A Country Doctor Writes:

Suppressing The Inward Eye Roll

The Canadian RuralMed listserv, which I was invited to join, had a comment today, inspired by my post “If You Are a Doctor, Act Like One“, Dr. Yogi Sehgal reflected on how seemingly trivial concerns can be very appropriate if you try to understand the context:

“[Dr. Duvefelt’s] post reminds of one of my little practice tips that I have learned over the years to reduce frustration in the ER.

When a patient presents to the ER or the office with a very minor complaint, and the nurse says to you, “OMG, I can’t believe they came to the ER/office with this,” followed by an eyeroll, it’s easy to get jaded or cynical. I find the simple question, “Was there something specific you were worried about?” or “What was it about this that worried you?” is the gist of the “FIFE” questions that we were taught in medical school and do so poorly except on exams. It opens up the discussion about what the real issue is and gives you a chance to educate (doctor, from the Latin “docere”, meaning “to teach”) and feel less cynical or jaded.

Real cases recently:

Patient with a tiny little scratch on their finger which probably doesn’t need a bandaid. “I have a cut I’d like to get checked out.”

You (suppressing inward eyeroll): “Was there something specific you were worried about?”

Patient: “My grandmother died of tetanus from a minor cut like this, my mother died of sepsis from blood infection from a wound like this, I’m worried I’m going to die of this too.”

You: (Aha, now I get it!) “Ok, it sounds like the issue is not your finger so much but your family history. When was your last Td? Screen for anxiety… etc.”

Teenage patient comes to ER (with Mom) with a sore foot that comes and goes for the past week, not an athlete, pain-free now: “I sometimes have a sore foot.”

You (suppressing inward eyeroll): “Was there something specific you were worried about?”

Patient and Mom: “We were worried it had something to do with her congenital hip dysplasia.”

You (Aha, now I get it!): “Ok, sounds like we need to know a bit more about the hip and mechanics of what’s going on.” (Turns out that indeed it likely was partly related to her hip in this case, and she needed to do some PT at home which she had not been doing.)”

(yogi sehgal)

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Sore knee? Maybe You Have a Fabella

The BBC has an interesting little piece about a small extra (sesamoid) bone that seems to be more common now than even just a hundred years ago, even though other sesamoid bones elsewhere in the body are not becoming more common.

The fabella (“little bean” in Latin) can be the cause of knee pain and perineal nerve palsy.

“Between 1918 and 2018, reports of the fabella bone’s existence in the knee increased to the extent that it is now thought to be three times as common as 100 years ago.
The scientists’ analysis showed that in 1918, fabellae were present in 11% of the world population, and by 2018, they were present in 39%.”

https://www.bbc.co.uk/news/health-47950258

The BBC originally picked this item up from a Wiley publication

“Hou (2016) recently investigated the effects of the fabella on posterolateral pain and palsy of common peroneal nerve following total knee arthroplasty. During trials, fabellae were excised from some patients but left in others. Post‐surgery, posterolateral pain and palsy of common peroneal nerve were only observed in patients who still had fabellae. Accordingly, Hou recommended removing the fabella when knee replacement surgery is performed.”

https://onlinelibrary.wiley.com/doi/full/10.1111/joa.12994

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Vaccination is Not Really Just a Personal Decision: People Don’t Understand Herd Immunity -NEJM

I may survive an infectious disease just fine, but what about vulnerable people I come in contact with? The less of it there is going around, the less risk for morbidity and mortality for everyone.

The New England Journal of Medicine editorialized about this:

Exposure to measles in the community certainly represents a danger to high-risk persons during a local outbreak; however, nosocomial transmission may pose an even greater threat and has been reported throughout the world. For example, during a measles outbreak in Shanghai in 2015, a single child with measles in a pediatric oncology clinic infected 23 other children, more than 50% of whom ended up with severe complications, and the case fatality rate was 21%.5 When the umbrella of herd immunity is compromised, such populations are highly vulnerable.
— Read on www.nejm.org/doi/full/10.1056/NEJMp1905099