Monday, March 19, 2012

Can you look at this growth on my back?

Dermatologists often do not like to admit that they look at skin growths all day.  Because the next thing they know, there is someone at a cocktail party asking them to look at a mole on their backside.  (And yes, all Dermatologists regularly attend cocktail parties.)

Should physicians diagnose or treat their friends and family members?  It is a tough issue.  Once you complete medical school (or sometimes even before), you are immediately seen as the know-it-all of everything medicine related.  Physicians want to be helpful to friends and family.  But how far should we go?

Let me start with diagnosis.  This is the most common thing I'm asked by friends and family.  "What do you think is wrong?  Could he have cancer? Why is my pee green?"  The process of diagnosis is probably the most complicated thing most physicians do.  Diagnosis is not as simple as looking in a book at the causes of green pee.  We spend hours in medical school learning how to arrange a proper diagnostic encounter, including how to look at the patient, what tone to use, what words to use, and even which way to cross our legs.  (Crossing your legs away from the patient signals that you are closed to hearing what they have to say.)

When I see a patient in my office, I start by asking open ended questions and letting the patient talk.  Based on what the patient is saying and how they are saying it, I continue down a path until I think I have a diagnosis.  I am also cuing into patients non-verbal responses, which can lead me to new and important questions.  This whole process is disrupted when a family member calls and asks, "Why is my pee green?"  Without the rhythm of the normal diagnostic encounter, the correct diagnosis could be missed.  

There is another reason diagnosis with friends and family members is difficult: some questions are off limits.  If my friend calls me and asks me why she is fatigued, I don't want to ask her if she could be pregnant, how heavy her periods are, or if she has any blood in her stool.  (Weird and awkward, but all causes of anemia.) If my friend asks me about some new joint pain, I don't want to ask him if he's a new sexual encounter, especially if I'm friends with his wife!

Finally, the hardest part of diagnosing friends and family is giving bad news.  What if I think my family member has cancer?  Is it right for me to have to give them that information?  It's unfair to both the physician and the patient.  Giving this type of news is something that only an unbiased physician should do.

Are there diagnostic questions that are ok to ask? Yes.  If I'm riding bikes with you and you fall off your bike, I'm happy to help you decide if you need an ambulance, or if you have a broken bone.  Why?  There's not much of a story to tell.  There are no questions about your sex life involved in broken bones (usually), and it's not likely we will have to address prognosis.  So most urgent situations are fine.

Treatment.  "So my doctor says I have high cholesterol.  Do you think I should take medicine?"  Most of you that know me would probably guess that I would say, "No. Eat more vegetables and ride a bike."  But, that's not fair, because that's my opinion.  Treatment decisions are another complicated interaction between a physician and a patient.  The dyad needs to account for the values of the patient and the long term implications of taking a medication.

But what can I ask you about treatment?  I'm actually much more open to talk about treatment with a family or friend, as long as the decision is made with the treating physician.  I'm happy to give you my opinion if it's in area I know about or can look up.  It actually can be helpful for me to arm you with some questions that you would want to ask your doctor.  But you should always make the final decision with your physician.

Summary: Being a physician that's asked questions by a family or friend is a tough situation. We always want to help, but do not want to hurt.  It's always ok to ask me about my opinion on something, but do not be offended if I suggest you talk to your doctor.  I'm not being rude.  I'm just trying to help.