I’ve seen it too many times over the years – a patient with an ill-defined constellation of symptoms “makes the rounds” among medical subspecialists, eventually coming to me for an Endocrinology consultation. Oftentimes, this process has played out over the course of several years, leaving the patient frustrated, discouraged and exhausted, but nonetheless hopeful that the answer is out there.
When I see this person in my office, I desperately want to help her. This is my raison d’être, right? You’ve probably heard some physicians refer to their chosen field as a “calling.” While my career is somewhere on the spectrum between “calling” and “job,” my day-to-day satisfaction is intimately dependent upon helping patients in some tangible fashion, even if it’s just to help them achieve greater clarity about an illness I can’t make much better.
Let’s say that, after reviewing the above patient’s medical records and taking my own careful history, I conclude that the chance of her having a problem within my realm of expertise is near-zero. What would you recommend I do at this point:
A. Explain the various hormonal diagnoses I’ve considered during our visit and discuss why I don’t believe she has any of them.
B. Refer her to any other physicians I think might have something to offer, assuming I suspect a diagnosis that is not within my field (e.g. Sleep Medicine to discuss possible obstructive sleep apnea).
C. Run a few additional tests to “rule out” rare hormonal conditions that she probably doesn’t have, but are within the realm of feasibility.
D. Run additional testing that is outside my area of expertise, in the interest of getting closer to a diagnosis.
E. Tell her I’m fairly certain I know what’s going on with her, and reassure her that she’s going to get better.
Before I dive into what I believe is the correct answer, I want you to note the thematic progression as you make your way from A to E. Choice A embodies the “binary approach” of many medical subspecialists: Does the patient likely have a problem within my field? Yes or no? When not paired with any of the other choices, choice A is unlikely to enhance physician job satisfaction. When used in isolation, it also has the potential to make the physician seem deliberately obtuse.
For example, I know a Neurologist who evaluated a patient who had recently been discharged from the hospital on a sizable dose of prednisone (a potent steroid). The working diagnosis from the hospital was Hashimoto’s Encephalopathy, a misleading misnomer that implies somehow the thyroid is playing a role in this central nervous system problem. Most of my Neurology colleagues know that Endocrinologists view this condition as a brain malfunction that gets better with steroids; it has nothing to do with the presence of thyroid antibodies. We call it a “steroid-responsive encephalopathy.” Regardless of whether HE is real or not, most Neurologists would probably agree that Endocrinologists are not experts in the treatment of encephalopathy.
In the above case, my Neurology colleague (appropriately) decided that the patient’s encephalopathy did not have a clear cause. He used the lack of a clear cause to justify his decision that her problem did not fall under the umbrella of Neurology and, therefore, was not his job. This illustrates a potential consequence of picking Choice A in isolation, where the doctor concocts a binary choice: is this my job or not? Given that her discharge diagnosis was “Hashimoto’s Encephalopathy,” he counseled her that the Endocrinologist would manage her steroid treatment, and he had nothing else to offer. 4-5 weeks later she landed in my office (yes, it takes too long to get an appointment), still on 60mg of prednisone daily, with no signs of encephalopathy. However, she had a litany of side effects related to the prednisone and was miserable. She had already been “dumped” by one specialist, so I didn’t think it would be appropriate to play hot potato with her, claiming that I don’t know anything about encephalopathy. During our visit, I excused myself and went hunting for a Neurologist to chat with, and we agreed that it would be okay to begin tapering the steroids.
What is the lesson here? While it may be the most realistic option for many encounters, Choice A (not my job) alone often leaves both patient and physician dissatisfied (I hope the above Neurologist felt dissatisfied). This is what leads clinicians to look at choices B through E.
Choice B (referring the patient to a different specialty) is a reasonable add-on to A; in fact, many of us do this every day. Although I’m not an expert in the treatment of sleep apnea, such a large percentage of patients I see have classic symptoms that I wind up sending at least a few people every week to Sleep Medicine. It is satisfying to see these folks at some later date, feeling much better once they’re on appropriate therapy.
As we move further down the list of options above, I need to exercise caution. Choice C (ruling out rare conditions), when approached judiciously, has the potential to reassure both patient and physician that no stone within the Kingdom of Endocrinology has been left unturned, within reason. There are literally hundreds of hormonal tests that the laboratory will be happy to run, but as I’ve written previously, you’ve got to know your assay and know your pretest probability. In other words, make sure that the chance of a false positive result does not outweigh the possibility of a true positive by a margin so great that it makes the decision to test look ridiculous. If you fail to do that, chances are you’ll be spelunking down various rabbit holes with nothing to show for it.
Choice D (running tests outside my area of expertise) is where I and many subspecialist physicians start to get into trouble. For example, on more than one occasion, I’ve sent patients off on a wild goose-chase to the local academic Hematology department for a porphyria workup. How did this happen? Well, the patient presented to me with numerous, nonspecific, non-localizing, seemingly disparate symptoms, so I decided to order a 24-hour urine for ALA and PBG (to screen for a condition called porphyria, which I admittedly do not understand well). When the levels came back mildly elevated, I was then stuck – I knew the elevations were probably false positives, but I don’t understand porphyria nearly well enough to counsel the patients to not worry. So I sent them to the only medical center in the area that knows anything about porphyria, and the unanimous verdict was that I don’t know what the heck I’m doing.
Why did I break my own cardinal rule about ordering tests I don’t know how to interpret? For that matter, why have I done it more than once?! It stems from the desire to help the person sitting in front of me, regardless of whether her problem falls within my area of expertise. Remember, the patient just wants to get better; she doesn’t care about the boundaries between Endocrinology and Hematology, Hematology and Rheumatology, or Rheumatology and Gastroenterology. The problem is, as we get farther into our careers as medical subspecialists, we move farther away from our general Internal Medicine training. That training included rotations in most – if not all – of the other medical subspecialties. As a result of that experience, we were at the top of our game when we exited Internal Medicine residency.
After years of subspecialty practice, however, our general medicine skills have deteriorated. This is to be expected, as it takes all of our time and energy just to keep up with the developments in our own specialties. In my view, it is exceedingly difficult to be an excellent Endocrinologist and an excellent internist. So I don’t practice or keep up with much general medicine. Should it be surprising, then, when I attempt to foray into a field I don’t understand and flail?
You can see how Choice D has the potential to lead physicians down a slippery slope. We may start with good intentions, but ultimately we haven’t helped the patient. It is a constant struggle to maintain our footing on this slippery slope when sitting across from a person pleading, “Please help me!” In my opinion, we need to temper our internal dialogue of “don’t just stand there, do something;” sometimes, it’s more sensible to “don’t just do something, stand there.”
Have I whet your appetite for exploring Choice E? Come back next week for Part II of this post, where I will dig into why good doctors go bad!
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