Doctor - Patient Problems

by Duane Bristow

duane@kyphilom.com

Doctors generally or often or sometimes:

Do not follow up on tests and treatments recommended.

Do not use the internet to communicate with patients.

Do not understand how patient information should work in the cloud so that they can demand software that works that way.

Do not have or use properly a good "tickler" system.

Often do not respond to patient's questions and requests in a timely manner.

Do not try to reconcile their approach with that of other doctors the patient may be seeing.

Ask the patient, "What are you here to see me about?"
rather than, "How is your life going and how can I help you figure out how to make it better?"
In other words, they treat the symptoms rather than the life.

Are often arrogant and think they know more than they actually do, not only about their field, but also about other fields.

Are often more interested in the health of their portfolio than in the health of their patients.

Want their patients to listen to them more than they want to listen to their patients.

Think of their patients as diagnoses rather than emotional, illogical beings.

Are trained to think within the box. Are not Dr. Gregory House.

Think that if it can't be treated by the methods they know then it is not really a problem.

Assume that their time is more important than the time of their patient and often set follow up appointments for something that could be done over the phone or internet.

Are prone to want to unbundle services that should be bundled.

Patients, on the other hand, do not understand that it is the doctor's objective to make as much money as possible with as little expenditure of his time as possible. This is not a bad thing because it is the objective of most people including patients. The trick is to reconcile the objectives of the two sides.

Most patients are undereducated, illogical, unorganized, emotional and dependent. They don't listen well, follow instructions or even remember to show up for appointments. They often doctor shop, seeing more than one doctor with the same speciality. This can lead to conflicts in treatment. A second opinion is not a bad idea. Having more than one doctor managing treatments without coordination is a very bad idea. Patients also think that what they hear on TV or from their neighbors or find on the internet is more authoritative than the training and experience of their doctor. In most cases this is untrue.

Some patients are not like this, but doctors, for good reason, often assume that they are all the same.

Some related web pages:

The Doctor/Patient Relationship

The Doctor expects the Patient to:

The Patient expects the Doctor to:


The Medical Examination

It seems to me that if a family doctor or general practitioner does a good job he or she should include in a medical examination:

Although annual medical examinations are a routine practice in several countries, it is poorly supported by scientific evidence in the majority of the population. A 2012 Cochrane review did not find any benefit with respect to the risk of death or poor outcomes related to disease in those who received them. People who undergo yearly medical exams however are more likely to be diagnosed with medical problems.

Despite guidelines recommending against routine annual examinations, many family physicians perform them. Advantages include detection and subsequent prevention or early treatment of conditions such as high blood pressure, alcohol abuse, smoking, unhealthy diet, obesity and cancers. Moreover, they could improve the patient-physician relationship and decrease patient anxiety. Disadvantages cited include the time and money that could be saved by targeted screening (health economics argument), increased anxiety over health risks (medicalisation), overdiagnosis, wrong diagnosis (for example Athletic heart syndrome misdiagnosed as Hypertrophic cardiomyopathy) and harm, or even death, resulting from unnecessary testing to detect or confirm, often non-existent, medical problems or while performing routine procedures as a followup after screening.


Modern Doctors

My great grandfather was a country doctor in south-central Kentucky throughout the first half of the 20th century. He did not have access to x-ray machines, hospitals or pharmacies. He mixed medicines and placebos for his patients, examined them and did minor surgeries in his office.

John Bertram was the first radiologist in the area operating the first x-ray machine installed at Maple Hill Hospital. He told me that my great grandfather could tell more about a broken bone by feeling the patient with his hands than John could with his x-rays.

I find that now doctors do not examine patients. They look at weight and blood pressure and lab blood results and x-rays and ask the patient what is bothering them and listen to their lungs and heart but they do not actually do a hands-on or eyes-on examination of the patient's body. For instance, my wife told her doctor that her legs, feet and ankles had recently became swollen to the point that she could no longer get any of her pants and shoes except her very largest pairs on her body. The doctor prescribed lasix pills but never once during the office visit did the doctor actually look at or feel her legs or feet. Maybe doing so would not have told the doctor anything useful but I think that it would, at least, have made the problem more real for the doctor.

I also find that doctors will not try to treat patient's symptoms until they have a diagnosis. That would seem to make sense until you realize that sometimes getting a diagnosis may take weeks or months of visiting specialists and getting all kinds of diagnostic tests and procedures each of which must be scheduled separately and each of which may not be available for one to several weeks in the future and that during all this time the patient may be, not only living with the symptoms, but the symptoms may be getting worse.

I call this the dead pig syndrome. When I would have about 150 young pigs on sows in my farrowing house, I would sometimes find one dead on my daily visits. The proper procedure was to take the dead pig to the animal lab at Lexington about two hours drive away and wait about three days while they would grow a culture and then they would furnish me a diagnosis so that my vet could prescribe an antibiotic tailored to the specific pathogen that was my problem. This worked well except for one problem. If the pathogen in my farrowing house was a particularly virulent strain I might lose 50 pigs while waiting for the diagnosis. For that reason I would start using the vet's best guess wide range antibiotic while waiting for the diagnosis and hope for the best. This usually worked fairly well. I don't think modern doctors are aware of the dead pig syndrome. Or maybe they are afraid that they will be sued for treating a problem without a confirmed diagnosis. I guess they wouldn't be sued for losing a patient while waiting for a diagnosis.


Our experience with pulmonologists.

In 2013 Eva Bristow told our family doctor that she was having trouble staying awake during the daytime, having fallen asleep while standing up preparing breakfast. He ordered a sleep study at the local hospital and based on the results of that, which was done on August 2, 2013, he referred her to a pulmonologist specializing in sleep medicine in Bowling Green, Dr. Zachek.

She met with Dr. Zachek in Glasgow, Kentucky. He was in a hurry to leave because he said he had to get to a talk he had to give to a group of other sleep doctors. He said that the sleep study done in Albany was insufficent and inconclusive, so he ordered another sleep study at the Samson Hospital in Glasgow which was done on November 25, 2013. He then said that that sleep study was inconclusive and ordered another which was done on December 10, 2013. Dr. Zachek then ordered a third sleep study at the Glasgow hospital which was done on April 2, 2014.

I then asked Dr. Zachek why he was doing so many sleep studies. He said that he wanted Eva to have an expensive medicine to keep her awake and that Medicare wouldn't pay for it unless he had extensive documentation. He said that Eva did have borderline sleep apnea and he prescribed a CPAP machine and gave her a prescription for medication. He did not schedule a follow-up visit.

When we tried to fill the prescription at the drug store they said that Medicare wouldn't pay and we would have to get the doctor to get pre- authorization. Over the next several weeks I called the doctor's office about three times and asked his nurse to have him contact Medicare but he never did so. As a result Eva didn't get the medicine he had prescribed. Later our family doctor said that was just as well because the medicine was a form of meth and he would not recommend it for Eva.

Eva used the CPAP machine for about a year and decided that she was just as sleepy as ever so she quit using it.

In late 2014 Eva was having trouble breathing and when she mentioned this to her rheumatologist he referred her to a cardiologist. After extensive testing and finding nothing wrong with her heart the cardiologist referred Eva to a pulmonologist, Dr. Sandy.

Eva first met with Dr. Sandy on March 10, 2015. After telling us how efficient she was as a manager, Dr. Sandy ordered several breathing tests which were done on March 26, over two weeks later. Eva could not get another appointment with Dr. Sandy until April 16, about five weeks of breathing difficulty after her initial visit. Dr. Sandy tried to pass Eva off on a nurse practitioner but Eva insisted on seeing Dr. Sandy. Dr. Sandy then gave Eva her diagnosis of pulmonary hypertension and bronchiectasis. She prescribed use of two breathing medications twice a day and gave Eva a pari lc nebulizer to use taking the medications. However, Eva did not have a compressor to supply air to the nebulizer and Medicare required a prescription from the doctor to get the compressor. When I called Dr. Sandy's office and asked for that prescription the person on the phone said to just use the nebulizer without the compressor which our pharmacist assured us was impossible. After calling back to Dr. Sandy's office a number of times, we were able to get the prescription after about three more weeks of Eva's labored breathing.

Dr. Sandy referred Eva to a cardiologist & pulmonary hypertension specialist in Lexington, Dr. Booth. Eva visited Dr. Booth twice at a six month interval and both times Dr. Booth told her that her pulmonary hypertension was caused by her being overweight and the only thing he could do was to get her to lose 50 to 60 pounds which Eva was unable to do.

In September 2016 Eva began to have more trouble breathing in spite of using the medication in the nebulizer twice a day. She called Dr. Sandy's office to get an appointment and was told that Dr. Sandy could not see her until at least January, four or five months later.

So Eva asked her family doctor to refer her to another pulmonologist and she referred her to Dr. Ahmed. At her initial visit with Dr. Ahmed on November 15, he told Eva how very good he was at fixing breathing problems and ordered an at-home sleep study to be done on Dec. 7.

December 15, 2016 - Dr. Ahmed says that he can now hear wheezing when Eva breathes which he couldn't when he saw her on Nov. 15. He says this can be caused by COPD or bronchitis or bronchiectasis or a lung infection. He prescribed Prednisone 40 for five days and use of a Spiriva inhaler. He did not prescribe any antibiotic. He said to repeat the sleep study and to do a breathing test. These were not done until January 15, 2017, a month later.

On January 19, 2017 Dr. Ahmed said that the breathing test indicated that the lungs were functioning normally but were unable to fully expand probably due to some unexplained pressure in the chest. He thought a CT scan of the chest was needed but, for some reason, did not order one. He also said that the sleep study indicated that Eva does have sleep apnea and needs to be using a CPAP machine for two months and then see him to evaluate whether it has helped her breathing. He also told her to discontinue use of albuterol and brovana and budesonide in the nebulizer and only use the rescue inhaler, Ventolin, as needed for breathing problems. He said he would send Dr. Bruner's office instructions for anesthesia to be used during a D&C. Dr. Bruner's office later said that they did not get any instructions from Dr. Ahmed. Dr. Ahmed's office failed to order the CPAP machine from Eva's medical equipment supplier and, as a result, she did not get the machine until January 31, 2017. Then Eva quit using her nebulizer and began using her CPAP machine at night as instructed by Dr. Ahmed. Without the nebulizer she had more trouble breathing the next morning so I called Dr. Ahmed's office for instructions. I was told by the person on the phone there that she would ask Dr. Ahmed when he came in at 1:00 and call me back. No one ever returned the call so Eva went back to using the nebulizer with Albuterol treatment followed an hour later by Brovana and budesonide twice a day which was recommended by a nurse practitioner at the local urgent care clinic.

On February 14, I took Eva to a fourth pulmonologist, Dr. Shaun Smith at the University of Louisville hospital in Louisville KY. Dr. Smith did a test of blood oxygen while walking which held steady for six minutes and did a comprehensive metabolic panel blood test and ordered a ventilation/perfusion lung scan and an overnight sleep study later at the Somerset Hospital which his office was supposed to set up. He said he would call Eva after he had had a chance to review all her medical records and test results. After two weeks when the tests had not been set up I contacted his office and after that contact, Teresa did set up the test and said she would set up the sleep study but did not. The ventilation/perfusion test was done at the Lake Cumberland Hospital at Somerset on March 3, 2017. After I contacted his office again to ask about the sleep study, Amanda said that she would set up the appointment for the sleep study and call us right back, but we never heard any more from the doctor or his office until I emailed his nurse, Elizabeth, to accuse their office staff of incompetence on March 23. She then called to assure Eva that Eva needed the sleep study and she would set it up and call us back. She did not. On March 30, she called to apologize and to say that after Dr. Smith reviewed the medical records he decided another sleep study was not needed and that she would call back later with more information about what Dr. Smith thought about Eva's diagnosis and treatment. She called back on March 31 and said that Dr. Smith said that Eva had mild cases of pulmonary hypertension, bronchiectasis and sleep apnea as well as diastolic dysfunction meaning that because the heart walls are stiff and thickened due to age and HBP the heart does not expand and contract as it should. He says the treatment protocol for Eva's condition is limiting salt intake to 1500 mg per day or less and use of a CPAP machine when sleeping. She told Eva to weigh daily to monitor fluid retention.

On April 28, 2017, I emailed Dr. Smith's nurse, Elizabeth, to report that, although Eva's weight had been holding steady, she had now gained ten pounds in the last week and was having more trouble breathing. I reported that we think she badly needs to control pulmonary congestion with diuretics. We asked her to ask Dr. Smith if there are better ways of using diuretics to control pulmonary congestion? Elizabeth called the next day to basically say that if Eva was having trouble breathing it probably was because she was eating too much salt and not weighing every day. After that she did talk to Dr. Smith and he added a diuretic, Lasix 40 mg., to the 25 mg Aldactone that she was already taking and said that she should have a heart catherization in Louisville.

Dr. Thannoli, cardiologist, was unable to find anything wrong with Eva's heart in early 2015 and again late in 2016. Dr. Sandy, pulmonologist said in 2015 that she has pulmonary hypertension and Bronchiectasis. Dr. Ahmed, pulmonologist, said in late 2016 that Eva's lungs were working well but they were unable to fully expand due to some unexplained pressure in the chest. His nurse practitioner told her about 5 months later that this chest pressure was probably due to her being over weight.

Dr. Smith in early 2017 said that Eva has diastolic dysfunction meaning that because the heart walls are stiff and thickened due to age and HBP the heart does not expand and contract as it should.

This is all supposed to explain why Eva has trouble getting her breath and tires easily with minimum exertion. Dr. Smith's nurse performed a six minute walking test with Eva during which her blood oxygen level remained steady at over 90%. I am not sure that all this paints a consistent picture so that we can have confidence in what these doctors are telling us.

So far our conclusion is that the pulmonologists that we have dealt with seem to feel that they are great doctors but they and/or their staffs seem to be very inefficient and seem to think that breathing problems are not very urgent medical problems and treatment can be put off for weeks. After five months of three pulmonologists and many tests, Eva is still having difficulty breathing.