Dr. Thompson's Blog

Looking Beyond the Primary Diagnosis

A seventy-five-year old man, who had been a professional athlete, was being treated for prostate cancer that had also gone to his pelvic bone. The man had told his doctor that he was unusually tired,  but the doctor assured him that was to be expected. He also told the cancer doctor that he was experiencing extreme shortness of breath, but the physician didn't seem concerned.

When the man told me about his symptons, I asked him if he had had a recent chest X-ray or seen a cardiologist. "No", he said, " I haven't had a chest X-ray or seen a cardiologist." I was appalled. I can not understand a doctor assuming that the patient's symptoms were all due to his prostate cancer. A seventy-five-year old man could have lung cancer, cardiac problems or anemia becasue of involvement of the bone marrow.

Far too often I have seen secondary symptons overlooked. I saw one youth with Duchenne muscular dystrophy who was going to the bathroom frequently.  His pediatrician had not done a urinaysis or sent the boy to a pediatric urologist. I felt something unusual in the teenager's abdomen and had his mother give him a laxative and an enema and then return. There still was a troublesome fullness in the abdomen and I referred the boy to a pediatric urologist. A treatable abnomality of the kidney and urinary tract were found. The youth's pediatrician  asked me how I detected this and my daughter's answer was, "Well, I bet you took a history and did a thorough physical examination!  

Too often, too, I have seen biopsies signed out as the admitting diagnosis when the slides were unreadable. A sceond opinion is always needed with a serious diagnosis or unusual symtoms that don't go with the primary disease.

The Tragic State of Veterans' Medical Care

I was talking to a father last week who had been one of my pediatric patients. His son had just come back from Iraq and was having great problems with post-stress syndrome. The young man  had tried desperately to get  psychiatric care at  a  Veterans' hospital and clinics, but the father said they basically just sent his son on his way. I replied that I knew this was happening from talking to other parents and doctors in the VA system. They are completely overwhelmed by the tragic outcome of Mr. Bush and Mr. Cheney's war. Now Iraq veterans are committing suicide, abusing their wives, and many marriages are ending in divorce.

There is not enough money for veterans in the budget to hire more doctors or pay for private psychiatric care. To make matters worse, Mr. MrCain has "tabled or opposed: 20 million dollars in veterans' health care facilities, 430 million dollars for outpatient care, one billion-500 million dollars in additional medical care to be created by closing tax loopholes for the rich and one billion-800 million dollars for additional veterans' medical care by closing other tax loopholes". * This is unbelieveable for a man who is a veteran and professes to care about the Iraq veterans. We should all speak out and make every effort to elect a president who will care about our wounded veterans.

*These statistics were given by the commentator Keith Olberman on 8/18/08.

Congenital Torticollis

I had an e-mail from a grandmother asking about the diagnosis of congenital torticollis in her granddaughter. Torticollis means a twisting of the neck and can be seen following a traumatic birth. She said the child also had had a broken clavicle and that one side of her face was smaller than the other. The family had been told to stretch the baby's neck to the uninvolved side, but there was no improvement. She asked about the next step and what the long-term effects would be.

My suggestion to her was that a pediatric surgeon should be consulted, as soon as possible. If the muscle that is pulling the neck to one side is not released, the baby could have her head pulled to one side permanently with a marked difference in the two sides of her face.  With a release of this muscle, the sterno-cleido-mastoid, the two sides of the child's face should gradually become the same size.

One of the other things that parents can do initially, in addition to stretching, is to put colorful objects, such as a cradle gym, to the side where the baby does not want to turn, so attempts will be made to look at the objects.

Parents, Schools, Doctors, and Childhood Obesity

There is a long article in today's New York Times about expensive camps for obese kids. These can cost as much as $1000 per week. Some give scholarships, so that is helpful, but I wonder how much good they actually do. If there was a good long-term follow-up of the kids, that would be helpful. It would make more sense if the parents attended the camp with the kids. Overeating generally starts at home. In my experience, obese parents usually have obese kids. If fast foods are the norm and there are lots of cookies, ice cream, cakes and pies, soft drinks, and chips available, how does a child learn to eat properly?

I think the schools can also be faulted. Do we really need vending machines in the schools with soft drinks, candy bars,  potato chips and other high caloric foods available? Also, what about the usual cafeteria diet? High caloric foods are the norm, I am told. Do any schools teach good nutrition?

I think pediatricians and family doctors can also be faulted. How many doctors who see obese kids for a routine physical examination talk about diet or take a diet history?  I think taking a diet history is important for all kids when you do a physical examination. That has always been part of my examination and it is amazing what people are eating these days. I saw one child for a consultation who was thought to have a muscle disease because of weakness and muscle cramps. The mother was a single parent with a very stressful job and she and her kids lived on fast food. By getting a three-day diet history and then giving the mother some ideas about shopping and cooking on weekends, I cured the boy's "muscle disease" ! I think we have to do a better job of helping kids before they become overweight.

Is Your "Doctor" an M.D. (Medical Doctor)?

With the increasing fragmentation of medical care, it is getting difficult to know if your principal doctor or specialists are medical doctors, physician assistants, nurse practitioners,  osteopaths, chiropractors, neuropathic doctors or ????  Now even nurse practitioners, who get a doctor's degree in nursing, are apparently calling themselves "Doctor". (New York Times-8/10/08).

I had an interesting experience a few years ago when I took a bright, professional friend to a doctor's office. She was to have a D and C and was frightened. When we arrived at the office building, we checked the directory to see where the doctor's office was located. I noticed that the doctor had D.O. after her name and asked my friend if she knew that her "doctor" was not an M.D. "No", she said. I don't know what D.O. means." My friend went ahead with the appoinment and had a terrible experience. Needless to say after that experience she always finds out ahead of time the doctor's training, credentials and if they are an M.D. Yes, there are some fine osteopaths who then get an actual  M.D. and go through residency training with other M.D.'s and they are good doctors.

If you check the training of any board-certified medical doctor, I think you will find that there is a great difference in the training of most of the other "doctors". Certainly, nurse practitioners have half the number of years of training of an M.D., even if they get a "doctor's " degree in nursing. So every patient must do research. It is your life and you are the one that can make a difference in what kind of a "doctor" you entrust with it.

Surgery in Hospitals or Dental Offices and Anesthesiologists

I was talking to a man last week about interviewing him on my weekly Internet Voices radio program. He asked which of the past interviews would be good to listen to and I suggested the one about emergency room care or the one about receiving an anesthetic. "Oh good" he said, "I'm about to have knee surgery and I'm not worried about the surgeon, whom I know, but I'm worried about the anesthesiologist." I said he was absolutely right and gave the man  the Web site for the program which is: http://internetvoicesradio.com/Arch-DrCharlotte.htm. The anesthesiologist is Dr. Geoffrey Thompson, Chief of Anesthesia at Sharp Memorial Hospital in San Diego, Califronia. The interviews are each 30 minutes and give considerable important information.

When I am asked by parents or friends about how to check on an anesthesiologist, I give them the following advice; First, go to a state's medical board Web site and look for the doctor's name. This should give you information about his or her training and if the doctor is board-certified. The latter information  is very important. If the doctor is not board-certified, that means the necessary examinations and training have not been completed.  Any malpractice claims against the doctor should also be listed. If a child is to have an anesthetic, you want to be sure the doctor is a pediatric anesthesiologist. (Some hospitals do not have these specialists on their staff.)

If you are to have an anesthetic in a dental or doctor's office, it is important to ask who will give it. Also, I would ask if the office has adequate equipment and the necessary preparations to treat an emergency. Some hospitals now use nurse anesthetists, in order to save money. Their training is about half the number of years as an M.D, who is a board-certified anesthesiologist, so this is important information to know. We each have just one life and asking the right questions could make  the difference between life and death.

A Bell's Palsy Needing Further Work-up

A parent contacted me about her six-month-old child. The baby was not closing one eye as well as the other and had also developed some mild facial weakness. The family doctor had referred them to an opthalmologist or eye doctor, but they could not get an appointment for a month. I urged the mother to immediately take the baby to see a pediatric neurologist and be sure that an MRI of the head  was done. I felt it would be important to look for something more serious. Sometime later, I received a very grateful message that a small, treatable brain tumor had been found.

I think this is an important case for all parents and grandparents to hear. If you feel that something is not right even though a physician is not worried, you must keep digging until you find someone who can point you to the right specialist or in the right direction. In the past, a physician was held in great respect and parents or patients did not want to seek second opinions. In this day of fragmented medical care and inadequate medical school teaching, we all have to keep looking until we find the right doctor or other professional. Never, ever be afraid to seek a second opinion, even if you have been going to the same physician for a very long time. No physician or other professional should be afraid of a second opinion. I have always urged parents to get another opinion if they felt at all uncomfortable with anything I said.

Diagnosis of Cerebral Palsy versus Charcot-Marie-Tooth Disease

I had an e-mail from a mother who was concerned about the possible incorrect diagnosis of Cerebral Palsy in her daughter. She said she had looked on the Internet and that her daughter's symptoms didn't seem to fit that diagnosis. She asked what I thought. The mother said her daughter had a funny walk and her legs were weak. In addition, her lower legs were quite thin. When I asked if she had a hard time buying her daughter shoes, the mother was surprised, but said, "Oh yes, we have a terrible time. She has a very high arch."

My answer to her was that it sounded as if the mother was describing a very typical case of Charcot-Marie-Tooth disease. Many of these patients have high arches, great difficulty in buying shoes, thin calves (formerly called "stork legs"), mild progressive weakness and they lift up their feet to walk in what is called a " steppage gait".  This is a hereditary disorder and most likely other family members have problems in buying shoes or some mild weakness. A pediatric neuromuscular specialist should be consulted and nerve conduction times need to be done. Often orthopedic surgeons are the first to recognize  the disorder becasue of the foot problems.Later on, some weakness of the hands may develop. There are different types of Charcot-Marie-Tooth disorder, which have somewhat different outcomes.

(  Dr. Charcot was a French neurologist, who did some work with Freud and Dr. Marie was a student of Dr. Tooth in England.)

Paying Doctors to Practice Bad Medicine

I wonder if we will ever get back to the "glory" days when doctors were paid to practice good medicine. Now the more tests doctors do, the more money they make. The art of medicine, which means sitting down and talking with a patient, really listening, and then doing a good physical examination seem to be gone. Yes, there are still some fine doctors. I saw one this week for an eye examination. Dr. Kartsonis takes an hour or more to do an examination and when you leave you feel as though you have had the best possible eye care. He even makes house calls! Unheard of in this day and age.

Now according to an article by Peter Bach in yesterday's New York Times, Medicare is "Paying Doctors to Ignore Patients." The more tests they do, the more money they make. How tempting it must be if a doctor has a CT machine to keep ordering CT scans, even after the machine is paid for. Those of us who did not do procedures, but spent our time talking with patients and actually examining them made much lower fees. I saw many Medi-Cal patients for whom I received no payment at all, even though their complicated cases took many hours of my time. (These were children with physical disabilities or neuromuscular disorders.)  I loved practicing medicine and am sorry for the doctors whose only interest is how much money they can put in their bank accounts. Even the medical schools are falling into the trap of not teaching their students the "art of medicine", but instead how to order countless tests.

We need some changes in the way doctors are paid and perhaps the idea being discussed of paying primary care doctors more will help improve patient care. I certainly hope so. I wonder how much worse our medical care can get with the present payment system and the way medical students are being taught.

Talk Show Host's Rude Remarks about Autism

It is hard to believe that a talk show host is so ignorant about medicine and the problems of parents today that he would say autism is just poor parenting and bad behavior. I hope the owners of Mr.Savage's radio station will either censor him severely or let him go.

I wish he could talk with some of the wonderful parents and grandparents I speak with who have one or more children with autism. It would be hard to mimic many of the autistic characteristics  just by behaving badly. I wonder if Mr. Savage is a parent? That would be interesting to know. I assume if he is that his children are little robots and don't speak unless spoken to and are perfectly behaved. It is hard enough to be the parent of a child with special needs without having someone tell you that it is all your fault and you are just a bad parent.

I do worry  that many parents want to be "friends" with their children rather than parents. Every child wants their parents to be in control. They want friends their own age and their parents don't qualify. Many kids have said to me. "I wish my parents would act like parents and give me boundaries." That way kids feel safe and know the rules.