Since the beginning of medical school, I have always been astonished at the fact that my preceptors often had no idea what was going on with their patients. Many times, they resorted to prescribing Tylenol, simply telling their patients to come back if the condition became worse.
Gastric ulcer? Tylenol.
Terrible headache? Tylenol.
Joint aches? Tylenol.
Period cramps? Tylenol.
Of course, they were family doctors with years and years of experience, but it came to a point where I became frustrated and started to question their judgment. Why weren’t they considering the possibility that these symptoms may in fact be from a stomach cancer, or a brain cancer? If they had no idea what was going on, why weren’t they doing research, using Access Medicine or MD Consult? Even a simple google search for “differential diagnosis of period cramp” can give them so many clues as to what may be wrong with their patients. Why were they not questioning?
Well, of course Tylenol may in fact be the right answer for all those conditions. Given the fact that they are the ones with the wisdom and knowledge which I currently lack, it’s hard for me to say whether they are doing the right thing or the wrong thing. But one incident during my volunteer shift at Downtown Eastside got me thinking.
There were two doctors during the morning shift. One was an older doctor, maybe in his mid-50’s, and he had a lot of experience working in the rural areas of British Columbia. He had Einstein-hair, with a shabby outfit resembling fishing gear. The other doctor was probably in her late-20’s, and she looked so young that I first thought she was one of the volunteers. She was neatly dressed, with checkered sweater and dress pants, and an iPhone to go along with her stylish look. I said hello to both of them, and started interviewing the patients.
One of the patients came in with huge blisters on both of his big toes. They were white, slightly red and inflamed around the edges, and painful to the touch. The patient really wanted to know what they were, and seemed to be most concerned about the pain, since he had to walk long distances to travel to his work. I presented his case to the young female doctor, and we went to see the patient together.
After a thorough examination of the blisters, she took her gloves off.
“What is it, doc? They hurt so much.”
“It doesn’t seem to be cellulitis,” the young physician remarked.
“Then what is it, doc?” the patient inquired.
“Well, you don’t have gout or diabetes, right? If it’s not cellulitis, you don’t have to be too worried about anything else. It seems to be inflamed, but I don’t think it’s filled with pus.”
The patient seemed confused.
“Do you have Tylenol at home? Just take Tylenol until it goes away.”
She turned around quickly and left the examining room. The patient began to put on his socks, with a disappointed look on his face. After a moment of hesitation, I told the patient to keep his socks off, and to wait in the room. I knew that I could have gotten into trouble for doing this, but I knew that the patient wasn’t satisfied with her answer. And I wasn’t satisfied with her answer, either.
I knocked on the door of the older doctor, and asked him if he had time to look at a couple of foot blisters. He happily agreed, and we came back into examining room.
After a thorough examination of the blisters, the older doctor took his gloves off.
“What were you doing yesterday?” he inquired.
The patient answered. “Well, I came to work, so I did a fair bit of walking in the snow. I noticed my blisters during a shower.”
“Did you do anything to make the blisters go away?”
“Yeah, but it didn’t really work. I put polysporin on it, deodorant too, and this cold cream this guy gave me.”
The question and answer period went on for another ten minutes or so.
Finally, after a long period of silence, the doctor spoke.
“I don’t know what this is.”
I was dumbfounded. I had never heard a doctor say this before. And he said it in front of the patient! So many doctors in my past have simply answered “Tylenol,” not really admitting whether they knew what was going on or not. He was different.
After fully informing the patient that he should come back to the clinic if the blisters worsened, I decided to talk to this doctor.
I told him about my frustration with my preceptors in the past, and asked for his opinion.
“Well, Tylenol does fix a lot of things. But you see, many doctors are afraid to admit that they don’t know. It does hurt your pride. I mean, you are a doctor, for Christ’s sake. You need to know. But that’s sometimes really dangerous, you know? Admitting that I don’t know something, well that at least gives me a motive to start learning. And admitting that I don’t know — but realizing what you do know, that’s important too. For example, the fact that these are white, round, blisters on big toes, that’s a starting point. Although I may not know a lot beyond the symptoms I am seeing, that sort of stops me from doing guesswork. And guesswork, in medicine, can be really dangerous.”
“If you see a patient with a cough, you shouldn’t go ahead making the diagnosis of bronchitis. What you have, is a cough. A cough and a cough only. That’s your starting point. No guesswork.”
And I completely agreed with him.
Doctors are humans, too. They are not computer software designed to spit out a diagnosis when the symptoms are presented to them. Everyone, including Einstein, have gaps in their knowledge. And putting on a façade of all-knowing doctor god can’t benefit anyone. Most importantly, it can lead to critical medical errors that endanger the patients’ lives. And secondly, it allows doctors to become lazy and stop learning.
And when the doctors stop learning, that’s when things get scary.