Knowing your Limits

I mentioned some posts ago that for the Spring Semester, I would be teaching in the Clinical Skills labs at the local medical school. Well, today was my first day as a "clinical instructor," and I think it went pretty well. The topic of the lab was how to properly perform an eye exam, and while OB/GYN doesn't usually lend itself to frequent ophthalmologic exams, the lab was a good refresher for my own physical exam capabilities. As I was teaching the first-year medical students, my mind drifted back to when I was in their shoes. I found myself remembering asking my instructor questions like, "How do I turn this stupid thing on," and "where's the optic disc?" I also remembered becoming excited about finding the optic disc, only to discover that I was looking at my partner's illuminated eyelid. Well, times have changed, and now I'm in the instructor's shoes, distinguishing optic discs from eyelids, and (hopefully) looking like I know what I'm doing.

It's amazing to me that after a few years of training, hard work, and getting their hands dirty, students can progress from asking "where's the optic disc again?" to caring for patients, performing surgery, or even (gasp) teaching medical students how to be competent physicians. We often take the knowledge this progression entails for granted, especially among other medical professionals. Unfortunately, just because someone graduates with a medical degree does not mean that they know everything about, for example, the eye. The first-year Ophtho resident who was helping instruct the lab today knew more about the eye than I ever would want to know. Likewise, I'm sure that my knowledge of pelvic anatomy and reproductive endocrinology could, forgive the pun, blow his eyes out of their sockets. As physicians, however, we're ok with this fact. It's the reason that specialties exist - I don't care about the eye, he doesn't care about the vagina, but we can still get along. Outside of doctors, nurses and what-have-you, however, those specialty lines often become blurred, and the layperson can incorrectly get into the "one doctor's the same as another" mentality. This often leads to incorrect management of the patient's disease, which, as you might imagine, can have dire consequences on their health. Now, don't get me wrong, I'm a firm believer in being a "total physician." Yes, I might be a Gynecologist, but that doesn't mean I can't treat Strep Throat, check cholesterol levels, or order an EKG for a weird heart rate. What it does mean, however, is that if my physical exam/history finds something, I will do something about it, be that treat (if I'm comfortable), or refer to someone who is comfortable for treatment.

So many of the patients I see while performing Disability Physicals are applying because their physician has been mismanaging their care. I know that I've talked about this before, but it needs repeating. If the management is not successful at treating the problem, maybe it's time to consider referring the patient to a specialist. There's nothing wrong with saying "this problem is too much for me," and sending them to someone who deals with said problem daily. Here's an example: my medical license gives me the right to perform surgery or prescribe medicine as I see fit, and if I opened my own surgery center, I could perform brain surgery if I wanted to. Seeing as I have no training in brain surgery, that might not be such a good idea, but I would legally be able perform that procedure. Now, imagine you have a brain tumor. You're applying for disability (of course), and therefore receive your application physical from yours truly. I say, "I know that you've tried some things before, and since you still have your tumor, they obviously didn't work. Why don't you let me do some surgery, and we'll fix things up in a jiffy." Would you let me perform surgery on you? I hope not. So why would you let a generalist try and manage your uncontrolled diabetes, heart disease, or whatever? Many physicians let their egos get in the way of patient care, and ultimately it's the patients that pay for it. We must remember that it is our sworn duty to protect the health of our patients, and to give them the best care we can, even if that means saying, "this is out of my league." It's much better in the long run to send them to a specialist than it is to try and manage a condition that you've only read about. Handing them a Wikipedia article about their condition and saying, "now you know as much as I do," does little to inspire confidence.

And now for the disability quote of the day:

Me: "So you say that your shoulder pain keeps you from working. How so?"
Very muscle-bound man: "Well, it really hurts me after lift a lot of weights, especially if I've been doing an upper body day."
Me: "So you're saying that weight lifting causes your shoulder to hurt, especially if you've really been pushing it?"
Man: "Yeah, that sounds about right."
Me: "What type of work do you do?"
Man: "Desk job, typing, that sort of stuff."
Me: "Well, it sounds like your pain is keeping you from working out more than it is from working."
Man: "Haha...yeah..."

Know your limits,
-DD