My most recent editorial in Today’s Wound Clinic is a tirade about what appears to me to be a lack of common sense and basic medical knowledge on the part of physicians. It’s not due to Covid but the pandemic has made all our weaknesses more obvious. A few nights ago I went to dinner with some dermatology colleagues who were telling me the medical conditions they had diagnosed which had nothing to do with dermatology simply because they insist on examining patients without their clothes on. One dermatologist noted an elderly patient’s woody edema that extended to the groin and got him emergently admitted for profound heart failure. The cardiologist had missed it, in part because he didn’t make the patient undress.
There also seems to be a decrease in the ability to tell when a patient is “sick,” even if you don’t know what they are sick with. A few years ago I was seeing a patient in her very late 80’s for a minor wound on her leg. However, both legs were unusually swollen. She was a retired triage nurse at the infamous Parkland Hospital in Dallas, where she had worked for decades. I trained there so I knew what sort of person she had to be in terms of intellect and energy, which probably explained how she was married to a man 15 years her junior. She said, “There’s something wrong with me – I have no energy.” Her cardiologist had told her not to worry. Then I saw a tear trickle down her cheek. I called my friend who was the top heart failure doctor at a large teaching hospital and said, “Would you hospitalize a patient just because I said so, even if I can’t tell you why they need to be in the hospital?” She said she would and she did. The next day the cardiologist called me breathlessly to tell me that the patient had gone to the operating room emergently, and there had been many people with cameras taking pictures of what they found. Her pacemaker wire had penetrated her heart and was tethering one mitral valve leaflet, and she had gone into acute heart failure. No one had ever seen anything like it. She asked me how I knew the lady needed to be in the hospital and all I could say was, “Parkland triage nurses don’t cry.” No doubt there were more objective physical findings that I would have found if I had looked. My point is that if I learned anything at Parkland, it was how to tell when a patient needed to be in the hospital. I am worried that this kind of instinct is being lost.
I am worried about the trend I see with doctors saying they are uncomfortable making a diagnosis outside their field, or not being intellectually curious enough to ask, “why?” Maybe we are all tired, but I think it’s more than that. I may be imagining that something has changed, but if I am right, it’s a particular problem for patients with chronic wounds. Chronic wounds are a SYMPTOM of disease(s), which means my job is know what all of those diseases are, and then mitigate their effects if I can. What scares me is how often I am the one who diagnoses a disease that is in plain sight. I guarantee you that it’s not because I am particularly smart. Maybe that is what really scares me. If it doesn’t take a genius to see some of these things, why are they getting missed?
Read the rest of my tirade here: