Advice From An Old Physician

Advice From An Old Physician

By

Leonard Zwelling

During Shabbat dinner on Friday, July 17, at my sister-in-law’s house in Cleveland, Ohio, my niece, a primary care internist, asked for some advice on a complex patient for whom she was caring. Without going into the details of the patient’s history, symptoms, and signs, the women, who was near 80-years of age, presented with iron deficiency anemia, a rapidly falling BMI, abnormal liver function tests, and a mass in one of her kidneys on imaging studies, as well as something seen on a chest x-ray in one of her lungs. My niece was sure she had a malignancy and was getting dreadful advice from her consults as to what to do to make a diagnosis and do what was best for the patient. What should my niece do next?

Two things struck me when she was relating the history, lab data, and imaging results to me. First, despite trying to get help from those various consults, she was getting little of use despite her obviously caring for this woman’s welfare. Two, the doctors to whom my niece went for expertise were providing her dreadful advice because, from my assessment, they had no idea what they were doing.

The radiologist who viewed her abdominal CT scan was very concerned about whether the cystic mass in her kidney might harbor malignant cells, but offered no next step. Could a fine needle aspirate be done? Was it safe in the face of a cyst of unknown content? Doing another study in a year was not an appropriate response from the urologist, but that’s what the advice was.

The hematology consult managed to charge for a huge battery of tests including a serum electrophoresis despite there being no indication that myeloma was in the differential diagnosis for this woman. More importantly, there also was no indication that the hematologist looked at the patient’s blood under a microscope, an absolutely mandatory step in any assessment of anemia, iron-deficiency or otherwise. This omission borders on malpractice. Why?

Iron-deficiency anemia is NOT a diagnosis. It’s a lab finding. Was the patient unable to make red cells or was she destroying them? That matters a great deal in generating a likely cause and a series of next steps to solidify the anemia’s etiology and bring together an explanation for the clinical findings.

As my wife will tell you, one of my pet peeves about today’s internists and, now, I guess, hematologists, is that they do not look at a patient’s blood under a microscope and instead rely on machine-generated numbers to assess why someone is anemic. As far as I know, that cannot yet be done very well. A doctor needs to look at a sample of the stained blood to assess it for signs of inadequate hemoglobin production or evidence that red cells are being destroyed by a number of mechanisms which can be distinguished from one another by looking at the morphology of the blood cells and knowing what you are looking at, something my niece’s hematology consult should have known and done.

My second pet peeve, I am glad to say, did not characterize my niece’s management of her patient. Doctors don’t have sufficient time to analyze difficult clinical presentations let alone care enough to pinpoint a diagnosis and formulate a treatment plan. My niece cared about this woman. That is why she spent two hours querying me about what to do next. Good for her. Her patient is lucky to have her. My advice was to send the patient to a good medical oncologist who could weigh the value of assessing the renal lesion vs. the lung lesion vs. her elevated liver enzymes (pancreatic cancer, bile duct cancer?) first as a potential source for tissue sampling to make a definitive diagnosis. My bet was on the renal cyst having malignant elements in it, but I saw none of the images, of course.

My other surprise that night was the fact that the knowledge from my three total years of clinical training—Duke internship and residency plus the year at the NCI Medicine Branch as a fellow–despite the rest of an entire career being devoted to laboratory research and administration–kicked into high gear as soon as the patient was presented to me. It was like riding a bicycle. Once a Duke intern, always a Duke intern.

So, my advice to all young physicians when faced with a patient who presents a dilemma in diagnosis and when advised by specialists who are not helping you despite collecting a fee is to:

1. Look at the blood film yourself, preferably with a knowledgeable old timer using a two-headed microscope.
2. Care as much as my niece did and never accept the bad and frustrating advice she was being given.
3. Don’t forget what they taught you in medical school and residency, I hope. History, physical, lab tests, imaging, differential diagnosis from most to least likely and rule them in or out.

That still works, just like it did 50 years ago for me.

The main reason I have a concierge doctor today is his great ability to take a history, listen carefully, and do a physical exam. I was blown away when the surgeon who is to operate on me in August did the same. I was also calmed tremendously by his care and skill.

Being a doctor has not changed as much as many would have you believe. It is still about listening, touching, observing, and, most of all, thinking and caring. While the latest AI software from The New England Journal of Medicine can be really helpful, it cannot look at the blood film and cannot exude confidence. Do those things. That’s my advice.