So You Want An Online Diagnosis?

Last week Doctor D sternly rebuked those who wanted him to answer illegal (diagnose-me-over-the-internet) questions.

Several commenters replied it was D's own fault for naming his blog "Ask An MD." I mean seriously, what answers could an MD possibly have worth reading if he can't discuss your bowel problems?

Oh, so THIS is what you wanted?

So "Ask An MD" is running a special this week only:

Doctor D will answer every single diagnosis or treatment question you ask in the comments of this post!

(Very important small-print disclaimer: None of Doctor D's answers will be correct or sensible in any way )

What good are bullshit diagnoses, you may ask?

The Weight of Perfection

One of the greatest stresses in a doctor's life is having to be correct all the time. Of course, we aren't always correct, but people always expect us to be correct. This leads to a lot of stress in a docs life.

The avalanche of questions started early:

When Young D was a Pre-medical student in college people started asking him questions that were totally beyond his abilities. "Hey D, I get this weird feeling in my stomach, but sometimes it isn't there. What is that?"

Ah, to be young and free of the heavy responsibilities of doctoring!

D would just smile, shrug, and say, "Probably either metastatic cancer or gas."

Young D became legendary for his smart-ass diagnoses, and a good time was had by all.

But then Medical School began and the game of diagnosis became one of life and death. A wrong guess could hurt someone—badly. People kept throwing unanswerable questions at him, but the weight of his profession had crushed D's carefree attitude. He began giving evasive responses and advising people see their own doctor.

D has been practicing medicine for a while now. It is heavy stuff to talk to people every day about the ways that their own bodies can cause misery or kill them.

Doctor D actually doesn't like talking about suffering and death. He would rather open your mind and make you smile. So D started this blog answering people's questions about the odd quirks of the medical profession. For D this blog is a lighthearted way to process the hard and nasty stuff he has to see every day at work.

But work found Doctor D in his secret online hide out. He should have expected it—answering questions about doctors brought patients, and patients have questions about diseases they want to ask doctors.

Unfortunately, I can't answer diagnosis or treatment questions, no matter how desperate you are. I have to admit: I don't even want to try. I miss sleep at night over the guesses I make in my real job. Trying to do the same thing on-line would lead poor Doctor D to have a nervous breakdown.

But Doctor D won't abandon you poor folks so desperate for answers. He can't diagnose you but he can offer you the next best thing: Utter Nonsense!

"Nonsense Therapy is all-natural and involves no harsh chemicals!"

Therapeutic Misinformation

Do you doubt the healing power of ridiculous bullshit?

Doctor D learned this lesson as a young doctor. He had been working for months with a patient who was miserable from one of those frustrating mystery illnesses. She was in the office crying and listing her symptoms. Finally Doctor D shrugged and grinned, "All I have left to offer you is racehorse therapy. We take a rifle and put you out of your misery!"

At first Doctor D was petrified. He had let one of his pre-med smartass comments loose on a real person with real suffering! Then the patient smiled—the first smile he’d seen from her in months. Then she laughed, and D laughed with her. They had a good hearty laugh and the patient hugged him as she left the office.

Things were different after that. We talked and laughed a lot. We never found a diagnosis for her, but we ridiculed the disease mercilessly. It made us both feel better.

Nonsensical bullshit from a doctor can have a wonderful therapeutic effect!

Ask any middle-schooler and they will confirm it: The human body is funny! The human body is silly! The human body is gross! The human body is ridiculous! The human body is a low-down Judas that will eventually screw you over then kill you!

The only sensible thing to do is to mock our bodies on a regular basis.

So send Doctor D your symptoms and he shall mock them fiercely! He shall diagnose you with improbable and silly things! He shall loose his inner child to laugh at your bodily functions! He shall suggest ridiculous and painful treatments!

Not a single one of you shall get any useful medical information from Doctor D’s snarky replies... but you still know you want to send D your symptoms!

Therapeutic Misinformation:

Just like Chiropractics!

It feels so good,
you won’t even care that it’s total bullshit!

All questions will be personally answered by the doctor. So send in those aches, tingles, throbs, swellings, and vaginal discharges!

Now, Doctor D is a busy man, and he doesn’t check his email 8 times a day like more dedicated medbloggers. (Grumpy you're embarrassing the rest of us with your annoying dedication!)

Be patient, and the doctor will be in to misinform you and mock your symptoms shortly!

Doctor D Strikes Back!

It's time we make something very, very clear:

This is not a personal medical advice blog!

A lot of people just stumble across the "Ask An MD" name and start firing off questions before they read another word. I realize you regular D Readers are not the offenders but I have to rant at somebody, so Dr. D is going to nip this in the bud right now:

I will NEVER answer diagnosis or treatment questions online!

"Luke, I am NOT your doctor!"

This isn't that I don't love you guys. It just can't happen. I challenge you to find any MD giving personal medical advice to strangers online. Nope it isn't there!

Doctor D put this info on the "Email Dr. D" page but still a majority the letters to Doctor D basically ask: "Here are my symptoms. What should I do?"

Doctor D used to write polite replies explaining that the blog is here to answer general questions about doctors and the medical system, but I really cannot diagnose you... etc.

..but as the popularity and google rank of this blog has grown Doctor D's inbox has become congested with please-treat-me-over-the-Internet emails. Abandoning all bedside manners, Dr D has begun sending snarky rebukes to the worst offenders: "Did you read the f*cking disclaimer!?!"

But that pesky medical compassion keeps D feeling sorry for all these people sending hopeless requests for help to some random medical blog!

Could These Emails Be The Symptom Of A Real Problem?

This deluge of unanswerable questions got Doctor D thinking. These people begging for answers reveal some real issues with the medical system:

1. Sick people are desperate for answers.
2. It is way too hard to get a doctor to talk to you. It costs too much money to get in, and even then the doc is in and out in like 5 minutes!
3. Doctors are terrible at addressing what is really bothering patients.

"Houston, we have a problem."

Unfortunately, turning to some anonymous doc on a blog is not the solution to these problems.

Do you really want to risk getting an answer from an anonymous doc who can't examine you—some dude who may sleep under a bridge and just plays doctor online to meet chicks? Trust me: you don't want to do that!

And Doctor D won't risk his medical license making random guesses over email for people he's never laid eyes on. Giving you a harmful misdiagnosis over the internet would make Dr. D feel terrible, and it could be the blood in the water that sparks a feeding frenzy of lawyers and disciplinary boards.

Perhaps someday doctors will be more accessible, better communicators, and be able to treat you over the Internet, but this just isn't a reality right now.

Now you have to deal with regular screwed-up doctors working in a bizarre healthcare system. Yes, it sucks, but you really don't have many other options.

This is why Doctor D runs this blog: To help you navigate the tricky world of real doctors.

If He Can't Be My Doctor, What Use Is Doctor D?

Well, if you would even consider writing some anonymous blog for help then your doctor-patient relationship is probably on life support.

It may not be your fault (doctors suck at relationships—just ask Lady D), but you will be the one who gets hurt.

Instead of desperately emailing random bloggers on the internet for answers which will likely be wrong, why don't you learn to work on with the doctors you have in your life?

Doctor D volunteers his time as a relationship counselor for your doctor-patient relationships. D isn't going be your doctor (although, he blogs anonymously so, who knows, he might actually be your doctor?), but he just might teach you how to make your own doctor useful!

So respect D's boundaries! ...And send me some questions I can work with!

What do you think?

Currently there is no way to get answers direct from a doctor online. Getting diagnosed by a doctor miles away who can't examine you is a recipe for mistakes, BUT it would be convenient.

Would you be willing to take a risk with an online doctor? Would you forgo the ability to sue if the advice harmed you? Should the standards of doctor-patient relationships change to adopt to the wired world?

By the way, if you ever sent Dr. D a forbidden e-mail now is your chance to grovel and beg for his forgiveness!

Mammogram Madness

The U.S. Preventive Services Task Force recently advised that most women don't need mammograms as early or often as previously believed. Now you can't turn on a TV without some reporter telling us how angry Americans are about this.

What is Doctor D's take on the new guidelines?

As a working clinician I trust the USPSTF. They have no agenda-axe to grind and spend a lot of time studying mountains of data. These experts meticulously examine the thousands of studies that I just don't have time to read. They crunch numbers and come up with carefully considered recommendations.

While I can understand all the public concern, I am irritated that many doctors seem eager to jump on the irrational bandwagon.

What no one seems to comprehend is that even relatively safe tests and treatments can still be deadly. Doctor D has hurt some very nice people with the "right" treatment because all medical interventions have risks.

Men can also get Breast Cancer, just less often. Men die of this disease. Would screening every male "save lives" by catching some early cases? Probably. Would there be lots of false positives? Absolutely. Would the number of men we maim or kill with work-ups and treatments outnumber the lives saved? Almost certainly. Hence the need for evidence-based guidelines.

Breast Cancer is a horrible disease, so it was worth a try to screen women in their 40's. But now we have years of data indicating that we hurt more low-risk women than we helped. Uh-oh! It's one thing to hurt people with what we hope will be the right intervention, but when we hurt people by doing something we know doesn't work it's shameful. The same thing happened with prostate screening for men. We don't need to keep doing things that don't work.

We have a natural bias towards doing something rather than doing nothing. People expect doctors to "do something!" Doctors like to do things for patients. Hence over-testing and over-treatment run rampant in all fields of healthcare. Sometimes we make educated guesses at interventions and hope they work, but when we have evidence showing we aren't helping people, it's time to acknowledge that doing nothing is safer and wiser.

The trouble is that the guidelines are based on mountains of studies that the public, politicians, and many doctors are unequipped to evaluate for themselves. So we go for next best thing: anecdotal evidence. We base our opinions on heart-wrenching stories of women in their 40's that died of Breast Cancer. All the evidence in the world is no competition for a really moving story.

What the USPSTF needs to do is come up with a convincing narrative. Stop referring to data that nobody understands and give your arguments a human face! Parade the widowers of and orphan kids of women that died as the result of a workups for false-positive mammograms in front of every TV camera you can find. Get doctors up on stage and have us apologize, "Sorry, we did what we thought was best, but now we know we were wrong. We'll do better in the future."

Doctor D realizes he'll probably loose some readers over this post, but somebody had to defend the USPSTF against this crayzee smear campaign.

Feel free to post your thoughts, but please don't accuse me of "not caring about women's lives." I follow the recommendations because I care about women, and I've been saying the same thing about PSA in men for a while.

Getting To Know Your Body (First Visits)

Now back to a question I only halfway answered before:

One thing I would like to see answered on your blog is, what do you do on a first visit? Especially if you're not sick?

On your first visit with Doctor D:

• First, you and Doctor D size each other up. A doctor-patient relationship can be a complicated thing. You gotta know who you're working with. What is the doctoring style of the physician? What are your wants and needs as a patient? How will the relationship work? It is a lot like a first date. We may not be discussing it directly, but Doctor D and his patients are carefully listening and watching to figure out if we are compatible. If you have strong opinions about your care, you should probably let me know, especially if your expectations are out of the norm: "Doctor D, I want you to take care of me without using any medicines" or "I refuse all preventive care." This helps prevent misunderstandings later.
  

• Second, we go over your medical history. This is when you tell Doctor D all the stuff that has happened to your body in the past. We talk about surgeries, pregnancies, illnesses, drug reactions, as well as any current diseases, symptoms, and medicines. For some of you this will be a short discussion but for those who have been through the ringer in the medical system this could take a while.

• Third, we evaluate your risks. We talk about what might happen with your body in the future. Doctor D will ask about diseases your family members had. He'll ask about your habits (diet, drugs, exercise, sex life, etc.) and do a review of systems to look for symptoms you may not have noticed. Then we talk about how to either prevent diseases or catch them early. Any Primary Care doc who only treats what you have now without preventing future illness isn't doing their job correctly.

• Finally, Doctor D takes a look at your body. I might find some hidden disease on this exam, but I usually don't. The real purpose is so Doctor D knows how your body looks, sounds, and feels when it isn't sick. Diseases change the body; to properly recognize these changes it helps to know how the body looked when well. You may say, "Come on doc, I feel and look great!" Doctor D also suffers from a delusion of physical perfection he developed as a cocky 19 year old, but the fact is that even healthy bodies still have lots of little quirks or abnormalities. If I see you for the first time when ill I might mistake one of these physical quirks for a new problem and misdiagnose you. Similarly I might assume some small abnormality has always been there when it's really an important clue to your problem.

A while back Doctor D was in the ER and a dude comes in with a runny nose and headache--pretty standard viral cold, except that one eye was much bigger than the other. This gets Doctor D thinking about tumors in the eye socket and other scary stuff.

Doctor D asks about the eye and the guy says he's never noticed any between his eyes. Uh-oh! Then Doctor D shows the dude his own face in a mirror and the man is like, "Which eye doc?"

WTF? How does someone totally not notice one eye is fricking huge compared to the other? We doctors are trained to notice physical weirdness you stopped paying attention to when your mom taught you not to stare, so maybe this dude never noticed his funny eye? So Doctor D calls the family from the waiting room and they say he looks normal. Dr. D points out the eye and they are all like, "Well, what do you know? It is bigger!" Nobody knows how long it's been this way.

Luckily somebody had a childhood picture of this dude, and D discovered one eye has always been bigger. Apparently this guy has had a odd eye his whole life and nobody noticed! Stuff like this happens more often than you think. A lot of times this dude would have gotten his head pumped full of radiation in a big workup just because he was born funny looking.

It is really important that you have a doctor that knows you and your body well. First visits take a while even if you are healthy, but they are really important so don't skip out on them.

Incidentally Doctor D has his first visit with his new Primary Care doctor next month. What is the weirdest thing that ever happened to you on a first doctor's visit? Doctor D would love to hear your stories in the comments.

Misdiagnosis and Regret

A reader who was recently found to have a rare, serious condition sent Doctor D a question about visiting one of several doctors who missed the diagnosis:

It could be terribly awkward to have an appointment with one of them—me with all my new scars and a scary prognosis and them perhaps with their former, incorrect diagnoses of various benign conditions hanging in the air. I'd welcome a chance to let them know that I understand that it's impossible to get these things right instantly every time, and I have no resentment. But would it be better to just see a brand new doctor? Or would my former doctors want to see me? Or would they rather I melt into the ether and just let them forget it all?

Human disease is extremely complex, and doctors sometimes miss the correct answer. Every doctor has had that “Oh crap! It was X? I thought it was Y!” panic after finding out about a misdiagnosis. The unspoken truth is that doctors guess—a lot. Usually we make informed, educated guesses, but even good guesses can be incorrect. Unusual conditions can be hard to discover, and we often make several wrong diagnoses on the way to the right one.

Doctor D has made some diagnoses he wished he could "do over" after using his Retrospectascope (D's only medical instrument that produces the right answer every time.)

So on behalf of all doctors, Doctor D wishes he could fall down and kiss the feet of the reader who sent this question! How gracious you are! We feel all patients demand perfection, and we work with imperfect tools and imperfect knowledge. Even the best care won't always produce the right answer—especially at the beginning. Your understanding and kind feelings towards your doctors makes even cranky Doctor D get misty-eyed!

So to answer your question: Go see your doctor!

I wouldn't advise you start out, “Hey remember me? You told me I had Y, when it was really a bad case of X?” Open with this and your doctor is likely turn sweaty and pale with terror. Doctors don't just fear lawsuits. We really hate letting you down. If your doc thinks you are angry about your care, he or she might suddenly become distant or angry too. (We doctors aren't very creative when it comes to covering our fear.)

But if you say, “I really appreciate what you did for me. I know that X is really hard to diagnose, and it often looks like Y,” your doctor might become so overwhelmed by your understanding that they may just break down and hug you. You could instantly become your doctor's favorite patient and be treated like family for years to come!

Have you ever been misdiagnosed? How did it affect your relationship with your doctor? Doctor D would love to hear your story in the comments!