Hello there friends! Ace reporter Mr. Fluffles here, back again to bring you the very best in hard hitting atheist interviews. Recently, a nuclear bomb was released in our community, as we discovered that many famous males in the skeptic movement are actually serial rapists. Some people doubted the anonymous reports that flooded in, but my friend PZ Myers had a wonderful post about these derpwads. In it he asks the question: how would we get by if doctors were ever skeptical of our claims? He aptly illustrates that if doctors doubted what we have to say, we would all die in parking lots. After my last job exposing Renee Hendricks as an evil Slymepitter, Mr. Gemmer has kindly allowed me a bit more power. He introduced me to one Skep Tickle, M.D., to talk about all things in skeptical medicine.
Mr. F: Hello Dr. Tickle. Thank you for talking to me.
ST: My pleasure.
Mr. F: So I’m sure you heard about the craziness that might occur if a doctor was actually a skeptic. LOL!
ST: Um, what?
Mr. F: Anyway, tell us a bit about yourself. How did you get into medicine?
ST: I was always interested in science, especially biology and chemistry. I’ve also always liked working with people and helping people, even though I’m an introvert. I went to a pretty hard-core science institution as an undergraduate, did well, did bench research, considered medicine but (a) my advisor (a wonderful genetic professor) dismissed medicine as “okay…for an applied science”, and (b) I decided that further education in the sciences couldn’t hurt, and that I shouldn’t step away from “real science” & commit to the long & expensive route of medical training if I wasn’t sure medicine was what I wanted to do. So I went to a pretty hard-core graduate program in chemistry for 2 years and did a bit of volunteering for Planned Parenthood and tutoring of inner-city kids on the side during that time. All of these experiences were good, and helped me decide that medicine really was a better fit for me.
Mr. F: Inner-city kids? You mean like black people?
ST: Um, I mean like kids who live in the inner city? Who could use help to keep up in school? Whoever they are?
Mr. F: Well just making sure. You know, you can work with black people and still be a racist. It’s important that you recognize your privilege.
ST: I’ve heard that before. I think I read it online somewhere.
Mr. F: Just making sure we are speaking the same language! You wouldn’t believe how many people who think that just because they “do things” and “help people” then that magically makes them good people. They don’t even have blogs! Anyways, where were we? Did you read Prof. Myer’s masterpiece?
ST: I did.
Mr. F: It was so great! So ok hypothetical! I walk in and tell you I need heart surgery. How long before I get on the operating table?
ST: Well, um, that depends I guess.
Mr. F: Depends. I just told you I need heart surgery. What does it depend on, my wallet? You think I don’t deserve a heart surgery because I don’t make enough money?
ST: No! I just mean we have to figure out why you think you might need heart surgery.
A lot of it depends on what type of heart problem is suspected. If you are having chest discomfort or discomfort radiating to your left jaw, shoulder, or arm, that could be “angina”, the term used for the discomfort (often not described as “pain”) from myocardial ischemia (heart muscle not getting enough blood flow) from atherosclerosis (“hardening” – actually, narrowing – of 1 or more arteries, in this case coronary arteries, which supply the outer ~2/3 of the heart muscle with blood & thus with oxygen & nutrients).
In that case, the approach depends on whether it seems to be “stable” angina (comes & goes, typically brought on by exertion) or “unstable” angina (present at rest, or progressing rapidly recently). For the former, an EKG and an exercise stress test would be the first step. For women, interestingly, an exercise stress test isn’t reliable enough – there’s a high rate of false positives and false negatives, attributed to estrogen’s effect on the EKG though it’s also true for postmenopausal women so I take that explanation with a grain of salt. Therefore, for women, some groups advise to do the stress test with additional imaging of the heart muscle to look for functional changes of, or from, blood flow – either echocardiogram or radionuclide imaging. (This makes stress testing more involved & more expensive for women.)
If you’re having shortness of breath with exertion, that can also be from myocardial ischemia, but the “differential diagnosis” is much, much wider, including deconditioning, obesity, impairment in oxygen-carrying capacity (anemia being the most common cause of that), impairment in oxygen exchange in the lungs (various lung and pulmonary vasculature problems causing that), impairment in cardiac output with exertion (problems with heart muscle – “cardiomyopathy” – from various causes, or heart valve dysfunction, or myocardial ischemia, plus some others I haven’t mentioned). The evaluation for that symptom would start at a different place, unless angina were also present.
Mr. F: Oh I see. You are trying to explain my heart to me. I suppose next you will say you know best how to treat my heart disease.
ST: Like I said, “heart disease” is a huge topic. There’s valvular heart disease, cardiomyopathies (in which the heart muscle doesn’t work), and arrhythmias (heart rhythm problems).
The approach depends on the kind of heart problem. If you mean coronary heart disease (CHD) meaning angina, myocardial ischemia like we’ve been talking about, the major categories are non-interventional (medications) and interventional (opening up a narrowed artery with a balloon or stent, or bypassing it with another vessel). The interventional approaches are always followed by medication approaches, but the exact concoctions (it’s never just one medication! usually at least 3) differ depending on whether one had no intervention, intervention with balloon angioplasty or a bare metal stent, intervention with a ‘drug-eluting” stent, or coronary artery bypass surgery). The medication management of CHD has been a very active area of research & development over the past decade or so. But still, I don’t know yet that’s what you have.
Mr. F: You are not listening. Hearts cause heart disease. Nothing else. The only way to treat heart disease is to stop hearts in the first place. Do you even value what your patients say?
ST: Of course! As a primary care physician and a general internist, I rely a huge amount on what the patient says – only the individual can report her/his own symptoms, concerns, and preferences – but I also use test results (judiciously, I hope, but there are lots of examples) to help us sort out together where things stand on those measures for which symptoms don’t tell the whole story of what’s going on, what condition the condition is in, and whether we should be discussing some intervention.
A patient-doctor relationship, and physician evaluation of any concern, always starts some type of information gathered from patient and/or other close observers, most often verbal but sometimes by other routes like observation. After all, the patient came in – or was brought in – for medical attention for some reason, and the goal is to help that person with their condition – whether that be reassurance that the condition is not dangerous and will resolve or at least not cause harm, or recommendations of measures for symptom control, or advice for further testing or on treatment options, or urging to pursue some major intervention ASAP. Even if a patient is in a coma, you ask those around him or her what happened, what they’ve observed, what they know of the patient, and you observe the patient for all sorts of clues: does he/she appear to be in distress? what posture is he/she in? what color are the tissues that reflect oxygenation (esp lips, fingers)? does he/she respond to certain maneuvers at all, or with hard-wired reflex responses, or with a higher-brain volitional-type response? And so on.
Mr. F: Oh, so you rely on “test results” instead of what patients say? That figures!
ST: The reliance on patient’s-words versus test-results does vary by specialty (and physician), for example when a patient is referred to a specialist for a specific intervention, such as coronary bypass surgery or joint replacement surgery, the specialist often does start by looking at the radiographic images previously obtained to see the physical problem for which his or her technical skills are being requested. But, still, the patient’s words about his or her experiences – “history” in medical parlance, including but not limited to “symptoms” – are often crucial in determining whether or not to proceed with that surgery, or what type of surgery to do, or what risks surgery might pose to that person in particular. Either the patient or the surgeon can decide not to proceed.
There are rare instances where an unexpected abnormal test result starts the ball rolling on evaluation of an asymptomatic problem, for example an EKG done routinely before surgery in an older person shows signs of previously-unsuspected heart disease, but still there will always be questions about the patient’s experience and history to help guide evaluation, including how aggressive to be about it.
Mr. F: You just don’t get it, do you. Fine, whatever. Well it’s not my job to educate you. How about medicine. Do you ask questions instead of just giving someone a prescription they tell you they need?
ST: Yes. I’d be remiss if I didn’t. I could harm someone with a medication they didn’t need. And certainly for some medications, some people are addicted and will say anything to get a prescription. It happens all the time. It’s a matter of keeping the possibility in mind while gathering information from the patient on his/her symptoms & concerns and “history”, and also gathering information from other sources where possible. It’d be awful to fail to address someone’s “real” pain, but also problematic to prescribe controlled substances for a false claim of a medical condition (though in that case the person has a problem, too, usually either drug dependence or desperation for income thus diversion for black market sales – but those need to be addressed differently than a narcotic Rx from a physician). My state now has a statewide database of controlled substance prescriptions filled; it’s been extremely useful in discovering patterns that a patient had not mentioned in your discussion. It shouldn’t be a surprise that sometimes the people who might best fit some profile of “drug-seeking” don’t have anything untoward in that database & are being up front, while others who many would assume are on the up & up actually are masters at getting these prescriptions.
Mr. F: So, you substitute your own thoughts for someone else’s lived experience. I bet you’d fit right in on the Slymepit.
ST: I do post there from time to time.
Mr. F: ………… That’s it. Cut this off. CUT THIS OFF!