We’re all on the same side
Mr. N, a patient visiting New York from Florida, came to see me because of headaches. In Florida, his family doctor had prescribed an oral antibiotic for several months for what he called chronic recurrent sinusitis. This doctor -- whom the patient had been seeing for several years -- apparently was confident that the headaches were a result of the sinus condition.
I wasn’t so sure. The sinus expert to whom I sent Mr. N reported no evidence of a sinus infection and didn’t believe the patient needed antibiotics. The infectious disease expert with whom I shared my office concurred. The neurologist who treated Mr. N for his headache thought he had a life-threatening inflammation known as temporal arteritis, and she started him on steroids to keep him from going blind or having a stroke. The arterial biopsy for temporal arteritis was equivocal, but the neurologist said this was often the case and continued treatment.
The patient complained that I was ordering too many tests and sending him to too many doctors.
Still, he showed a dramatic decrease in his symptoms two weeks after taking the steroids, and I was able to document an improvement in his inflammation count (known as erythrocyte sedimentation rate, or ESR). He returned to Florida relieved.
I left a message for Mr. N’s family doctor in Florida, but he didn’t return my call. When I telephoned Mr. N, he sounded edgy and told me his family doctor didn’t believe he needed to see all those so-called experts in New York. This doctor also apparently thought that there were many intangibles to this patient’s case that only he could know because of the long history together. I acknowledged the value of this; I merely saw the imperative to communicate the new findings.
Specialists are helpful in the case of a prolonged illness that doesn’t respond to treatment, but I made it clear to Mr. N that I had only been pinch-hitting for his regular doctor. “I hope you stay on the steroids,” I concluded, and Mr. N promised that he would. I left another message for the family doctor, but again he didn’t return my call.
Several weeks later Mr. N called me to say that his liver tests were now abnormal and that his doctor intended to stop the steroids and remove his gall bladder. “You need to stay on your steroids throughout any operation,” I said, my shaky voice betraying my worry. “Surgery is a stress, and steroid requirements increase during stress.”
Mr. N didn’t seem to understand me, and I was faced again with not wanting to undermine his local care. This time I didn’t try to reach his physician. There was no point in subjecting myself to his dismissal. Luckily, Mr. N got better before an operation was necessary and left the hospital.
Afterward, he decided that he no longer was happy with his local doctor. I was able to recommend another doctor with an office nearby. This doctor had similar training to that of my own and Mr. N’s old doctor and was known to be a good communicator.
Knowing when to call a specialist is at least as important as knowing the answer yourself, especially in the case of a rare disease.
Mr. N continued steroids under his new doctor’s guidance, and his inflammation was soon controlled. His gall bladder stayed with him as he deleted fats from his diet. His sinuses never bothered him again, and his headaches disappeared.
Complex cases often require specialists for proper evaluation. A doctor’s skills are multiplied exponentially by communication with specialists, diminished drastically by isolation and know-it-all care.
The ostrich doctor had his pride, but no one was competing with him or trying to show him up. He did his patient a disservice by shutting himself off from other physicians who brought a different perspective to the case.
Mr. N told me that he ultimately switched doctors to enter a world of cooperative medicine. The growing technology and sophistication of medical practice these days demand this ongoing exchange. Patients’ lives are precious but must not be hoarded.
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Dr. Marc Siegel is an associate professor of medicine at New York University School of Medicine. He can be reached at marc@doctorsiegel.com.
