Friday, 5 February 2016

Withholding information

I don't like asking questions.  I really, really don't.  I wish I could scan a barcode on your wrist and get every detail about your health both past and present.  Unfortunately that technology doesn't exist yet (BUT HOVERBOARDS DO?  COME ON, SCIENTISTS!), so instead every patient I see gets the same exact series of questions.
  • What are your medical problems?
  • What surgeries have you had?
  • What medications do you take (including over-the-counter and herbal)?
  • What medication allergies do you have?
  • What medical problems run in your family?
  • Do you smoke/drink/use illicit drugs?
There are other general questions about current health status (Any headaches?  Recent illnesses?  Are your vaccinations up to date?) followed by a detailed physical examination.  All this takes time, and I'd really prefer to skip it, because generally people suck and I don't like talking to them.  But sadly I can't avoid it, because every question I ask has a specific purpose, and none of them deserves to be skipped.  

In other words, when I ask you a question, you'd damn well better answer, because I need to know the answer.  Unlike my daughter (who seems to enjoy talking just for the joy of hearing herself speak), when I speak it is for a reason, and my questions are purposeful and meaningful.

I guess Gary (not his real name™) never got that message.

The emergency physician called me for a patient with a perirectal abscess.  It seemed that everyone in the entire {redacted} metropolitan area had a perirectal abscess that night, and Gary was yet another guy with pus in his ass.  At least it wasn't midnight, when most other people decide that they've finally had enough of the exquisite pain in their ass and decide to seek care.

When I first arrived, I saw the usual suspect - a relatively young, healthy-appearing gentleman who couldn't sit still.  He reminded me of a kindergartener who just can't keep his butt in his seat, but unlike the little tots, this guy had a very good reason for his restlessness.

I went through my usual thorough evaluation, asking the questions I always do.  His answers were all very straightforward - No medical problems, no medications, no allergies, no prior surgeries.  Simple, right?

If it were simple, I probably wouldn't be writing about it.

I was expecting to see a swollen painful area surrounded by redness.  Ha!  Not even close.  On examination, the area around his anus looked like a bomb had gone off.  Everything I touched hurt, and it was far too painful to allow me to perform a full exam, but from what I could see his posterior was a total mess, probably the worst I had ever seen.

"No medical problems at all?" I probed, my suspicions rising.

"Nope, healthy as a horse, Doc", he replied quite confidently.

Unfortunately his process was way too complex to deal with under local anaesthesia, so I booked him immediately for the operating theatre.  Once he was asleep I was able to assess the situation better.  There were at least a dozen areas draining pus, several old scars, and what looked like an anal fistula (a connection between the anal canal and the skin).  I had a feeling I knew exactly what I was looking at, but what I definitely did know was that I was most assuredely not the first surgeon to have been here.

I drained two large abscesses and placed a seton through the fistula.  During the procedure I was explaining the purpose of the seton to the medical student (it allows the fistula to heal without damaging the external anal sphincter, if you were wondering), and at one point I said, "If I didn't know any better, I would swear this guy had Crohn's disease.  But he insists he doesn't."

I admitted him for wound care and antibiotics, and the next day Gary felt much better.  His fever had resolved, his white blood cell count was improving, and he was able to sit still for the first time in weeks.  I told him that he could probably go home the following day.

The next morning the student called me with some surprising (not really) news.  "Doc, I was rounding on Gary and he told me that he does have Crohn's disease.  He was diagnosed about 5 years ago."

Stunned (not really) silence ensued.

I went to discharge Gary a bit later that day, but before he left I felt obligated to ask him why he omitted that rather important bit of pertinent information.  Hopefully his response will make more sense to you than it did to me, but I'll let Gary tell you the reason in his own words:
"Well Doc, you asked me if I had any medical problems that I took medicine for, and I don't.  Because I stopped taking my Crohn's medicine a few months ago."
It was then that I realised I had tried to simplify (and thereby shorten) my questions, and I had combined "Do you have any medical problems" with "Do you take any medications," and the result had been "Do you have any medical problems for which you take medicine?"  And Gary had taken it literally . . . to the word.

At his follow up appointment, Gary and his ass were both looking and feeling much better.  I advised him quite firmly to go back to his Crohn's disease specialist to get back on his medication.  And to tell any future doctors that he does, and always will have, Crohn's, even if he decides to stop taking his medication.  Oh and by the way, if you're wondering why he stopped (as I was), he apparently had spent all his money on beer, cigarettes, and video games (seriously) and didn't have enough left over.  For his medicine. (Yes I realise that paragraph had two sentence fragments.  I'm not proud of myself).

Withholding information is generally stupid, with one notable exceptions: not telling young kids the truth about Santa Claus and the Easter Bunny is reasonable (I hope mine aren't reading this right now).  However, if you really feel the need (and you really enjoy delayed pain), go ahead and keep secrets from your spouse.  Withhold information from the police (if you're really that stupid).  And if you are truly masochistic, don't tell your accountant and lawyer everything.

But for fuck's sake, don't withhold information from the one person trying to take care your your body, especially if you aren't.

44 comments:

  1. Some of the people I know scare me with how much they think they can get away with not telling their doctors. As if it was third grade and they were lying to the teacher about throwing a spit wad or something. Things like eating before surgery or a colonoscopy or not taking their medications.

    ReplyDelete
  2. so have you EVER had a patient who has had more than "a couple of drinks"?

    ReplyDelete
    Replies
    1. Sigh. I read that doctors will commonly multiple number of drinks that a patient says they have in x number of days by 3. It's unfortunate for me because I have about 12 drinks a year and I'm telling the truth. Luckily even overshot it still is a small amount; it just bugs me that's all.


      Delete
    2. I have started asking if they have had more than usual to drink - since I only have to deal with acute cases, it comes close to a usable answer to pass on.

      Delete
  3. I have a list that I carry with me that has all that information. I do it because if you need to ask, I won't be in any shape to remember it. Unfortunately some doctors consider that a sign of hypochondriac. I can't for the life of me understand your patient. However, I have withheld information about depression and anxiety disorders simply because most doctors and nurses, especially in an emergency setting, won't hear a thing I say after that. I could have a zit the size of Manhattan on my forehead, but if I said that after talking about my depression they wouldn't believe it is there.

    ReplyDelete
    Replies
    1. In the past I have brought lists and sometimes corroborating information. Doesn't matter - ain't nobody got time for that anyway, and you do look like a hypochondriac. So electronic medical records are a boon for me in that respect. Although it still would suck if doctors think you are psychosomatic from your records. And, sometimes God only knows what other doctors have written in there.

      But still, I agree with the OP. Better to have the information known by your treating physician than not.

      Delete
    2. the list sounds like a good idea for emergency care. big time savings. many of the elders in my community have the list of medications typed up and ready to go.

      Delete
    3. So Electronic Medical Records are great if you are at a facility or system where you get all of your care, but stray outside your home range or get a specialist from somewhere else and that info is no longer at hand. As an ER doc, I LOVE a patient with complex medical issues that comes with a med list and list of diagnoses, procedures, etc. Sure, sometimes there is more info than necessary, but I can sift thru that in about 4 seconds, Also, on the iPhone, there the "Health" app that contains a "Medical ID" if you fill it out and activate it (I think, it's been a while since I set mine up), it can be accessed from the Emergency access screen, even if your phone is locked.
      Lisa, I responded to your similar accusations about Emergency Medicine providers on the Hypocrisy post, but suffice it to say, I agree with Doc on this one. Withhold information and lie to your Healthcare Providers at your own risk.

      Delete
  4. General surgeon salary in Australia

    "On an average, a general surgeon in Australia receives an annual salary ranging from between AU$48,796 – AU$254,341. In addition, a bonus of about AU$51,712 will be credited to his or her account. In fact, a general surgeon in Australia receives his or her total earnings ranging between AU$44,937 – AU$357,523 per annum."

    It's chump change to American dollars.

    ReplyDelete
    Replies
    1. Your colleges are chump change to American ones too.

      Delete
    2. Probably won't be for much longer. Have you seen what they're doing to the university fees?

      Delete
    3. I detect a troll at 20:43.

      Delete
    4. those figures are inaccurate

      Delete
  5. Hmmm...This tells me that it would be a very good idea to write down and laminate a list of my medical issues. I think I will type it so it is easier to read, and make several copies.

    I have told my doctors things that embarrassed the tar out of me, but they needed to know so they could make an informed diagnosis. Every one of them told me that, while I was embarrassed, it didn't bother them in the least, as they had already heard many things far worse. I got over being embarrassed real quick.

    ReplyDelete
  6. That's nice John but what does the salary of a general surgeon in Australia have to do with this post?

    ReplyDelete
    Replies
    1. There have been several irrelevant troll comments that I've deleted so far. I was hoping he would come back and make his point. I'm still waiting.

      Delete
    2. You talk about withholding information but what about the type of fistula Gary had? Don't you think that's important Aussie? I know you won't post this but that's how you are when outed.

      Delete
    3. Oh, so that's why you posted the Australian surgeon earnings. Got it.

      As for the type of fistula, I have no idea why it matters so much to you. But since this is at least the second time you've asked (I deleted the first one), perhaps you missed the part where I said "what looked like an anal fistula". I suppose I could have called it a fistula-in-ano, but I didn't feel that using that particular term would have added anything to the story, since everyone knows what "anal" means. Except you, apparently.

      Now please explain what exactly you think you've outed. I must have missed it.

      Delete
    4. Geez doc. That's the location. I'm talking about Park's classification of fistulas in relation to the structures surrounding the anus and rectum. I have a feeling you won't be posting this GS.

      Delete
    5. As I've explained numerous times to you John, that level of specificity is irrelevant to the story. Do you think anyone cares if it's transsphincteric or intersphincteric?

      You probably consider is a victory that I allowed your comments through, but be assured that I only let them through so everyone can see your desperation. It's really rather pathetic. But I think everyone deserves to be as amused by you as I am.

      Delete
    6. This comment has been removed by a blog administrator.

      Delete
    7. You're correct. I don't care what type of fistula it is nor should it matter.

      You attract some winners here, don't you?

      Delete
    8. I totally agree. Doc's blog posts are meant to share an anecdotal account of a particular experience, and his own opinions about it, with his readers. Though many who read here are medical professionals, some of us aren't, so we don't always need the level of detail that would be included in a patient's chart entry or a medical journal article to get the point of the story.

      Delete
    9. in fact, as it is not an educational format, none of the readers NEED that level of detail.

      nor can captain google comprehend it. he just wants to try to derail the thread.

      Delete
    10. Too bad he can't get that double hemispherectomy from the last post. I'm betting it would result in immediate improvement.

      Delete
    11. If the Doc' were writing for a medical journal then I'm quite sure that he would include all of the relevant medical technicalities. As some people consistently fail to understand, this is a blog, written to entertain and amuse (and maybe inform just a little) but is not a technical reference or a selection of academic case-studies.

      Keep it up Doc'! Always a great read.

      Ugi

      Delete
    12. Telling us the type of fistula it is would be like Doc also telling us the color of his shit that morning- we don't want that type of information/don't need it. Its irrelevant.
      Connor

      Delete
    13. John wants us to think he is an expert on assholes? Takes one to know one, I guess.

      Delete
    14. comes from seeing his own so closely for so long.

      Delete
    15. That's a common problem among those who suffer from CRIS.

      Delete
  7. Twat. S/He obviously thinks he's outed you. My diagnosis is s/he's a twat.

    ReplyDelete
    Replies
    1. I suspect he is also suffering a cranio-rectal inversion.

      Delete
  8. But Doc, why did you end up taking the patient history in the first place? Doesn't a nurse ask all those questions and create the patient record before you show up?

    Also (completely off-topic but I'm crazy curious about this!), can you please explain why the medical profession seems to have totally fumbled this Zika virus? First, they said it was transmitted by mosquitoes. That made no sense to me because A) it isn't a new disease and B) it's relatively innocuous (the symptoms are so mild that most people never know they have it), so how can it suddenly have become teratogenic? Aren't diseases (vs. toxins or drugs) that cause birth defects pretty rare? Now they're saying mosquitoes aren't the only vector, that Zika is also an STD, which means anyone can get it. But again, isn't it rare for an STD to cause a serious birth defect like microcephaly? In poor countries in the southern hemisphere where folks have no air conditioning & no cars to get around in, almost everyone gets bitten by mosquitoes. If Zika really causes microcephaly & it's really being transmitted by mosquitoes, wouldn't there be tens of thousands of babies with microcephaly by now?

    ReplyDelete
    Replies
    1. The history is often on the chart, but I always ask again nevertheless, just in case the chart is unreliable.

      As for Zika, I won't claim to know anything other than what I've read. I don't feel qualified to answer those questions.

      Delete
    2. Doctors dictate H&P not nurses.

      Delete
    3. technically, Zika would be considered a bloodborne pathogen. and I suspect it is another case of being as much an outbreak of information as an outbreak of disease.

      Delete
    4. I am sure Ken is right - Zika has been around for years (so I understand at least) but coincidental with lots of rich first-worlders (I guess that's not a word, but it should be) coming to Brazil for the Olympics this year, it's suddenly a "global" issue.

      Delete
    5. I read a couple of reports that blamed the incidence of microcephaly on Monsanto. No. Seriously. I suppose there might be something in it, but I couldn't follow the argument. More investigation is certainly called for,and is being done.

      Delete
    6. monsanto is teh ebil. they short sheeted my bed last week.

      Delete
  9. Another great read, Doc. I admit, I winced when you described the state of his arse.
    I have schizoaffective disorder and take a shitload of meds. Then I take meds for side effects. And PRN meds. So I keep a printed list of all my meds, what they're for (it's amazing how many doctor's have no clue what "artane" or "haldol" is, believe it or not), what time/how much I take it... in a little chart. I also did the iPhone medical emergency thing and keep my donor card with my license and health card (Canuck here).

    Most doc's are pretty good about the mental illness. I got 51/50'd wrongly once, for 12 hours. Ya, that suicide attempt in 1999 sure was relevant to my broken ribs from falling off a horse in 2013...

    Try going into an ER with "nephrogenic diabetes insipidus" and NOT get asked what your blood sugar is, then yelled at for "not checking it enough". You sound like you actually paid attention. I've had one doctor immediately know what NDI was, and he's now my physician. (I got it from lithium carbonate, after a year on HCTZ, which is also fun to explain to doc's, it went away, kidneys are back to normal function and I don't have to sip water every 5 seconds or pee for an hour every 10 minutes... if you have NDI, you'd understand what I mean by that)

    ReplyDelete
    Replies
    1. I've reached a point where I list a medication that is completely new to me around once a month. - I guess that speaks to the consistency of ailments in my community. - most being related to getting older.

      Delete
  10. Luckily, at least, these days, there are bracelets that let you keep a usb with your medical information on it, but few people who don't have a reason for a medical id bracelet would use them. I would think that it would be the kind of thing people would jump on. I'm actually thinking of getting one just to help calm my anxiety. (Yes, it'd be mostly a pacifier, shut up. I like my security blankets)

    ReplyDelete
  11. This is a fantastic website and I can not recommend you guys enough. Full of useful resource and great layout very easy on the eyes.Herts Super Cars |

    ReplyDelete
  12. When I recently took my mother to a new-to-her dentist, she checked "no" on the new-patient questionnaire to the question that asked if she has a thyroid problem. I reminded her that she's on a thyroid medicine, and she said that as long as she takes her meds she's fine and doesn't have a thyroid problem.

    In my mother's defense, she's 94 and has Alzheimer's.

    But nobody with a brain that works right should be thinking that way.

    ReplyDelete

If you post spam or advertisements, I will hunt you down and eliminate you.

Comments may be moderated. Trolls will be deleted, and off-topic comments will not be approved.

Web-hosted images may be included thusly: [im]image url here[/im]. Maybe. I'm testing it.