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:
https://www.hmpgloballearningnetwork.com/site/twc/letter-editor/how-did-we-get-here
Dr. Fife is a world renowned wound care physician dedicated to improving patient outcomes through quality driven care. Please visit my blog at CarolineFifeMD.com and my Youtube channel at https://www.youtube.com/c/carolinefifemd/videos
Caroline you are amazing! It is frustrating especially in the Covid era. Wounds are being missed and unreported. Orders are being written for wounds 3 times a week for a patient with a TCC telemedicine can be good, but it can be bad when people don’t ask questions.
I LOVED your tirade Dr Fife and I think some of it goes back to how we are training our Med Students and House Staff that medicine is a 9 to 5 job and not a 24/7 vocation. I see students scrubbing out of amazing surgical cases because it’s 5 pm and the rules say they are done. How do you develop those intuitive skills that tell you a patient is sick, really sick if you’re on duty for 8 hours a day? I’m not saying the old way of beating the house staff to death was perfect, but the decisions I made as an Anesthesiology resident on my own in the OR at 3am were what taught me to go with my gut and listen to that little voice in your head. I worry about the future of medicine.
I love your insight! Thank you for what you do. You are a true inspiration!
It’s an honor to call Dr. Fife my friens
Dr. Fife,
So grateful and honored that I got to train under your guidance! It is a really worrisome trend.
I have diagnosed multiple myeloma in a patient who came in as direct admit from podiatry with foot wounds into the hospital but was discharged a day after MRI did not show osteomyelitis. I saw him in clinic 2 days after discharge for the wounds and he kept complaining that he was very tired. He was being told its just the wounds of his feet that is causing all his fatigue. No other medical issues. Wounds were clean and had no active infection. I had a hunch that this doesn’t seem right- very active, educated smart man ( ran 4-6 miles a day until 2 months prior) suddenly feels no energy. Had to admit him again on a hunch after speaking with the hospitalist, and comparing his labs from last visit triggered further work up and the diagnosis was made quickly.
I wonder if its being a primary care physician at heart, while taking care of wounds, we are more attuned to general well being of the patient as a whole. Also, the eye doesn’t see what the mind does not know.