How Country Docs Think (HCDT)

        After reading some excerpts of Dr. Groopman’s book,  “How Doctors Think,” and also Ted Lehmann’s review, I decided it was a must read for me.  Ted (The English Professor) often serves as this busy doc’s personal Internet Cliff’s notes, but this was one I needed to get.  The book is all about my line of work, and I need to read the whole thing.

        Before the book even gets here, I am compelled to start up a series in response.  For lack of a better title, I’m gonna call it “How Country Docs Think,” or HCDT for short, in spite of the proposed NBEMA  (National Bureau for the Elimination of Medical Abbreviations.)

        A couple of caveats are in order.  First of all, I believe Dr. Groopman’s work to be very important.  It might well be historic ground-breaking kind of material.  By all accounts, Dr. Groopman is a true Board Certified intellectual; the kind of cat a country doc like me reads to try to kick up his daily performance a notch.  By contrast, I am but one little country doc who grew up with a love of books and some bad habits of picking too much music and playing golf.  In the “What it’s Worth” department, my opinion and a buck and a quarter will get you an extra large coffee down at the County Line Diner.  On the other hand, my advice on the Net is free, and where else can you get a doc to give you that, huh?

        Before I get started, that brings up a  very important point.  Advice.  When I started this blog, my agent warned me not to turn it into a medical advice forum, and I agree with him 100%.  It is hard enough to make an accurate diagnosis in person, but impossible in cyberspace, so I ain’t gonna try.  All I can do is give you some insight into how this doc thinks (watch out- it might be dangerous) and hope it helps you in your relationship with your own doctor.  Remember, you get what you pay for, and my Internet advice is free.

        In this series, I would like to follow Dr. Groopman’s lead, and address each of his concerns. 

        Early on, he discusses diagnostic errors.  I find this a good place to start.  After all, when you go see your doc you kinda hope he’ll make the correct diagnosis, right?  With that in mind, I’ll tell you how country docs (at least this one) think.

        For purposes of keeping this borderline ADD doc on task, let’s break it down a little from there, and divide this thing into two categories- acute and chronic. 

        For this segment, I’m gonna discuss acute illness only.  In other words, say you’ve been sick as a dog for a day or two, and you need to go to the doc.  How does your doc think?  It is my hope that by writing about it, the next time you go, you will find it easier to communicate.  (If you go in N.C. they might ask if you have been talking to that crazy Dr. Bibey!)

        Acute illness.  No one likes to be sick, me included. (Docs often do make the worst patients.)  Your doc should understand this.  I feel like when my folks are sick they often are at their worst, and I need to allow for that.  As long as my patients don’t threaten to sue or shoot me I can get along with them.   (No one has had much success so far- one did buy a gun, but had a change of heart, and didn’t pull the trigger.)  

         Here’s where there is often a divergence in thought.  Many patients, and I do not fault them, just want to get something to feel a little better and go home.  I’m want that for them too, but I also try on each encounter to not make a diagnostic error.

        What do I mean by that?  Lets say a patient comes to me with a cough.  Usually, they want some kinda of cough medicine and go to the house.  I’m glad to accommodate that, but feel obligated to be sure why they have a cough first, and that takes a few questions and some time.

          You see, for me as a doc, here is my number one rule regarding acute illness.  I try to never overlook anything that might do my patient in before I get another chance to see them.  So far, I have not pronounced anyone well, and then had them drop over dead in my parking lot, (it could happen tomorrow) and I want to keep it that way.  I always tell my patients sudden death is against office policy.

        So, how can we avoid breaking office policy?  First of all, no matter how hard you try, it ain’t always gonna work.  When I was young, I thought if I cared enough, read enough books, and was intense enough, none of my people would die.  Well, I found out I wasn’t that good, but I have avoided major disaster so far by this thought process. 

        I found one of Dr. Grooman’s points very well taken.  He says docs only average eighteen seconds before interrupting the patient.  When I come in the exam room, I like to ask something like “Hey, Ms. Smith, what kinda trouble you having today?” and give ’em at least a few minutes to run with it.  (Although if Dr. Groopman put me on the stopwatch I’d probably be disappointed to find I don’t do much better than the national average.)  

        Maybe a good Christmas present for your Doc would be Dr. Groopman’s book.  It might help us all improve.  Just don’t tell  Dr. Bibey suggested it- some doctors can get a little touchy on the subject.  If you think your doc is in that category give it to the nurse instead- they’ll enjoy it, and appreciate your empathy!

        So, lets go back to that patient with a cough.  Yeah, they probably have a cold.  In my line, though, betting ain’t allowed.  Every time I see a patient like this, I go through a mental check list.  Could they have heart failure from recent myocardial ischemia?  (Heart attack or dang near it.)  How ’bout a pulmonary embolus?  (Blood clot in the lung- very dangerous.)  Maybe a dissecting thoracic aortic aneurysm- I saw one of those a few years ago.  When I let ’em roll those first few minutes, I’m listening for any clues that make me think any of these terrible things might be a possibility.

        Now I know you might say, “Well shoot, Doc, those are rare.  That ain’t happening to me, I’ve got a cold.  And usually you are right, but I gotta try to be right 100% of the time.  It ain’t gonna happen, but I have a saying-  “Just ’cause I can’t be perfect won’t stop me from trying.”

        So, I run it by the cerebral check list on each patient, every time, without fail.  (O.K., if is a Cub Scout physical, maybe not every question.)  It is sort of like an airline captain.  He has a check-list at his side to complete before every take-off.  If he doesn’t, he might get away with it most of the time but, like overlooking myocardial ischemia, if he crashes it’s 100% for the poor souls on board.  100% is bad, too.  Another doc saying here- “You can’t be any deader than dead.”  (I warned you was gonna let you all the way inside my head.)  Us front line docs are not the fly boys, we are only the lowly crop dusters, but I think Dr. Groopman would say it is just as important for us to go by protocol as the big boys.  In some ways, it is more so, ’cause our folks are undiagnosed at the time of encounter.  Most of the specialists see our people when some of the process of elimination has already taken place. 

        My point- when your doc asks all those questions about shortness of breath or chest tightness, or blood, or what your grandma died of, bear with ’em.  I know you’re miserable.  I realize I’m running behind, and I really am sorry, but I want to give you my best.  At the very, very least if I make the wrong diagnosis, I don’t want to miss anything that might kill you before I see you at church Sunday.  If I ever do, it’ll be a long time getting over it, and I’ll pray that when we meet up in heaven you’ll have found a way to forgive me.     

        Now, you’ll notice we ain’t even got around to thinking yet.  We’re still just gathering data by a protocol.  And, I promised you I’d tell how Docs think.  To illustrate my point, in my next post I’m gonna tell you about an acute illness case from a few years ago.  And, it won’t be a HIPAA violation to do so, ’cause it was my own case- a kidney stone.  So, I’m only violating my own rights here, and I ain’t gonna sue myself.  

        For now, though, I promised my Ms. Marfar a matinee movie she wants to see, and it ain’t even a chick flick.  If it was I’d still go – she deserves it and more for taking care of me.  

        I’ll be back in a few days to tell you more on how docs think about acute illness and all about my kidney stone.  Painful as the memory might be, I think the story will make a few points.

Dr. B

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8 Comments on “How Country Docs Think (HCDT)”

  1. Ted Lehmann Says:

    It’s really always nice when a doc takes the time to listen. It gives the patient the impression (perhaps false) that a relationship is being established. Meanwhile, if I read Groopman correctly, his point about protocols is that they’re valuable and not infallible. The problem with them and various other decision making processes (like decision trees and computer algorithms)is that they may narrow a diagnosticians viewpoint too quickly and settle on a diagnosis that hasn’t considered all the possibilities. He believes in the doc’s experience, knowledge of the patient, and deep insight as a bridge to help cross the river. He’s deeply suspicious of strategies trying to make diagnosis doctor proof.
    As teaching “progressed” through the last couple of decades of the last century, decision makers (always to careful of top down) tried to make curriculum teacher proof by narrowing their scope for decision making. Today’s hyper-charged anti-teacher/school bias has taken all the fun out of teaching. – TEP

  2. drtombibey Says:

    Ted, This is correct. The protocol only gets you to the starting block. There is no substitute for knowing, and listening to, your patient. In this series, I want to explore how we do that. Perhaps in some small way it might improve the process for both docs and patients.

    -Dr. B

  3. Parson Bob Says:

    Interesting thread, Doc. Let me add my own two cents. “Cent” #1 is to raise the question, in what way does a doc’s thinking/interview style differ from others? Off the top of my head, it seems pretty much the same as everyone else’s — my mechanic goes thru the same process when I take the family fliver into his shop. Is there a difference? I’d like to think so, but I can’t see it.

    The other “cent” is my own frustration when my doc, a good man and a fine MD, spends the first several minutes (or more) talking about church stuff: scandals, schism, programs and such. I’m not particularly interested in that stuff on a good day, and especially not after an hour with old National Geographics. I try to steer the conversation around to what’s more important (ME!), and get away from churchy talk.

    There…I feel better already.

  4. drtombibey Says:

    Absolutely right Parson. One reason my mechanic and I get along so well is I like the way he takes a history on my car, and he likes the way I allow him to ask the questions. If I go to the shop and and try to tell him what is wrong with no input from him, I don’t know any more about the car than I did when I got there. (Which is not much.) By the same token, if he doesn’t listen to my concerns he’ll be lucky to figure it out.
    Maybe part of this is to figure out how we are more alike than different. One lawyer I highly respect (yes, not all of ’em are enemies to docs!) told me he thought it was important to be human first, and doc second. Maybe we docs need to be careful not to let all that training get in the way sometimes.
    Regarding point number two, I have to be careful with my musician friends not to talk too much bluegrass. Often they enjoy it for just a moment, but when they come to the office they are there about their troubles. I try to be sensitive to their cues that it is time to move on.
    One patient told me when we are in the exam room, he is my boss. I never forgot that, and find it good counsel.

    -Dr. B

  5. bobleckridge Says:

    Great post as usual Dr B, I’m looking forward to this whole series. I think I should probably get hold of that book too and see what it says. I do remember reading a review of it when it came out and that review mentioned the average time till a doc interrupts a patient in a consultation. I was shocked! Do most doctors leap in so quickly?
    Can I add something here?
    In my training, one of the areas I worked in was Paediatrics and the consultant there told me that in my training time with him (6 months) he wanted to teach me one thing – how to spot an ill child. Well, I thought it was some kind of joke, but it wasn’t. He was right. And I bet you have this same experience…….you walk in a room and you see this child and maybe you hear a little bit about what’s wrong, maybe not, but you know instantly this is one seriously sick child and you act straight away. In such a circumstance it’s about observation, isn’t it? Taking in everything from the colour of the child’s skin, to the speed of their breathing, to their behaviour, all in an instant. To some extent we do the same with adults who are acutely unwell too. I’ll never forget the farm hand in the midst of rural Scotland who’s “flu” just didn’t “feel like” flu straight off and one question – have you been abroad recently? – got me to the right blood test to show he had malaria (and I can tell you I have NEVER seen a case of malaria in Scotland before nor since!) The point I’m making is that we start making our diagnosis before anyone says anything at all some times!
    OK for another point?
    Arthur Frank, who wrote, The Wounded Storyteller, tells us what’s important is not data, but stories. And he goes on to show the common kinds of stories patients tell. In acute disease, like your cough example, the commonest kind of story is what he calls “The Restitution Story” – it’s “the quick fix”, “the fast oil change”, “the MacDonalds meal” – it means “just fix me doc, and I’ll be on my way”. You’ll see that kind of story coming up all the time.
    Oh, and one more thing…..cripes! I’m turning into Colombo! Research into witness interviewing by the police has shown the more questions you ask the witness, the worse the accuracy of their reports. Same thing happens in medicine. The more questions you ask, the more misleading the answers become. It’s way, way better to sit back, lay down the pen, and listen – to the patient’s own words, in their own time.
    Ted, you’re spot on. If we try to replace active, reflective listening with algorithms and decision trees, we’re going to end up with a lot worse medicine.

  6. drtombibey Says:

    Right on Dr. Bob. I hope all my readers do take in the comment section. My agent predicted the comments on this one would prove more insightful than the post. He is going to tell me “I told ya so!”
    Listen, listen and more listen. From patients and docs alike this seems to be the ticket, huh?
    I agree with you 100% on those children. If my gut, (or the mama) is uneasy, I never dismiss that sensation.
    Hey, speaking of kids, you’ll like this one. Years ago I was on a Pediatric Cardiology rotation. Some kid had been referred in from way out in the country. He was about three, and was one more energetic young’un- just racing around the exam room.
    Zero history accompanied the child except a crumpled up note on a prescription pad the poor old doc had scribbled down. It said, “Can’t hear heartbeat.”
    I was the med student that saw the child, and I told the attending, “I’m only a med student, but I promise you that kid has a heartbeat.” I got an “A” before I examined the patient- the history was enough.
    I guess the old doc who referred the child in was hard of hearing, had a noisy office, or both.
    And speaking of abroad, if I ever travel to Scotland and come back with a belly ache it might be that haggis business. Tell me about that sometime. Is it somewhat akin to chittlins? (sort of a southern fried hog intestine.)

    -Dr. B

  7. Billy Says:

    Very interesting post. However, what websites can I go to that will ask me questions that when answered with a yes or no, will give me a list of potential problems I can present to you when I visit. I mean I enjoy our weekly blood pressure checks, and simi annual blood tests, but I think I could be better prepared so you will know what to look for. You just don’t seem to understand how sick I really am. You keep saying to exercise, and working at the local Piggly Wiggly is good work, but I still have a studder in my step.

    How can I help you get the right answer?

  8. drtombibey Says:

    Billy,
    So good to hear from you. I think in some cases, the web can’t help as much, and there is nothing like a visit. Call Lynn O’Carroll and come on in- I’ll check it out first thing in the morning. I’m off today, so if it gets worse all of a sudden, better head on over to the E.R. Make sure they send me a report- tis hard to keep up with everyone.
    Hey, you remember when you had your kidney stone? Heck, you made the diagnosis- you called and said, “Hey Tommy I got me a rock,” and I knew it was you over the telephone. And you were right. So see- you helped me out on that one.
    Speaking of kidney stones, I’m gonna tell about mine Wednesday, so tune in, and I’ll tell you about it at your next office visit too.
    I tell ‘ya Billy, our patients help us more than what they realize- I appreciate your friendship.

    -Dr. B


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