not have more experience. Prevention is not taught. What do you recommend as a general health prevention routine besides diet? Vitamins? doses of vitamin c supplements? Homeopathic supplements?
Also, her lack of curiosity also revealed her ageism, willing to accept these symptoms just because her patient was older instead of questioning him about his baseline state.
Just discovered your Substack and I love it!! What do you think the infection was in the end?
We never figured it out.
Hubs is 83. DM II well controlled. S/P CABG 2002. Very smart but a bit scattered engineer (like many). He works out, walks the dog, reads constantly, wins at poker. I always tell them that stuff so they know he’s a good 83. Had chest pain/?belly?symptoms so went to ER. Resident, long-term cardio, long-term internists and I all thought it was GI, but they kept him anyway b/c he’s a pretty good 83 and we’re worried little. Retired RN. Always tell them.
Wise woman. I definitely think that people get better care in the ED when they have someone else with them. Thank you for reading and commenting.
Many doctors have failed art class when it comes to listening and the laying on of hands. They order labs and imaging before even seeing patients and examining, which wastes money and time and can be dangerous. They don't provide adequate histories to the doctors who interpret imaging because they don't know the history or they don't like elaborating. They duplicate tests because they skim charts to see what's already been done. Sometimes, they withhold histories to see if some specialist can figure it out on their own. They pooh-pooh the suggestions of their subordinates who might propose an alternative to their diagnosis or treatment plan. They don't answer questions adequately or in a way that people can understand. They are not willing to admit when they're wrong or when they forget to address something. They propose solutions that aren't realistic for their patient or don't follow up on how those solutions are going. They also don't supervise their PA's, who sometimes have no clue and also do things that aren't necessary or could be harmful. I've seen it all. I think you're on your own these days in the medical arena. I give thanks when I actually encounter a good doctor, one who listens and has good sense. They seem to be rarer these days.
Ouch.
I've done the first one. If someone calls with a cough and fever, I might say, "Tell them to get a chest xray on the way in so we have that" as an attempt to make everything more efficient. Sometimes it's not helpful. I'm especially likely to do that if the xray will be closed when after their appointment. I do try to make it clear when I do that and why. If a patient said, "I want you to listen to my lungs first," I'd be fine with that.
Pooh-poohing the suggestion of a subordinate is something that is 100% guaranteed to get a doc in trouble. If a nurse feels they have something that is important enough to go against all of their training that tells them to do what the doctor says, I want to hear it and ignore it at my own (and the patient's) peril. I cannot stress this point strongly enough.
When I was a younger doc, I felt terrible about admitting mistakes and was probably defensive about everything. Now that I'm older, I readily admit: "Sorry; I got distracted and forgot to send your medication in." We were taught in med school to always admit and apologize for mistakes and I do and have been amazed at the grace my patients give me, but especially if it's a more serious mistake, it requires a lot of courage.
Proposing non-realistic solutions! Don't get me started on that one! hooboy! sometimes people will come out of the hospital with a discharge plan and I'll wonder if the discharging doc knows anything about who the patient is besides "a 79 year old male with urosepsis."
Retired Ob/Gyn-my husband would not have been so nice and might have made things very bad for the PA. He thinks because he is married to an MD he might as well be an MD himself.
I find there is very little relationship building left in medicine, especially at the urgent care level. Reminded me of my physician father who practiced in rural Maine and would be so appalled at our current system.
I enjoy your newsletter very much!
Thank you! I'm glad you enjoy it. Yes, the lack of relationship building makes me sad.
If you don't find people fascinating and the medical reasoning leaves you cold, what joy is there in the job?
I'm not sure I could have stayed incognito. Yet I applaud your ability for doing so. At a certain point, when someone is as incurious as the PA was in your story, to raise your voice to try to make yourself heard is pointless because the level of incuriosity means they won't hear you anyway, and you have wasted your breath and energy. In this case, you got what you wanted, a chest x-ray, and it came back clear. Sometimes we don't need a name to put to our condition as we just need to know and trust that the human body can heal itself if you provide it the right circumstances and nourishment.
I read my hubs your line "When Mister I-don’t-need-no-doctor asks about going to the clinic, you know it’s bad." and he chucked. He said that if I ever asked about going to a clinic he would know it's serious, drop everything, and put on his advocate voice.
Yes, really all I wanted was prednisone and a chest xray and not to feel like I was supposed to be my husband’s doctor. She was able to give me those things (barely, but still).
I felt that I had nothing to offer the poor PA, really. If I worked with her, over time, I might be able to help her see why the human tableau in front of us is interesting and entertaining instead of just something that is standing in between her and going home at the end of the day, but as a patient spouse, I didn’t see that I could do anything helpful for her.
Enjoyed reading your article Mary- thank you 🙏 I love how you went incognito so you could experience the 'other side' of care.
Unfortunately, it seems like too many young doctors are already jaded before they even fully get into their careers.
We had many hair raising experiences in the ER with residents and my autistic disabled son,until they finally put a Careplan in place. Now it's mostly smooth sailing from the time EMS picks him up to being settled in the ER. Of course I realize that they only do this for 'frequent flyers'.
Glad you got your son a care plan in place. It’s amazing how much of a difference that can make!
Yes, it seems that enjoying the human pagent is a skill that is at least a little bit taught and we are so busy no one has time for it any more.
Sadly true
Retired internist: Been through similar situations with my husband.
I am constantly shocked at how incurious people have become in general - my kids and I talk about their challenges with their teachers not asking questions or encouraging children or teenagers to think but rather just be passive recipients of information. Made worse because so much information is provided without context or shaping, there's little nuance. I am so sad that it has become this prevalent in medicine too
I think a vicious cycle gets set up where we are trying to see more and more patients and noticing less and less about who these patients actually are or what diseases have them and then the people are less interesting to us and so we are comfortable rushing through their visit ever faster and the faster we go, the less interesting the patients are! This is one of the things I’m trying to point out to the world.
Patients (and doctors) and diseases are charming and interesting and have quirks and crannies that are worth knowing, for the beauty of knowing them, for their own intrinsic interest, *and* for the usefulness of knowing them.
Sigh, my grandson is probably going to go to medical school. I think I should have him read your blog.
I have no one medical in my family, and I was/always will be a nurse. I know how much paid attention to what was going on with my dad. Oh dear, who will advocate for me? My son does have a Family Practitioner/pediatrician as one of his best friends, so I am going to tell him if we get sick (we are 77 and 79), to please not simply rely on "the Dr. knows best." and to consult with his friend for us. My husband will be worthless if I am sick:) He's lucky he has me is all I can say!
Thank you for the nice compliment! I would love for people in training to read it; that's part of the point!
It is so important to talk with your loved ones who will be your decision makers about what your wishes are! My planned articles keep getting pushed out of the way because more pressing articles come forward, and this has perhaps just pushed to the front.
Wow. Had an ear infection which cleared up with antibiotics so went to visit a friend who had a terrible sinus infection. A couple of days later, I had a horrible headache, a bit of fever. Slept all day and headed back home the next day (2 day trip). Once home, I worked out and by the next day, I had the worse cough and couldn’t believe the amount of snot. Bad cough for a few weeks. Never went back to the doctor but I think I may have had whooping cough based on this post. It was horrible. I see my provider next week and I will ask them what vaccines I need.
Good plan!
You are a better person than I am. I tried to go incognito to the urgent care a few weeks ago. After 2 and ½ hours of waiting in a waiting room with only a few people, then a med tech incorrectly taking my blood pressure, followed by a dismissive, distracted NP doing a non-exam diagnosis, I blew my cover. I hope to not need “urgent care” again because what I experienced was neither urgently conducted nor careful care.
That sounds awful! I hope you are getting better. It definitely helped that really all I wanted for my husband was prednisone and a chest xray. If she had refused those, it would have been a very different article.
Your story made me smile. I have an Extensivist clinic where I stabilize patients outpatient after discharge. One of my mantras is NEVER go to Urgent Care without consulting me first. Usually, I squeeze them in if it’s a weekday. If it is in the weekend and it’s not a bladder infection, I direct them to ER.
I am sure some good urgent care mid levels and docs exist.. but the pressure to triage 10 patients an hour makes it difficult.
And what is this trend of listening to hearts and lungs over clothing? Or taking blood pressure over sweaters ?!
An internist, geriatrician, and fan.
I love that! An Extensivist Clinic! It sounds like a great job!
In the exam room, if it is worth doing, it is worth doing correctly.
Thank you.
Are healthcare workers supposed to take blood pressure on a bare arm and listen to hearts and lungs on bare skin? What a novel concept! I routinely get my blood pressure checked over my sweatshirt and my heart and lungs checked over my clothes. I guess if the readings are more serious, I should say something?
I have more than once had my GP note that I had surprisingly high blood pressure on a visit, only to tell her that the nurse took it through my clothing, and...surprise, it always drops back to normal when I roll up my sleeve.
And, to be completely correct, rolling up your sleeve can affect the measurement too if it's tight. I have people pull their arm out of the shirt. It stretches the neckline out a little bit briefly, but only a few patients complain about that. Also, you are supposed to be at rest for at least five and, ideally, more minutes. Ha! Ain't no way that can happen in a clinic! If I don't like the initial number, I recheck at the end of the visit. People's blood pressure often goes down at the end of the visit, I think, because they can relax that I'm not going to say something terrible. I think even when people are coming in for a simple follow up, they worry that I'm going to find something bad.
I remember when I was in training in Minnesota, I would see immigrant patients from Africa frequently. I would say, "I'm going to lift your shirt" and I would and there would be another shirt underneath. "I'm going to lift your undershirt" and I would and this would go on for four or five shirts because Minnesota was so shockingly cold for them. In the summer!
But, yes, if it is important that they listen to your heart or lungs, you can say, "Oh, I don't mind pulling my shirt out for you." and that is a non-confrontational way of saying, "I would like a minimal accurate exam"
When they approach you with the blood pressure cuff, you can already be pulling your arm out of the sleeve. Don't push the sleeve up bc that can be constricting too. Wear stuff with a stretchy neck and have one arm in and one arm out. With your feet flat on the floor, and your back supported. And being silent. And not having to pee. And after having sat still for at least five minutes.
The simple logistics of the clnic make it almost impossible to do a blood pressure correctly in a clinic.
Say something. It’s also totally okay to remind them to wash their hands if they don’t do it in front of you.
Good point!
If you had seen your husband’s case in your clinic, what would you have done differently? Test for pertussis for starters haha
She would have looked at all of those things the article says the physician assistant failed to look at.
In terms of tangibles: CXR, prednisone, the outcome would have been the same. I would have understood my patient and his wife better, I would have done a better exam, I *think* my patient would have felt connected with (never underestimate the healing value of the healer's presence and attention), and would have had more instructions for when to call back, call his PCP, what else he might get at the pharmacy, etc.
Your hubs is lucky to have you in his life, Dr Mary. It's hard for me to be incognito at 6'5", but I promise, I will do better.
For two decades -- from her 76 to 96 -- I was my mother's healthcare advocate, and Mama Peggy was not the ordinary elder.
To a new medical person, I'd explain that mother was not your normal elder, she was a star athlete that had gotten older.
Often, they ignored me, and I would slightly raise my voice and ask, "Do. You. Hear. Me. Now?"
Okay. I'll admit. I'm poor at being incognito. You are my sHero!
Lol. It's always a dillema to divulge or not. I like to know when the grandson MD from California comes to my patient's appointment, but I also like to think that I treat everyone with the same courtesy, interest, and attention, regardless.
Informative- like the incognoto observations. it seems the "medical system " has levels of filters, like the medical assistant ( did you mean a PA?) who becomes the filter for the Doctor who may or may not have more experience. Prevention is not taught. What do you recommend as a general health prevention routine besides diet? Vitamins? doses of vitamin c supplements? Homeopathic supplements?
thank you. The questions you ask are too big for an off the cuff answer. Stay tuned.