Bah Humbug

I think I have sinusitis. The post-nasal drip is giving me a scratchy throat, and I have a lot of nasal stuffiness and head pressure. It's more annoying than anything, but it's making it hard to sleep, and I think my sense of smell has been affected, because food isn't appetizing. I'm getting hungry, but nothing looks good. This is a problem, because I like to eat. Big girl's gotta eat, ya know.

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So I'm on internal medicine at our large private hospital, and I think I'm done. My residents all said "but you would be such a good medicine doc!" last night, and one even said "you work too hard to go into urology", but I think I'm done.

I realized that the attitude of internal medicine is what bothers me. The doctors tend to treat patients like "great teaching cases" or "fascinating differential diagnoses", treating numbers and lab values instead of the patients. The doctors I'm working with are all competent and empathetic, and I am not trying to bad-mouth them at all. I just don't want to be like that.

My First Aid for the Wards had a quote that, to me, summarizes the best and worst of internal medicine in one fell swoop: "If it's not in your differential, you can't diagnose it." This is entirely true. At morning report, we write out probably 10-15 differential diagnoses on the presented cases, some of which are truly "out there". I'll admit, formulating long differential diagnoses is not my strongest suit. In fact, I tend to get too narrowed in, focusing on one or two diagnoses, and not looking too much further, so I need some practice in this. Considering rare or unusual diagnoses can help in the cases when a patient has an unusual presentation, or you suspect something further, or something just doesn't fit, or you are feeling particularly academic.

So what is wrong with this mindset? The opposing viewpoint is fairly well-summarized in a truism I got from Surgeonsblog: "Common things are common, and rare things are rare." After you get through thanking Captain Obvious, you realize the wisdom behind this statement. In medical school, and academic medicine, we look for rare things, and are often referred unusual cases, and sometimes we forget what is the most common.

An attending asked the students yesterday, "What is the most common cause of osteomyelitis in sickle cell patients?" Almost every one replied in unison, "Salmonella." "No!" hollered the attending. "It's staph! Sickle cell patients just tend to get osteo when they get salmonella." Everyone knew that association, drilled into their heads by USMLE Step 1 studying, but no one stopped to think about it. (It's the same when you're asked "What's the most common cause of pneumonia in AIDS patients?" It's strep pneumo, just like the for the rest of us; they are more susceptible to common as well as uncommon pathogens.)

I presented a new patient to my attending yesterday afternoon. She was a middle-aged lady with diabetes, HTN, chronic renal insufficiency, and cocaine abuse; she had a chief complaint of belly pain. Crack was her drug of choice, documented in multiple discharge summaries. As she was too zonked on crack and benzodiazepines to talk, I spent nearly and hour pouring over her old chart, reading about multiple admissions for belly pain (dx: constipation), hypertensive emergency (dx: cocaine), and foot abscess with 4 toes amputated (dx: glucose 400+). My assessment: she's zonked on coke; her belly pain is likely constipation, like last time (she was eating, she was not tender to palpation, afebrile, CT showed nothing acute); her elevated creatinine is likely chronic + dehydration, and caused by her diabetes (if she'd had toes removed, and painful neuropathy, it stood to reason that she'd have nephropathy as well); her hyperkalemia on admission likely due to renal insufficiency, spironolactone, and lisinopril in combination (her EKG was normal, and she responded to insulin + kayexelate). Her echo was mostly normal except for pulmonary hypertension; I could explain that, too: as she slept through my exam, she snored so loudly you couldn't auscultate her chest. Dx: obstructive sleep apnea, due to her obesity and massive neck size.

I thought this was reasonable; this was what the resident, intern, and myself came up with.

As I presented the case to the attending, she started looking at stuff in pieces. "Why is she anemic? We should work that up!" (It's already been worked up.) "Why are her kidneys not working well? Her A1c is too low for that!" (A1c only measures 3 months of compliance, and hers had been much higher in the past.) "Why are her eyes protruding? Maybe her thyroid is malfunctioning, that would explain her hypertension, and if she had other pituitary malfunction, that could explain the hyperkalemia!" (She had a normal TSH on previous admission, 2-3 months ago.) "Maybe we should check the TSH again--it could be early thyroid." (??) "What is this thing in her kidney on the CT [it showed a tiny hypodensity/cyst, no hydronephrosis]? Have we figured out why her kidneys aren't working? Could she have an obstruction?" (Again, no hydronephrosis, bilateral enlarged kidneys, chronic renal insufficiency, improved with fluids, DIABETIC HYPERTENSIVE!)

"I just don't think she's been worked up properly, I think there's something going on here, I don't understand all her findings." Shit. Those are like the worst possible words to say to a busy resident.

So this morning, when I talked to the patient, who was off her coke and benzo trip, she told me she'd last done crack on Monday, that she'd indeed been constipated prior to her belly pain, that she'd pooped in the hospital and felt fine now, and wanted to go home.

At least the attending let us let her go today. My old attending from LBJ, Dr. C, would probably have kept her.