The Easiest Diagnosis

One of my rules on this blog has always been that I will not mention names unless someone decides to ask me for it in private mail.   The reasoning for this is simple, in my opinion:   I don't want my opinion to necessarily influence whether or not someone else goes to see that same doctor.  After all, it is always possible that when we visit a doctor once, he or she is having an off day.  It is always possible that even specialized doctors have areas of expertise within their own specialty; perhaps a doctor who wasn't so helpful to Colleen can be helpful to you if your condition is in their "jackpot" zone; something they have seen before and know exactly what to do about it.   Every case is different, and no doctor is going to score 100% when it comes to diagnosing a patient.

So, why do I feel the urge to mention a name in this post?  The reason is simple:  I find the doctor we contacted to go over Colleen's possible endocrine issue to be a complete waste of time with absolutely no credibility whatsoever, regardless of what the diploma on his wall may say.     To be precise, if you live in my area, and you have an endocrine issue, and you see the name "David Kleinman" pop up when you do a Google search, don't even bother to click on the link.

Colleen made two visits to him - one to discuss her blood results, then another to discuss the results of new tests he prescribed.   To backtrack for a moment, Colleen's primary doctor ordered a cortisol test a while ago.  The test came back with very low levels of cortisol in her blood.  Low levels of cortisol can be an indicator for adrenal dysfunction, with a common cause being Addison's Disease.   Her primary recommended that she see an endocrinologist, with a few recommendations.  The first recommendation was a doctor I have seen in this area (Joseph Birnbaum), who I found to be very thorough and pleasant.  Unfortunately, they no longer accept my insurance, so we decided to go with another doctor that was on the list.   And that is how we got to where we are today.

First, Dr. Kleinman comes off as very arrogant, which actually does not bother me much personally.  If a doctor is good and can solve a problem, I don't care if they think we should bow before them due to their extensive knowledge.   However, in this case, not only was he arrogant, he didn't really seem to know what he was talking about.     When Colleen told him she had Gastroparesis, he told her that a neurologist should be the first place she should look (He saw the word "paresis" in the name of the disease and instantly thought neurology - for someone who is not a doctor, I can see this as a mistake you may make.  For a doctor to make it is just inexcusable - if you don't know what it is, admit it.  There are thousands upon thousands of diseases in the world - no doctor is expected to know about all of them.  It aggravates me more if you pretend to know something rather than just saying "I don't know about that condition".  It is tough for any patient to be honest with a doctor who is not being honest with them).  On top of that, it would have been acceptable - he is in endocrinology, and shouldn't really be expected to know much about Gastroparesis - just like I wouldn't expect Colleen's gastrointestinal doctors to know everything there is to know about thyroid disease.  (Though more on that at the end of this entry)

Second, Dr. Kleinman seems to have a one-track mind when it comes to diagnosis, unless you are diabetic with a blood sugar reading of 350:  If you are sick, and he has no clue why, it must be in your head.  He even was willing to give Colleen the name of a psychiatrist.   Even when Colleen pleaded with him that  anxiety is not her problem, he didn't even seen to flinch.   Note that this wasn't after 20 visits and completely studying her case and coming to an expert opinion that the mind may be playing a role.  This was after 2 visits without having any idea what was talked about in the first visit (he asked Colleen many of the same questions he asked the first time) and not studying much of Colleen's case at all.     Colleen will be the first to admit she has anxiety.  She will be the first to admit that health anxiety is something she has dealt with.  She will tell you she has seen a few therapists,  and even went to one recommended by our primary.   She has anti-anxiety medication.     She isn't hiding behind any of that - has been honest with every doctor she has seen.   In a way, you almost have to think about hiding the fact you have anxiety - go to the doctor, tell him or her you have no problems with anxiety, and see what conclusion they come up with.   If you dare be honest and tell the truth, some doctors seem to go down the path of "You have anxiety.  You say you are sick.  I see nothing wrong with you.  Hence, it is all in your head."    It would be like a mechanic looking at a car that won't start, not being able to figure out the reason why, and coming to the conclusion that it isn't starting because the car has general anxiety and just doesn't want to be driven anymore.  

Thirdly, yes - Colleen's cortisol numbers were supposedly normal this time around.  Dr. Kleinman instantly came to the conclusion that her adrenal function must be fine because of this, completely ignoring the results of her first test.  What if the second test is the wrong one, and not the first test?  How exactly would he know?  He doesn't.   And this is another reason why some doctors are just not useful:  They look at numbers on a sheet of paper and decide if you are sick or not.    Not only is this lazy, it is borderline criminal.   This is not to say blood work should be avoided - of course not - but the results in the hands of the wrong doctor can still be dangerous.     BLOOD WORK NUMBERS ARE NOT DIAGNOSTIC.  This is why we have doctors (supposedly) and not just a robot that comes into the room, draws your blood, and leaves.   Blood work numbers are a guide - something that can lead a doctor to further investigate your condition, if warranted.  If they come back normal, that doesn't mean the person is healthy (The opposite is also sometimes true: An abnormality in blood work does not mean you are sick.)   When a number comes back abnormal, it  means "Here is a red flag for you, doc - now see if it means anything".

Fourth (yes, there is more), Dr. Kleinman didn't even know who Colleen was when he walked in today - and read off the script he had for ANOTHER patient of his when he first walked into the room.  That is right, he started talking to Colleen as if she was someone else.   Look, people make mistakes - don't get me wrong - if he was a good doctor who one day made this mistake, we would have laughed it off.  When I was sick, the doctor's office once placed the results of someone else's testing in my chart - a strange coincidence, it turned out.  Both of us received a specialized blood test at around the same time, and his results ended up in my chart accidentally.   I was even called in to talk to the doctor immediately at the time.  If this doctor was incompetent with me in the past, I may have flipped out - but she wasn't.  It was a mistake - nobody likes mistakes being made when it comes to their health, but it happens.   But when an incompetent doctor makes a mistake like this, it gets magnified - it reassures you that the doctor has no idea what he is doing and is just waiting to move onto the next patient on his schedule.

Seriously, the nurse who took Colleen's blood pressure today may have been in the room for a longer time than Dr. Kleinman was today.  "Your tests are normal, you have anxiety - your issue is anxiety.   The bill is in the mail"

To get back to a point I made above, wouldn't it be nice if most specialists understood conditions that go beyond their specialty?  I think some do - I think Colleen's gastrointestinal doctor likely has knowledge of how different things can impact her stomach condition.   But it just appears that many doctors just don't want to take the time to piece together the entire puzzle.  You end up having an endocrinologist looking only at adrenals and coming to his conclusion.  You have a gastrointestinal doctor looking at only the digestive system and coming to his conclusions.  You have a primary who is looking at all of the numbers from all of the tests and trying to reach his own conclusions.  You may have even more doctors than that - all with their own charts, all with their own conclusions, all based on their specific area of expertise.   There is nobody looking at the entire puzzle, sitting down in a chair for a few hours, trying to figure out what the answer can be.  It is like having two detectives working on the same murder case and not comparing notes.   It just doesn't work - no one person has every piece of information in front of them, trying to figure out if there is a condition that can connect everything.   Perhaps there is nothing that jumps out as obvious - but it would be nice just to have someone who will try.

It is times like these that make you want to sometimes give up on the medical field as a whole; and I don't mean to get down on every doctor Colleen has seen.  I find a few of them to actually be helpful and useful.  But the majority of doctors she has seen have not been useful, and that is a serious problem.

Today's doctor, however, took it to a new level of incompetence.  Some of the doctors we thought were incompetent in recent years suddenly looked like geniuses compared to this guy.    It was simply a bad day that left a terrible taste in both of our mouths.

The Endocrinologist Visit

Someone reading this blog for the first time may be a bit confused by the title of this particular blog entry, and I can see why:  Gastroparesis and Endocrinology do not appear to really mix very well.     The endocrine system does not include the stomach, after all - it includes the glands that control hormones (thyroid, pancreas, etc.).    However, the endocrine system (like many systems in our bodies) is quite complex - and the stomach actually does perform secondary tasks for the endocrine system.   This is where I sometimes think "specialists" can actually end up not being as useful as you would hope; especially specialists who may be unwilling to think outside the box.  The cause of your stomach issues can come from many different sources.  It is like a pinball machine - you may aim for one section of the board you wish to hit, and it causes a chain reaction, where it bounces all over the board, including places you did intend for it to go.   The same type of thing can happen to your body - one system goes out of whack, and it causes a chain reaction where many different things start going wrong.   

As I mentioned in a previous post, Colleen had one test which showed a very low cortisol number.  As I have stated many times in this blog, it is just a number on a page - in and of itself, a number that shows up on a blood draw is essentially meaningless.  No doctor can look at a number and tell you that you have a disease, or tell you that your are healthy.  Numbers are a guide - and always remember one thing about the "ranges" you see on the side of the page:  Those numbers weren't just picked out of a hat, nor are they 100% reliable.  They are statistical - you look at people who are healthy, see what their numbers are for various factors, and come up with a suitable range.   It is very possible to be 100% healthy and have numbers slightly out of range.  But the reverse is also true:  You can be sick as a dog but have blood work that looks normal.  No doctor should tell you that you are healthy or sick based on a blood draw - IT IS IMPOSSIBLE.

As for Colleen's visit, we didn't exactly learn anything revolutionary - however, the doctor did seem knowledgeable in his field, which is the most important thing at this point.   Many specialists can come off with a bit of an attitude - the attitude that "I am the specialist, you are the patient - just listen to me".  In some cases, I understand where they are coming from.  However, a doctor should always be willing to listen to a patient who questions things.   Patients indeed are not doctors, nor are most of them medically trained.  They should have the right to ask questions about treatment options, etc.   Being someone who is good at computers, if I recommend to someone that they should replace their hard drive, their first instinct shouldn't be "Sure.  I'll do it today!".  The first thing out of their mouth should be "Why?"    That is how the doctor-patient relationship should work.   Patients should be allowed to ask why - and shouldn't be afraid to do so.

Anyway, as I said above, one cortisol number was not going to lead to anything revolutionary.  Colleen now has to take a second cortisol test, including a 24-hour urine test.  It likely is as tedious as it sounds.   The problem is we have been hit with some snow in this area, and she has to do the test in a fashion where as soon as she is done, she has to get the container to the lab.   We can't sit on it for a day or two.

There are a few other things he seems to be looking for; I don't know if any of these tests would give us a clearer picture on diseases such as Addison's Disease, but I do think he is following protocol with what he is doing.  Colleen will see him again in a few weeks.  It is possible that she will once again be referred to a university hospital for further testing.

I hope everyone enjoyed their holiday season.  And since this is a blog dedicated to health, here is to a healthy 2014 for everyone.......