Leonard Zwelling

As a physician of long standing whose clinical skills are terribly dated, I find it encouraging when going to a doctor to have that doctor discover something I did not suspect. Unfortunately, that is sometimes bad news, but nonetheless, there is an element of being thorough that I have come to appreciate in truly gifted clinicians which many of my doctors are.

My best example of this is my dermatologist. She is absolutely meticulous about reviewing my skin every few months even as she has seen it so many times before. And in doing that, she frequently discovers a new actinic keratosis or even early basal and squamous cell malignancies that require liquid nitrogen or extirpation, sometimes by a Mohs surgeon. There was even a time when she had to second guess her own original diagnosis with a more significant one. She did it well and was not reticent to revisit her original impression and tell me what she thought. These are signs of an excellent clinician.

Recently, I have found myself in the middle of a far more painful predicament—sciatica. Trying to avoid surgery, my internist opted for a regimen of physical therapy. I added ARROSTI, a soft tissue recovery plan as well as acupuncture and massage therapy. On that regimen I was improving. The working diagnosis was an L5 spinal problem on the right and my x-rays ordered by my internist showed significant degenerative changes probably deriving from my long running career, my long career on Earth, and gravity.

I was improving with the regimen which included over an hour of home morning exercises, but I wasn’t back to where I had started in October 29 when I played 18 holes of golf and was crippled in the late afternoon.

I took matters into my own hands even as I admit that the whole point of having a concierge doc was to not manage my own illness. I thought I needed an MRI and a surgical consult to rule-out an anatomically remediable cause of my symptoms.

On December 15, I was greeted by the surgeon’s nurse practitioner. The surgeon was not in the office. The nurse had been with the surgeon for over ten years and had done over 500 operations last year, so I thought I might be in good hands.

He did an exam that included me walking on my toes and heels. I could not walk on my heels. I had a real foot drop. None of the prior examiners had picked this up.

The nurse went into action. He ordered the MRI and with and without contrast (pending as of this writing). He reviewed the x-rays I had brought and thought it a bad idea to do surgery as it might wreak havoc on the current state of stability of my deformed spine. He thought I should give a steroid dose pack another try and thought gabapentin might be of use to alleviate my symptoms. He was detailed in informing me to go very slowly with the gabapentin as it can cause somnolence. He suggested I start with one or two capsules at night and use my judgment depending on the relief (if any) and side effects (if any).

So later that day I went to the pharmacy to pick up the dose pack and the gabapentin. The dose pack was as usual, but the gabapentin prescription on the label of the two huge bottles I was given was for three 300 milligram pills three times a day.

That was not at all what the nurse had asked me to take. So, what to do? It was after five on a Friday and there was no one to ask. What else? Consult Rabbi Google.

There I learn that gabapentin is a rather complex drug that comes in several forms for different clinical applications. The web sites recommend starting with a very low dose at night. Confused, I did not take the drug that night.

The following day I returned to the pharmacy and consulted with the pharmacist. She said the label prescription was partially right, but that the prescriber had written one to three tablets three times a day below the maximum dose. That last piece didn’t make it to the label. I suggested that the pharmacist coach the person who filled my prescription about the drug and reminded her that the pharmacist is a major point of safety in the pathway from doctor to patient. Any pharmacist should know that gabapentin cannot be started in a drug-naïve patient at 2700 mg per day.

All day I was reminded about the importance of details in clinical medicine. As an intern I had missed one of two shadows on a chest x-ray that would have told me the patient I had just admitted didn’t have primary pneumonia but right-sided endocarditis seeding her lung with Staph. As a fellow when my lymphoma patient in remission complained of being tired and his lymphoma work-up was negative, it was my attention to detail that made the diagnosis of apathetic hyperthyroidism. I had grown in my attention to detail in the two years since missing the endocarditis.

In clinical medicine, detail is everything. I hope the younger docs coming along pay close attention to detail and don’t just believe what the last person wrote in EPIC.

Attention to detail may help in solving my current back problem. The MRI will be determinative. But without that careful physical exam that no one else had done over 7 weeks, the nurse would not have known the seriousness of my L5 disease and the correct way to define it.

Good for him. Good for me even if it may mean a worse diagnosis. At least it is more complete in its detail.

2 thoughts on “Details”

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