Symptoms vs. Treatment Plan

Report symptoms; don’t propose a treatment plan.  That’s one rule of obtaining good medical care that’s quickly apparent when reading medblogs.

Knowing that’s how doctors feel, and having an excellent family physician who I don’t want to annoy, I was a bit hesitant to phone my doctor’s office and give my reason for visit as “I need a cortisone shot,” so I followed that with, “But if you want, you can just say ‘shoulder pain’ and let the doctor determine that I need a cortisone injection.”  That earned me a laugh and the comment, “It sounds like you’ve figured out how things work.”

The way it’s supposed to work is that patients report symptoms, then doctors consider those subjective symptoms as they decide what type of exam to perform and determine whether it’s necessary to order any tests.  This generates objective data.  Doctors then assess the information to develop a treatment plan.  The entire process is carefully documented in a SOAP note (another SOAP explanation; real-life example).

When I called the doctor’s office, I’d hoped that there would be an appointment available early next week, but by a huge stroke of luck, I got the office manager on the phone instead of my doctor’s brand-new receptionist, and was offered a same-day appointment.

Once in the exam room, I explained to the nurse that my rheumatologist offered to do a cortisone shot at my two previous appointments, but the first time I didn’t think it was bad enough, and the last time I said yes, but then she got busy confirming that other pain was costochondritis instead of a need for a cardiology referral and she didn’t do the shot in my shoulder.  I’ve been living with it, but it’s getting worse instead of better.  It hurts all the time, and I have limited range of motion that interferes with my ability to demonstrate various strokes to the kids in my swimming classes (it also interferes with my ability to dust the top of my refrigerator, but I don’t mind that nearly as much).  Constant pain is something I’ve learned to live with, but I need to be able to swim.  I doubt that I’ll ever do the butterfly again, but a basic crawl stroke is a must.  Also, it would be nice to be able to play my guitar again.  This is interfering with my life.

My doctor always reads the nurse’s notes before entering the exam room so he knows what he facing.  This time, as soon as he walked into the room, he asked, “Do you want a cortisone injection?”  It was sooooooo nice to get right to the point!  Of course he still did an exam and documented the limited range of motion, the crunching sounds, and all the rest, before giving the shot, but it was more along the lines of, “prove the patient right” instead of being treated as if I know nothing.

I like the fact that my family physician is thorough about doing an exam.  Documenting the extent of the problem and finding the most appropriate treatment is important.  The fact is, maybe I don’t need a cortisone injection.  In the past, these symptoms have led to a shot, but that doesn’t automatically mean that’s what’s best this time.  There might be a different problem, and it’s good to not make assumptions.

I’m not very appreciative when people with no training tell me how to do my job, and it’s no surprise when others – including doctors – feel the same way.  It was nice to discover how easy it can be to stick with describing symptoms, reporting facts, and letting my doctor determine the best treatment plan.

I Don’t Understand

Dear Dr:

This problem with my GI tract has been going on for two months, and the more I learn, the more frustrated I get with how you have handled my case.

Why did your partner do an EGD instead of an ERCP?  From comments I’ve heard, I’m not the only one asking that question.  I really don’t understand.  The scope was already in place – he could have kept going until he found the problem.  That would have eliminated the need for the subsequent MRCP and the second CT.

Once you decided that I needed a lithotripsy, I don’t understand why you would only refer me to big-city when there’s somebody right there in mid-sized-city who does the procedure.  Referring to a competitor when you can’t provide the needed procedure looks like you want what’s best for the patient.  Conversely, making the patient wait months for treatment because you won’t refer to a competitor looks like you don’t really care if patients are suffering.

I don’t understand why you only told the big-city GI department about CT#1 and not CT#2.  Shouldn’t they know about both of them?  I don’t understand why the referral you wrote flagged me as routine so that they thought they could contact me in their own sweet time instead of treating me promptly.

When you wrote that referral, I’d already been suffering four weeks.  I don’t understand why, when it took three more weeks for big-city to call and set up an appointment even further in the future, and I begged your office to expedite the process or find me a different doctor who could do it sooner, you waited another week to respond.  I don’t understand why your response was to send my paperwork to big-city’s medical school, where it could gather dust for a few more weeks before they called me to set up a routine appointment.

You seem to view the fact that my entire abdomen aches and I can’t eat as routine, not serious, and not worthy of your attention.  Why is that?

Maybe you’re not familiar with any of the doctors in the competing healthcare system, but there is a doctor in mid-sized city who does lithotripsies.  He looked at my CT images and said that I needed to be seen promptly.  He even re-arranged his schedule to fit me in and get the procedure done as soon as possible.  He performed the ERCP/EHL last week.  My pancreatic duct was 80% blocked.  Eighty percent!  Maybe you think that’s routine, but I certainly don’t.

When I saw you in the middle of September, I had no idea this problem would drag on so long that it could affect my family’s plans for Thanksgiving.  What’s so incredibly frustrating is that it didn’t have to be this way.  You could have – should have – handled this very differently.

If you had referred me to your competitor, the procedure would have been done promptly, I’d have returned to you for follow-up, and all this would be in the past.  Instead this is ongoing and I’m not particularly inclined to return to you for follow-up.  Since you wouldn’t act in my best interests in this situation, why would I trust you in the future?

When I go to my family physician for help, I know he’ll listen to me and do what’s needed to get me well. When I go to my rheumatologist, I know she’ll listen to me and do whatever it takes to get me the treatment I need.   When I go to you… well, it’s so sad that the same thing can’t be said for you.

Good News!

It is so nice to be taken seriously.  This new gastroenterologist looked at my CT images and said, “We need to get this done soon.”  He rearranged his schedule to fit me in.

Next week I should be able to eat without pain.  I’ll be able to visit people over the Thanksgiving weekend without fear of landing in the hospital again.  My kids will be able to concentrate on their schoolwork instead of worrying about me.

Instead of just dictating when I had to show up, the nurse asked about my schedule and gave me options.  I told them to do it as soon as possible, and I’d make it work.  It turns out I have some juggling to do because my pre-op appointment with anesthesia conflicts with my children’s violin recital, and the actual procedure conflicts with another doctor’s appointment that I’ve had scheduled for a month.  BUT it will be done!  I’ll juggle the other things as best I can, and I’m happy to do it.

The nurse said they would have done it this past week, except they couldn’t schedule an operating room at the hospital without a guarantee that the machine would be here.  Apparently the EHL/ERCP combination is a special procedure that requires borrowing a machine.

It’s funny how different medical practices can take such different approaches to their potential patients.

Practice #1

Practice #2

 Phone call to schedule appt  3 weeks after receipt of referral  1 day after receipt of referral
 First appointment  5 weeks after receipt of referral  2 days after receipt of referral
 Procedure appointment  8 weeks after receipt of referral  2 weeks after receipt of referral
 Asked about my schedule  No  Yes

The second place will perform the procedure two days before the first place will even get me in for an initial appointment.  Is it solely a matter of how they do business, or is there a difference in how the referrals were written?

I owe my family physician huge thanks for getting me the new referral.  I wish there were something I could do to convey my gratitude to him.

Edit to change ESWL to EHL