Making a self-diagnosis of acute appendicitis is unpretentious especially when the patient is a family physician with over 30 years of clinical experience -right lower quadrant pain, increasing in intensity over a three day period associated with anorexia and chills. I arranged to undergo the appropriate tests which corroborated my diagnosis. After calling the surgeon, I headed to the hospital for the appendectomy. However, from the moment I arrived in the emergency room, until the time I was discharged from the hospital on post-operative day number 9, I became increasingly dismayed by our modern health care system. My surgical abdomen became the subject of stat entries into an electronic medical record (EMR) while the old-fashioned H and P was basically ignored. Had I not been a well-trained and experienced physician I am convinced that I would have suffered a fatal post-operative event. The medical students assigned to my care would never have known that I died, unless they received a notification on their Twitter account.
In the ER, the unsupervised 4th year med-surg rotating medical student wheeled in a large computer and began to ask me questions related to my abdominal pain. Within 5 minutes, the student had somehow acquired all the information he needed for my admission. But wait a minute. My medical history is somewhat complex and I was taking 11 different medications on admission. As the student doctor was wheeling his computer back to his lounge, I reminded him that his H and P was deficient. Oh, he DID listen to my bowel sounds, or lack thereof, through a blanket and hospital gown. He forgot to listen to my lungs, and never examined my mouth, eyes, feet or ears. He forgot to check for peritoneal signs. But to play devil’s advocate, why do an exam anyway? The CT scan of the abdomen showed evidence of acute
appendicitis. The confident student stated that he would see me in the OR in a couple of hours to which I opined, “Hey, you forgot a few important aspects of your H and P.” Shocked, the unsupervised student asked, “What do you mean? You have appendicitis. The CT scan confirms your diagnosis. This is the easiest case I’ve had all day. Let’s get you to surgery.”
“OK, ‘doctor,’ slow down. You failed to ask me about my past medical history. You see, I have type 1 diabetes and am on a pump and continuous glucose monitor. I believe that might be relevant to my comprehensive care plan.” The student proceeded to role his EMR computer back into the cubicle. He attempted to search the EMR for whatever additional questions might be pertinent in my case. Oops, I guess he needed a little help with his inquiry. While lying on the gurney in pain, I began to teach him how to interview a patient with diabetes. I suggested that he ask about the type of diabetes I had, the duration of the disease, how well the glucose levels are controlled, the most recent A1C, and if I had developed any long-term microvascular or macrovascular complications. He appeared lost and confused by my suggestions. Even more troubling, he had never heard of the insulin analogue I used in my pump, nor did he have any knowledge regarding my GLP-1 RA dosing. He had never seen an insulin pump. The use of the CGM seemed to shock his psyche. “Where did you get that device? We are going to have to take those meters off you before surgery.” So now a 4th year unsupervised student is telling a diabetologist to remove the very devices which provide intensification of care. “Sonny,” I said, “No one is touching my pump or sensor. As long as I am conscious I will regulate my blood glucose levels with these devices. Besides, these pumps emit an electrical charge. If you touch it, you will be shocked and you may need resuscitation!” That was the last time anyone at the hospital told me that they were going to force me to remove the pump! As the student walked away once again, I could see his mind working in a devious way, “how dare this old-timer be questioning my diagnostic skills? Who does he think he is?”
In 1980, my senior year in med school, we had no EMR. Instead, we received a gifted education. Our supervising interns, residents and attendings taught us how to communicate with patients. We learned to question, listen to, and interpret the data provided by each patient. We listened with our ears, our brains and our hearts. We were encouraged to use our hands in a process known as “physical diagnosis.” A rectal exam was mandatory for every patient with an acute abdomen. Tests were ordered to CONFIRM
our suspected diagnosis, not as primary means by which patients could be diagnosed. We learned to question the lives and disease states of each patient using a “review of systems.” Even negative aspects of this inquiring had to be recorded so that we would become use to medical inquiry and nomenclature. A history and physical would take 30-45 minutes. We were never rushed, but we were criticized if we took shortcuts. Should we have questions about how to proceed, we would ask one of our attendings, not a computer. Our time on the wards was spent speaking with patients, looking at Xrays, reviewing lab studies or in the library reading. The term “meaningful use” implied that our lab and ancillary testing requests appropriately reflected our clinical impression. Today the best students are those who have become adept at computer simulation and data entry. They spend time in a computer lab learning patient simulation. These students are not clinicians; they have become experts at finding Wi-Fi hot spots from which they might access social media. Their hands are better at texting than evaluating patients for abdominal distension.
Although my laparoscopic appendectomy went well, the postoperative course was complicated by an ileus which persisted 8 day. I received no food, liquids or oral intake during that time, yet my glycemic control was perfect. By the 6th postoperative day I was in ICU sprouting a shiny nasogastric tube which was draining over 2000 cc of gastric contents. I felt myself becoming dehydrated and even hypokalemic. I was beginning to hallucinate and become weakened by my acute renal failure and electrolyte imbalance. The attending doctors, none of whom examined me, were not concerned. They may have been had they examined my distended abdomen, looked into my parched dried mouth, or noted that I was unable to hold my head upright. Finally, in an act of desperation and self-preservation, I demanded that the nurse to provide me with a 250 cc normal saline rider and to increase the IV infusion rate from 50 to 150 cc/hour. Potassium was also provided. The surgeon who did not carry a stethoscope noted that my abdominal distension was becoming worse. “I can’t understand why your ileus is still a problem. Let’s get a barium swallow,” the results of which demonstrated a functional bowel obstruction with no gastrografin moving beyond the gastric outlet. I could have told him that as I continued to deteriorate.
On post-op day number 7, a hospitalist came to see me suggesting that my diabetes was the cause of the ileus. “Yeah, I see this all the time. You have gastroparesis. I am going to place you on parenteral nutrition, remove your pump and meter, and let the pharmacist manage your diabetes.” This doctor was quickly relieved of his duties by myself and my wife. He never returned for a follow-up encounter. By postoperative day number 8, the ileus was resolved thanks, in part, to the role of gastrografin in increasing gastric motility. The hypokalemia, acute renal failure, and dehydration had all resolved and I was ready to leave the hospital. As a physician and as a patient, I survived this very difficult perioperative course, due, in large part to my self-advocacy. I was lucky. A regular Joe would never know how to protect himself from or reverse dehydration, hypoglycemia, hyperglycemia and electrolyte imbalances. These hospitalized patients would be at the mercy of medical professionals who could potentially make inappropriate clinical decisions.
Upon my discharge from the hospital, I attempted to mitigate my frustrations about my experience with modern medicine by contacting the Dean of the local medical school. I explained that her 4th year students were ill-equipped for clinical medicine. Unsupervised, they were not able to perform an adequate history or physical exam. They did not know how to follow a patient during the perioperative period. In fact, they did not know who to even communicate with patients, although they always said, “Have a great day. We’ll see you soon.” The Dean appeared stunned at these revelations and appreciated my concern. She proceeded to provide me with the corrective action plan that she had been working on for some time. “We need implement our patient simulation computer program which is designed to teach our students how to appropriately interact with their distressed patients,” said the Dean. Really? “What you should do, Dean, is to have these medical students unplug their smart phones, computer, and iPads. Let them spend a day or two with one of us ‘old-time docs’ who still work with our hearts, our brains and our hands. We’ll show these guys how to become caring, intelligent, and dedicated clinicians.” The Dean thanked me for my suggestions and implied that she would have one of her IT guys call me so that I might provide guidance on their patient simulation software.
God help us!