Trying to move the BPL membership thread here that drifted onto medical docotrs, here's a place to (civily) air you bad doctor experiences.

Two that stick out in my mind (besides the one I posted in the BPL membership thread) also involve GP mis-diagnosis:

a) going to my GP when I was 25 due to some lumps I found in my armpit. She sent me straight to a surgeon, who had me quickly booked for a lumpectomy. I lived in fear for weeks as I was *sure* that their concern and urgency meant the chances were high it was breast cancer. Turned out it was just mononucleosis...a simple and quick blood test would have diagnosed it.

b)I injured my ankle a few years ago. I was pretty sure it was broken as I couldn't bear any weight on it. I went to a local medical centre (I decided it wasn't an 'emergency' plus I didn't want to wait 8 hours in the emergency department with all those sick and injured people). The clinic had a gaggle of GPs, X-ray facilities, and was a close taxi ride to home. Naturally they x-rayed it and pronounced there was no fracture (I can't read x-rays to save my life). They sent me off with crutches and instructions to start trying to bear weight. A week later I was back as the pain was no better. They referred me to physiotherapy, which made it worse. After three weeks of this torture, I finally got a referral to an orthopod who x-rayed it again, and even I could see the whopping big lightning shaped fracture through the distal fibula. 6 more weeks of non-weight bearing cast (a Goretex lined one yipppy) and a couple more in a walking boot, and I was on my way to a full recovery. But next time I would go straight to emergency and wait to see an orthopod!

Edited by retropump on 06/28/2009 19:34:24 MDT.

a) Were you ill or otherwise mono-looking at the time? Was there a lump in your breast? They can't test for everything every time. And, yes, a woman with a lump in her armpit has cancer until proven otherwise. (Are you a woman?) Breast cancer is simply too common and the consequences of missing the diagnosis too severe not to make that assumption.
All that said, I personally would have done my "standard" lymphadenopathy workup before heading for an excisional biopsy. That would have included a monospot, and you would have gotten a week of antibiotics to see if it cleared up. Maybe longer if you had trauma to your chest or arm- especially a cat scratch. And I would do a mammo and breast ultrasound first, too. But I might very well do a fine-needle biopsy of the offending lymph node in clinic on the first visit. It all really depends upon just how dramatic the lympadenopathy was, and what the rest of your storey was. it's a more complex diagnostic dilemma than you think.

b) This is VERY common. It is annoying, but not malpractice.
A nondisplaced fracture can be invisible on an early xray. After a few days, when your body starts to form a callus to heal it, it becomes MUCH more obvious on the xray. In such cases we count upon patients doing exactly what you did- return in a few days complaining that it is no better. I'm not sure why they didn't re-xray you at that point, though, instead of sending you to PT. THAT might be malpractice.
But, maybe that's just the NHS for you... :o)

Edited by acrosome on 06/29/2009 05:11:42 MDT.

Japan has a truly awful medical system (in spite of having some of the best technology in the world). I have been visiting the hospital every month for the past eleven years and have seen it all.

Back in 1994 I had been feeling pain in my lower abdomen for about a month and it just wouldn't go away so I went to a small hospital in a town west of Tokyo. The doctor prodded me with his fingers for five minutes before announcing, "You have pancreatic cancer. You have about two months to live." You can imagine my utter shock. Being younger and more naive I took his words at face value and for a week I thought my life had ended. Of course I went to get a second opinion and the second doctor said I was fine.

One thing that did come out of it: after leaving the first hospital I took a walk along the garbage strewn beach (I mean absolutely stinking awful!) with my wife. I don't think I ever saw so much beauty in my life!

"Were you ill or otherwise mono-looking at the time? Was there a lump in your breast? They can't test for everything every time."

The GP didn't ask me any questions about my general health, though I was going through periods of being chilled. My throat was mildly sore, but again I wasn't asked, and it didn't occur to me that the two were related. Anyway, this was 25 years ago, and I would hope in this day and age a fine needle biopsy and appropriate blood work would be a minimum, but you never know! If a GP can mis-diagnose my 18 year old son and shove antibiotics down his throat twice without even considering mono (a much much more common condition than breast cancer, and a very common cause of inflamed throat/tonsils in adolescents), then maybe the same would happen again.

"This is VERY common. It is annoying, but not malpractice."

Agreed. I never mentioned malpractice.

"After a few days, when your body starts to form a callus to heal it, it becomes MUCH more obvious on the xray"

Actaully, after 4 weeks of mobilisation and weight bearing, the fracture gap widened, which then became more obvious, but the orthopod was able to show me the original fracture line on the first x-rays. They were faintly but clearly there to a 'trained' eye.

A good lesson I learned here was that just because a physio says it's good for you, listen to your body foremost!

"But, maybe that's just the NHS for you... :o)"

No NHS here, though accidental injuries are covered to a certain extent, but we have to make up the shortfall between the supplemented fees and real costs. The lymph episode was 100% private health care.

Well, I certainly agree that mono would be in the differential for both you and your son. (Especially the bit with your son.) And I certainly don't deny that you and your son had a bad experience. But second-guessing other practitioners is a fool's errand (from my point of view) because I wasn't there and didn't hear the history as presented and do the exam. It's just impossible. Especially regarding your lump/nodes!- A lot of that management would be driven by your history and the exam. I can easily envision circumstances where I might proceed straight to excisional biopsy- though that is not typical.

>> I never mentioned malpractice.

And I never said that you did. :o) It was just my observation, by way of trying to categorize what had happened.

>> No NHS here

Really? Curious...

I would have expected one in "the antipodes of La Coruna." (I'm shortly moving to 180km west of the antipodes of Ile Saint-Paul...) In fact I thought I had googled it, once, but I guess not. How does it work there, then? Do you have private insurance or HMOs? Or government-subsidized insurance, like in Germany? Or what? (You mentioned private insurance but I'm asking for specifics because the Germans, for example, call their insurance "private", too, and it really isn't. Sort of. It is government-mandated and often government-subsidized. Actually, they have a pretty confusing system... even for an American!)

I had thought it was an NHS partly because that made a certain amount of sense to me regarding your son's mono disdiagnosis that you describe. NHSes tend to be rather penny-pinching and thus might have a policy that one doesn't waste money on a monospot if the physical exam looks classic for strep- beefy red phayngitis and the characteristic white spots on the roof of the mouth.

Contrast that with the situation in the U.S. in the 1970s or so- the days of fee-for-service medical care, when healthcare consumed 1/3 of our GDP. (And grant us this much- we have one HECK of a GDP.) If you showed up with a heat rash you would get $2000 worth of bloodwork simply by walking through the door- because we could bill for anything we wanted! Probably best that such things came to an end, all things considered. But we in the U.S. still tend to be much more aggressive (and, by implication, wasteful) about such things than, say, the British NHS.

Edited by acrosome on 07/02/2009 04:48:37 MDT.

NZ health is a combo of "private" and "publc" health care. Basically, most prescriptions are fully subsidised, but IF you are over 18, under 45, and not on welfare, then you pay to visit your GP. Other groups get a subsidy to visit the same GP, but the GP is a private practitioner. There are other subsidise for costs incurred due to accidents (this is to prevent litigation going crazy), and a public hospital system that admits anyone who is sick enough to get in the front door. On top of that, there are private health insurers (which is waht I had when I was 25) who cover many treatments either not coverd by the public system, or not treatable in a timely manner. In other words, the public system is composed of triaged waiting lists, but the job usaully gets done in the long term, or in urgent cases (such as my son's head injury or my smashed ankle). So far, my treatment in the public system has been much better than the private. Oh yeah, standard tests ordered by the GP ARE fully subsidised, but it is unusual for a doc to forgoe a standard test like mono spot or throat culture because of this, especially when 7 days of antibiotics didn't fix the problem first time around!

Wow. And I thougt Medicare was confusing...

Obviously, my specialty colors my perception of any given problem. If a woman is sent to me with a breast lump or an enlarged axillary node then as far as I am concerned she has cancer until I can prove that she doesn't. That's simply the way it is- with all general surgeons.

A GP's or FP's job is different. They are, in many ways, "screeners" for the specialists. They see many more people with nothing more serious than a self-limiting virus than I do. (If I see someone with a self-limiting virus, odds are that I will have a talking-to with the nut who referred them to me...) As you presented your son's case, yes, as I said it seems like I would have ordered a monospot. But, again, I wasn't there. I really can't say anything more than that. As I said, second-guessing another provider, especially without access to the chart, is a fool's errand. :o) He may have had thought-processes that he didn't express to you at the time, and I can't know them without the chart.

How long ago was this, by the way? If it was a while ago then mono testing might not have been the trivial thing that it is nowadays, with the monospot. Not that that makes a big difference, but maybe enough to explain his delay. After all we don't even treat mono. The biggest reason to test for it is so that the kid can be quarantined, and avoid contact sports for a few weeks so he doesn't rupture his spleen. Now THAT sounds like how an NHS would think about it! :o)

Also, as a fine point, giving antibiotics for strep throat is NOT meant to cure it. In fact there have been many studies proving that antibiotics have no statistically significant effect on the duration of illness. Instead, the antibiotics are to prevent the bacteria from becoming blood-born and causing heart valve vegetations, which happens occasionally with strep.

Edited by acrosome on 07/02/2009 04:47:19 MDT.

"Wow. And I thougt Medicare was confusing...'

Naaah, medicare is just pathetic ;)

I probably made that more complicated than it is. Suffice it to say that those that can best afford to pay for their healthcare, do. Those that can't will qualify for some degree of subsidy depending on how bad off their illness and finances are. Children are free for most things, regardless of their parent's income.

"If a woman is sent to me with a breast lump or an enlarged axillary node then as far as I am concerned she has cancer until I can prove that she doesn't."

In no way did I expect the surgeon to do otherwise. What started this whole conversation was my assertion that it really helps 'when visiting a GP', if you know what *might* be wrong with you. By the time you get to the specialist, the basic diagnostic tests should have already been done.

"He may have had thought-processes that he didn't express to you at the time, and I can't know them without the chart."

It turns out you are right, but not necessarily in a good way. I found out last night that the GP in question receieved his medical education in India, and has only recently started practicing here. Not that that should matter, but there may be both cultural and language barriers involved here. I found this out when told by my son's father that the doctor had rung him up with the mono results (two days after I had already found out by ringing the nurse), told him it was positive and that he needed to get my son back on antibiotics! There is something seriously wrong with this individual, so we are laying a formal complaint with the clinic who WILL have access to all the notes.

"The biggest reason to test for it is so that the kid can be quarantined"

Well in this case the reason I wanted it tested was so we could ascertain if the second course of anitbiotics was necessary. A kid that sick isn't interested in getting out of bed, so quarantine was not a problem.

"In fact there have been many studies proving that antibiotics have no statistically significant effect on the duration of illness".

They would be studies in the minority I suspect, after a quick survey of medline. Also the Mayo Clinic has this to say:

"These antibiotics reduce the duration and severity of symptoms, as well as the risk of complications and the likelihood that infection will spread to classmates or family members. Once treatment begins, you or your child should start feeling better in just a day or two. Call your doctor if you or your child doesn't feel better after taking antibiotics for 48 hours. If children on antibiotic therapy feel well and don't have a fever, they often can return to school or child care when they're no longer contagious — usually 24 hours after beginning treatment."

Aside from that, we are well aware of the difficulties a family can face when there is an asymptomatic carrier in the house, or a person re-infects themselves through dirty toothbrushes etc...but that's a different issue as my son does not have strep throat.

>> These antibiotics reduce the duration and severity of symptoms,

Ha. Was that from an 'information for patients' section or something? Of course, they can say that antibiotics "reduce the duration and severity of symptoms", because the studies show that they do. (And that's what patients think, and if you tell them otherwise they think that you're a nutter. That's how patients end up getting antibiotics for a virus, too.) But it is a trivial reduction! Believe me, the big benefit is meant to be reducing the incidence of endocarditis and vegetations.

Unless some new data has come out in the past five years or so...

I'll look.

P.S. You REALLY don't want me to start posting my own medical horror stories. I would terrify everyone... :o)

Edited by acrosome on 07/03/2009 09:19:25 MDT.

"You REALLY don't want me to start posting my own medical horror stories. I would terrify everyone... :o)"

I conduct a trombone choir that consists of mostly retired medical doctors. I learned real quick not to ask them stories about their practice! =)

"and that's what patients think, and if you tell them otherwise they think that you're a nutter. That's how patients end up getting antibiotics for a virus, too"

Yeah, I know. Antibiotics in NZ are the most precribed *placebo* treatment used by GPs. And the reason cited for prescribing them lacking any clinical evidence is that the patients expect some pill to take before they leave the GP. THAT's why I was concerned about the blatant mis-prescribing that my son experienced. I *know* the machinations of the average GP too well to NOT be a cynic when it comes to things like "just take this antibiotic and hopefully you will feel better in a few days". Apparently my son is not very susceptible to the placebo response (probably my fault as it is my special interest area of research). Anyhow, I am sure that many of us would like to hear your medical mis-adventure stories...

Well, I'm certainly not going to post something that might be admissible in court! :o)

Sorry.

I could supply endless funny stories about various objects I've pulled out of people's rectums, though. I'm the guy they call for that...

A toy train (the wheels had something to do with it, apparently).
A bottle of cologne.
Turkey basters.
Turkey baster bulbs.
Light bulbs.
Various fruit and vegetables, of course.
A nail (!)
Pens. (Actually, I guess it is easier to loose smaller objects up there...)
A wax candle that softened and deformed sideways and caused a perforation when his rectum contracted. Ouch.
Actually, I found a vacuum cleaner attachment all the way up by a guy's hepatic flexure, once. That had to be a good story, but he wasn't talking...
Various plastic bottles: shampoo, vegetable oil, whatever.
And, of course, various objects actually designed for such things.
Oh! And a fish! It was a small de-finned trout, as I recall. With a prophylactic over it. The tail was still sticking out, but he'd missed a fin and just couldn't remove it on his own. We sedated him and dilated him, and got it out.
I could just go on and on. Suffice to say that if it seems like it might just possibly fit, I've probably removed one.

And they all "fell on it."

Incidentally, when a guy comes to the emergency room SPAK (status: post a$$-kicking) the story is ALWAYS: "I was walkin' down da street, mindin' my own bidness, when TWO DUDES jumped me for no reason." The implication being, of course, that if it was only one dude the victim could have taken him. When someone comes in stabbed more often than not the perpetrator was "some FEMALE DOG", if you know what I mean... Evidently, in that demographic the women like to carry knives. Men carry guns, of course. This is America, after all... :o)

Edited by acrosome on 07/04/2009 05:48:15 MDT.

"I'm the guy they call for that..."

Wow, how do you manage to get all the good cases :)

>> Wow, how do you manage to get all the good cases :)

Every specialty has an albatross. This is one of mine. :o)

Eeeeeew. There's a lesson for you folks: Use your Easton tent pegs only as advertised. And don't get any ideas just because your Steripen is called the "Adventurer"...

Edited by ashleyb on 07/10/2009 01:59:53 MDT.

Love it, Dean-

Over a dozen years in prehospital care: I remember one guy who "fell on" about 16 inches of curtain rod. I also clearly remember a fuzzy "picture" of D-cells framed by a great mass of male pelvic girdle... How is it that everyone "falls on it?!"

I was temporarily confused by the seemingly lucid guy who told me he had the "smilin' men of Jesus."

(Yes, spinal meningitis.)

Cheers-