Although your commenter’s observations do have some validity (as a 51-year-old woman I am at roughly the same vantage point), she may also be expressing some frustration with the gradual disenfranchisement we’ve been experiencing as we get older, not only by the medical community but also from attitudes in the culture at large. Regardless, I know whereof she speaks. It takes only one physician encounter from which you walk away feeling belittled and patronized to sour you on the whole bunch, at least for a while. It would definitely behoove younger physicians to not act as if they expect to find manifestations of senile dementia in every patient over 40. By and large, though, my own experiences with internists and hospitalists young enough to be my children have been positive. Specialists are another story. But then, haven’t they always been?

No sympathy here. I’m the enemy- a middle aged white male surgeon who has little patience with folks like you who come into our exam rooms with a chip on your shoulder and an attitude because of your status as a scientist. You have the uncanny ability to cram 30 seconds of information into 15 minutes of conversation. You don’t like it that your doctors spend your precious time ruling out common problems before going on to the esoteric and rare problem that you ended up having. You may be the only honest woman in town, but I guarantee you that your doctor has been lied to enough that he knows that he will only get his patient and himself into trouble if he believes every woman who sears that she couldn’t possibly be pregnant. You seems to be aware that 90+% of what people read on the web is trash or worse, yet want your doctor to be grateful that you have “discovered” all this wonderful information. Your doctor has developed a system of evaluating common complaints that took longer than ideal to get to your diagnosis. You don’t like that, and I wouldn’t either, but unless you are in a concierge practice where you pay high dollars to be one of a few patients who receive concentrated care, what your doctor did is reasonable. You demand to know all the details about all the tests your doctor did; that is like expecting him to read you the full PDR description for every prescription he writes (or did you demand that also?).

It’s not that you are too stupid to understand studies; it’s that it really does take years of training and experience to understand how a particular study pertains to your particular situation. You also appear to lack an understanding of the medicolegal aspects of practice, which explains why physicians often do things that seem irrational (like checking you for pregnancy). You may not like it that he put you through the test to cover his own ass, but you also seem like the type of person who would pursue litigation if he did not check for pregnancy and your ectopic ruptured. Just guessing, of course.

I have assembled a really great medical team, and it’s not easy, since I have 2 specialists I see on a regular basis, an Oby/Gen, and a primary care physician.

The endo is the best at listening, but he’s used to working with diabetics and believes in empowering us.

However, I have yet to meet a gastric doctor I can deal with which is a shame as I have GERD and a hiatal hernia. I’ve seen 3 in the past 6 years, and haven’t been back to any of them. In every case, they made assumptions based on my appearance and made judgement calls before they had the facts.

My sleep specialist and the primary care physician end up handing the GERD.

Abby- You don’t have to know my real name. You can be confident that out of the past ten interactions with physicians you have had, and of the next ten, 8 or 9 were channeling my thoughts as you go on about what you think you “deserve,” but do not want to pay for in a concierge practice. As to “printing stuff out from a textbook,” buy your own damn books. As for me, while I am certified (and recertified) in my specialty, I do not understand much of the information contained in articles in texts outside my specialty, despite 9 years of formal medical education and 2 decades of experience. You may be the world’s smartest person, and therefore able to understand the meaning of articles in a textbook of rheumatology or oncology. I know the vocabulary but that doesn’t mean I understand the meaning enough to act on it. Like a lot of human activity, practicing mediciane is a lot harder than it looks. After my training and experience, on my better days I may be able to make it look easy. It isn’t easy. Good luck.

Kitty, you make some good points and you make some bad ones. The worst one you make is about the pregnancy test. In my scant three years after escaping the medical school classrooms, I’ve seen 4 virgin pregnancies. When a woman lies about her chances of being pregnant, the physician might spend thousands of dollars looking for a non-pregnancy cause of symptoms, or might cause birth defects by prescribing the wrong drugs. Getting pregnancy tests liberally and routinely is just good medicine because the stakes are so high.

Last year, as a medical student, my doctor at the Student Health Center told me he was going to test me for chlamydia. I told him I had no risk factors. He told me he still wanted me to pee in the cup. I didn’t protest, because I would have done the same in his place.

JB you don’t really know me, but you make assumptions – in fact I try to waste as little of doctor’s time as possible; I have never sued anybody or considered it; only twice in my life have I brought the material I found on the web – once after my POF was diagnosed an and my ObGyn didn’t see the difference between it and normal menopause (would your 30-something wife or sister like to read material intended for 50+ women after her doctor told her “you are post-menopausal”?), and another time after WHI report about HRT. A couple of other times I didn’t agree with the doctor, I simply said “I don’t want it” – my responsibility.

Premature Ovarian Failure may be an “esoteric” problem (although 5% of women in 30-40 age range is hardly that rare – I am sure you test for many conditions that are rarer), but does it have to take years to diagnose it? If a 30-something woman mentions that “she had some delays during last year” (this was ignored), then comes back a few months later complaining of a 3-month delay; then another 3-month delay, is it so difficult to order a hormone test? What about when she complaints of hot flashes? Know of too many conditions that can cause it?

I might went overboard with pregnancy test since I didn’t see any reason to lie about this possibility; and it was upsetting for me because I wanted it so badly at the time and was so worried about my fertility. People who have children very rarely understand how the rest of us feel; doctors are no exception

Kitty, I may not know you, but your personality comes through quite clearly in your posts here. You are precisely the type of patient who does waste a lot of your doctors’ time, through passive aggressive resistance to the recommended evaluation. You criticize your doctors’ use of screening tests, stating that we do not mention such things as probability of benefit, when ultimately you were found to have a disease with a zero mortality rate. I looked through your recommended article. While my previous statement that practicing medicine is not easy is true in general, I can tell you that it is laughably easy to work back from a defined diagnosis and make a determination of what your doctor should have done previously to figure out what your problem was in the first place. We call it “looking through the retrospectroscope.” I note that the author of your article is ”Chief, Gynecologic Endocrinology Unit, Section on Women’s Health Research, Developmental Endocrinology Branch, National Institute of Child Health and Human Development. National Institutes of Health, Bethesda, Md.”
In this role, he is someone who works regular hours for a government paycheck, has no worries about overlooking the life-threatening ectopic or other situation that might kill or maim a patient, does not have to worry about malpractice liability, and spends his entire professional time concerned about a very very small, highly specialized, area of gynecology. He also states that there is no treatment available for your condition, and that only 10% of women diagnosed with POF do become pregnant (between the lines I infer that these 10% were misdiagnosed).

It is truly unfortunate that you were not able to fulfill your dream of having a baby, and also unfortunate that you hold such resentments against your gynecologists who were not able to rapidly diagnose your condition. Please understand that for any complaint that a patient has, physicians first must consider if there is something life- or limb-threatening that may be going on. They then concentrate on the more common conditions, which may not be life-threatening, but are subject to intervention which may improve the situation. You fit into neither of these categories, and while you will never agree with the approach that your doctors took, you should understand that your situation was managed in a responsible and appropriate manner.

here is more banter to think about.

1. As I primary care doc, I routinely refer out those things I am not well versed at. POF is one of those things.

In fact one of the most widely used medical resources primary care docs used is called “Up to Date” which is a 400 dollar/year electronic textbook updated every 90 days by experts. Here what they say in the opening remarks:

“Although the early diagnosis of premature ovarian failure is important for osteoporosis prevention, many women experience a significant delay in diagnosis (as long as a five-year delay in 25 percent of women) [6]. In addition, over 50 percent of young women with spontaneous premature ovarian failure have reported seeing three or more clinicians before laboratory testing was finally done [6].”

Please be assured that many doc’s are inept at making a diagnosis at POF, including me.

2. I am much more adept at diagnosing Pulmonary emboli, Congestive heart failure, Myocardial infraction, Asthma,
colon cancer and a lot of other stuff that kills enourmous numbers of people every year if not detected early.

3. I know when someone is about to die of a gangrenous gallbladder, appendix, collapsed lung, ruptured tubal pregnancy …….etc…..etc…..at 1:00 A.M. the odds are a surgeon is likely going to be there in a matter of minutes and will truly perform a miracle by operating between 2:00-5:00am. No way will a “specialist” be on the premises.

4. last night my call was lousy as usual. I had three admissions from the ER between midnight and 5:00am. ALL the patients were in their late 70’s and 80’s and all were patients I never met before and all very ill. (sadly)
Despite booking my schedule today very light, I was swamped ( 4 were urgent walk-ins who could not be turned away and my colleague is away this week moving his kids in college) I arrived home tonight at 8:00pm
The surgeon on call last night in our same hospital much harder thsn me. (as usual)

I do not know POF well, but I know I can still help a lot of people a lot of the time. I do not know everyhting.
sorry.

as for abby’s statement that there are very good specialists around is true. The number of people training in primary care and OB/gyn is plummeting

http://www.aafp.org/match/graph05.html

http://www.aafp.org/match/table11.htm

specialists usually have better hours, rarely come in to the hospital for emrgencies, and just deal with a very narrow range of problems. But if I and my family was on a Island and could have only two kinds of physicians available…I would wan’t a general surgeon followed by a
primary care doc.

and as for people choosing other carreers than medicine. .you are right on target..
In the past decade the number of applicants have plummetted and almost anybody who want’s to go to medical school can get in….paying for the tuition is much harder. Many med schools have filled the vacant slots with foreigners who have no intention of staying in the U.S after graduation. (check out the admission class profile for Boston University School of medicine, for example)

I realize POF is rare and non life-threatening, but its diagnosis is nonetheless devastating. Remember; you have all menapausal symptoms, except they are much more severe than those of older women; you don’t understand what is happening with you; you cannot sleep night after night after night. You feel something is wrong but your doctor tells you everything is great; and you accept it because it is what you want to believe.
Also ObGyn is a specialist which is supposed to know this – I have no problems with my primary care doctor.

Here is by the way how the whole thing with POF unfolded, so that you can have it in context — keep in mind that I only started looking at the web after my diagnosis; before it I always blindly trusted my doctors:

year one; age 31: Dr: Are your periods regular? me: until this year they had been very regular but I have been having some irregularities lately Dr: when was your last period? me: two weeks ago. Dr. OK. — no additional questions, end of conversation and office visit; no record in my file; no attempt to find out more; no referral to specialist; no other questions (why ask for my periods if you are going to ignore the reply?)

year two: how are your periods? me: I had some delays, sometimes long, I am starting to worry about it. dr: When was your last period? me: last week. Dr. OK — again end of office visit. Now, as I said I was really trusting back then; so if my doctor thought everything is fine, I am leaving relieved; I really started to worry, but since doctor assures me I am fine I believe her. After all, I really want to believe it.

6 month to a year later: a visit to investigate a 3-months delay; a pregnancy test (the one I mentioned; you need to keep in mind two things: 1) this was preceeded by complaints of irregularities 2) certain muscles in my body are so tight, the doctor can barely fit the finger in (aren’t internet nice?) 3) if I had been pregnant it’d be 3 months; I say OK (whatever I thought or wrote in my posts, I didn’t mention at a visit, but it was difficult emotionally since I wanted so badly to have a reason to believe that it can be positive), I have to call to find the results, then call the doctor; get prescription of Provera dialed to my pharmacy. Again, if my doctor is not concerned, why should I be? We shall always trust the doctor, right?

another year brings another 3 months delay: Dr: I’ll take your word that you are not pregnant; here is Provera to bring up period.

== moved to another doctor hoping he can help – I am really starting to worry now; I start suspecting that what I have are hot flashes and not heating problem (before I kept calling maintenance complaining about A/C)

new doctor’s visit: me: I am really worried, I have big delays, I think I am having hot flashes. He smiles, shrugs of my mention of hot flashes; assures me that I am not going into menopause; schedules an ultrasound scheduled (btw – some time later I checked on the web the symptoms of ovarian cysts, uterine cancer and ovarian cancer; nothing mentions my symptoms); periods come back by the time ultrasound comes back normal; so everything is fine.

next visit: same story, but this time Provera fails. I am told I am postmenopausal, given a prescription of low dose PremPro and a brochure for 50+ women. no referral to a specialist (why not say “this is a rare condition; I don’t know much about it, maybe you should see an endocrinologist”?)

Now tell me that this was great medicine; that there was no need to investigate my original complaints of irregularities or delays. I can’t help thinking that if my complaints of irregular periods hadn’t been ignored during year one and two, maybe I would’ve found some way to have a baby then. If I had been give some kind of hormones during year three; e.g. BCP, maybe my bones had been in better shape now. At least I wouldn’t have to suffer years of symptoms, worry.

The fact that the same happens with women in my situation all over the country doesn’t mean it right. And talking about sensitivity: some time ago a young woman in one of the POF-related forums mentioned how a doctor told her ‘you should be happy you don’t need to worry about getting pregnant’. Hah?

I don’t want to go into two times when I told I don’t want to – but those where on unrelated controversial subjects that many doctors don’t agree on; I read all there is to it and simply said no. The doctor said OK, there was no argument.

The two times I had longer discussion was after my POF diagnosed when I brought some materials – it was the visit specifically scheduled for discussion – my ObGyn at the time was supremely uninterested in what I found. For some things he said “this is what I told you”; for others like the fact that the higher HRT dose was recommended, he just shrugged of and I didn’t pursue it. The other discussion I had was with my current ObGyn because the knee jerk reaction after WHI report was to stop all hormones, so I wanted to point out that my situation is different.
I guess this makes me passive-aggressive…

When I left the original post it was in a very angry moment. I went into the ER five times in two weeks. My GP would not talk to me and told me I had to call my endocrinologist. My endocrinologist would not return my calls. I could no longer drink water without becoming delerious, was shaking almost all the time, and on one day I could no longer feel my hands and feet as I had little to no peripheral circulation. At various times I appeared intoxicated after drinking just a small amount of water and my speech was severly impaired.

Some of JB’s comments are quite valid. As a dr you are very short on time. You walk in the room, Step through a predetermined algorithim and deduce the cause. Thanks to reading some of db’s rants, I do have a better understanding of the “other side” (the dark side!) now and the HMO pressures drs are placed under. As a physician, at what point do you realize that it is time to step out of the algorithim and actually really start creatively thinking? You reach the end of what is known and you don’t know where to go. At this point you may be dealing with the 1-5% patient. Or in my case the one in 5000 patient.

This is where the problem happens-instead of admitting “I don’t know” or going the extra mile, I think many physicians become a bit cowardly or lazy. If you can’t understand it then it likely isn’t real. It’s just “middle age” or “menopause” or “PMS” or an old whiny woman. Or (I love this one!) “psychsomatic” or “hypochondriac”. Blame the patient for your lack of understanding.

It is okay (or maybe in the current lawsuit eager america it isn’t ?) to not know what is wrong. My endocrinologist screamed at me on the last visit. “I can do nothing for you. I have done everything I can and you just need to keep taking your meds. ” I believe that is the definition of insanity-to keep doing the same thing even though it never works-I guess she wasn’t the one in the ER though…

The ability to take the next step, admit you don’t know, and let the patient know takes humility. Hmmm… The next step is to listen to the patient and think on a global creative level. Hmmm… Now granted, as a scientist creativity is an attribute. However I am not really sure how creative I want my neurosurgeon to be. (Dude, this is so cool, I wonder if we could do move this instead….!)

This same thought pattern-the inability to admit uncertainity crops up in science too. If you have any interest check out Myers-Briggs. Google it. It is a TJ trait. Most drs are STJs. Read a bit there and consider how those personality traits work in a physician setting.

For now I have moved on to a new endo. I likely drove him nuts on my first visit. I never said much of anything to the last one and she hated me for not understanding me. This one will hate me as I didn’t stop talking the whole time. Trying to be a bit more proactive these days. I stopped taking my synthroid and feel pretty damn good again. I keep taking my TSH 190 body out jogging and we are doing okay.

I agree with Tina. Most of my anger stems from the fact that none of my genecologists have simply told me: I don’t know why this is happening, I don’t think there is any problem, but if you are really worried you should see an endocrinologist. At the time, I thought is that genecologists are the main specialists who deal with this type of problems; I only found out differently after I started browsing the web. But even after my diagnosis, nobody told me: “I don’t know if what I am doing is the right thing; an endocrinologist may know more”. I wouldn’t have thought any less of doctors for admitting it; in fact I’d have way more respect for them.

It is perfectly fine not to know something, and admitting it is actually a sign of confidence in what one does know not the other way around. But many doctors seem to be afraid to admit it.

Kitty, I’m with the guy who apologized for all the Gyn’s who didn’t figure it out, and also with JB. I’m definitely channeling his thoughts much of the time, while also actually caring a lot about the health of my patients. The thing is, when I’m evaluating a patient, I don’t really have the time (and I don’t really care) to hear about “15 years ago I got sick for a week and my neighbor thought it was pneumonia but it turned out to be…” which is a long story of basically no relevance, and is pretty typical of what most patients want to tell me. Patients who are like you claim to be, who are prepared with specific questions and an advanced understanding of their problems, are rare, and of these, I’m sorry to say a large number are deluding themselves that they actually know how to apply a particular study or bit of research to their own condition. JB is right – it’s hard to do even for the pros, we get it wrong plenty of times, and there are entire journals filled with junk science (and expensive ads from drug companies) masquerading as clinically relevent info. It’s too much for your doctor to absorb 100%, and too much for 99.99% of the general population. As for “what patients deserve,” you deserve respect and courtesy, as much as anyone does – as much as your doctor and as much as the mailman and as much as the woman who gets up at 4 am to clean the wastebaskets in your office or whatever. You also deserve exactly the kind of care you pay for, and as much of your doctor’s time as you pay for, and so on.

DD

Okay. I apologize.

My new endo admitted that he had no idea what was wrong with me and was totally baffled. He listened attentively and made suggestions where he could. He ADMITTED a lack of knowledge. He even threw his hands in the air! I think I love this guy just a little.
You can see how much he really wants to help when he sits in the room. He smiles and is honest. Most importantly he is open to ideas and suggestions. I told him I have found about five other people like me on the (evil source of inaccurate knowledge) internet. He wanted to know what thier drs did. I said the same thing mine have been doing which gives us all a null answer. Next week I think I’ll tell him what I think maybe wrong-in 45 seconds or less of course. Today we compromised on a treatment plan. He ACCEPTED I might have some knowledge. He TRUSTED that my symptoms were real.

I guess Dr. disgruntled, that it bugs me, the thing about not knowing how to apply knowledge you find to your own health. It seems that likely with half an hour of time a patient can gain a more “deep” level of knowledge than their GP about a health condition by sitting in front of a computer. The patient lacks the broad knowledge of an MD, but that doesn’t mean the knowledge they have is incorrect.

Should the MD begin to serve as a health consultant as opposed to a health director in the future?

Okay Pj,

But what do you do when your electrical problem causes your hotwater heater to malfunction, which in turn spills water all over the floor, causing severe damage to the carpets in the basement and leaks through the foundation widening a pre-existing crack. The electrical problem also causes the attic to catch fire. Now you need a carpenter, a plumber, someone for the foundation, a fireman, a flood cleanup service, an exterminator, and an electrician.

In my case my electrician refused to admit the electrical problem and kept sending me to the carpenter than the plumber then the exterminator, who all said it was an electrical problem and they couldn’t help.

What you need isn’t a handy man now, it’s a general contracter to organize this show and keep it moving. Or I guess you could just move…

A few years ago I went to my GP with bacterial tonsillitis. I told her my symptoms – fevers, chills, sore throat – and after viewing the pus on my tonsils she prescribed penicillin. I also asked if I could have my iron levels tested, as I thought they might be a bit low. When she asked why I thought they might be a bit low I said that I’d recently lacked kick in my running and that as a vegetarian, a young female, a distance runner and a regular blood donor I thought I had a good chance of being iron deficient. A blood test was duly ordered and I did have marked iron deficiency. The GP suggested that perhaps I should have a gastroscopy to exclude any gastric problems leading to blood loss. I declined. I took iron tablets and every three months I returned to the same practice (as advised) to have my iron levels rechecked. My iron stores didn’t rise all that much and every time I was repeatedly asked if I was taking the tablets. I assured the doctors that I was. They seemed very doubtful and suggested reasons that I might not be taking them (perhaps they make you constipated? perhaps you’re forgetting to take them – it’s easy to do).

I guess if I had discovered at a later date that I had coeliac disease or a gastric ulcer then I might be able to run around proclaiming that the doctors should have diagnosed it earlier – that all the symptoms were there. Except that the diagnosis wasn’t obvious (or correct, although I had appropriate symptoms) and there was no reason to investigate further. Unless I was overly concerned or litigious, in which case further investigation may have been warranted for medico-legal reasons. I refused the gastroscopy because I’m a doctor and I personally judged that the low yield of the procedure did not warrant me undertaking it. I didn’t get too fussed by the repeated suggestions that I wasn’t taking the iron tablets because I know that most people don’t take their tablets as prescribed. It was the most likely reason (albeit incorrect).

I haven’t bothered visiting my GP in the last year to tell her about my irregular periods. Perhaps I am developing premature ovarian failure (POF). The symptoms are all there. But I think more likely it is related to my overnight shifts, irregular meals, weight loss and the stress of being a surgical registrar. I know another female surgical registrar who has menstruated four times in the last 3 years of her training. Tell me, am I being irresponsible in not going to my GP and asking her to investigate me for POF? Should I and my colleague go and have hormonal tests? We know we’re not pregnant, we’ve checked to make sure.

I’m sorry that you feel your concerns and symptoms weren’t taken seriously, Kitty. It’s unfortunate that you feel your condition wasn’t diagnosed or managed appropriately. Rare conditions are difficult to pick and it’s impossible to make every patient happy. It’s best to avoid blaming people. Blaming people doesn’t make your life better.

Hey PJ,
I hope you are still around. Do you think a possible idea might be to have nurse practitioners working under GPs? You are looking at an exceptionally complex system and it doesn’t seem like GPs or doctors really have the time to spend on each patient. This makes me wonder if people aren’t dying due to overlooked problems and interactions between conditions. Maybe if well educated nurses served a general contractor role and consulted with physicians as needed each nurse could be allowed to see less patients and spend more time with each patient.

I went for several years to a WIC clinic with a nurse and several years to a University Family clinic with a nurse. In each case it really was slower spaced and they knew my name and all about my family. They talked to me about my conditions in depth and were very accepting of questions. The nurses would do whatever they could but would refer out as needed for things like seperated sacrums, dislocated hips, and broken fingers (that’s my husband!). More time means less mistakes and that you know your patients better. That seems to be better medicine in my mind at least.

As I understand it, and as you guys keep saying, most of you got into to help people. If you aren’t helping people than something is wrong and the system needs some work.

Funny joke: What did it say on the hypochondriac’s tombstone?
“Do you believe me NOW?”

Worst thing I have ever heard a doctor say:
A pediatric oncologist: ” I F**ing hate kids but these kids are all so sick they don’t make much noise.”