The Doctor is definitely in!

LTC Dan sent this Forbes article.

Dr. J. loved the point about swimming pools being far more dangerous. His insurance agent is quite aware of this statistic, and thus Dr. J. will NEVER get a swimming pool. Besides, his kids could easily make the one mile bike ride to New Atlantis Country Club, anyway, so it’s a moot point.

The take home point is here:

Instead, physicians should not routinely ask patients whether they own guns, because it could compromise the integrity of the doctor-patient relationship.

Indeed Dr. J. agrees with the author, the therapeutic alliance is sacrosanct if you are going to be able to provide the best care. Unnecessarily creating mistrust is the best way to to disrupt that relationship, as happened recently in Chicago.

The Volgi serendipitously slipped a copy of today’s Chicago Tribune into Dr. J.’s stack-of-stuff™, and asked him his thoughts on this article.

The short version is  that a 16 yo strapping young Chicago young man was admitted to Advocate Hope Children’s hospital in Oak Lawn, Chicago back on the 4th for what sounds like getting IV antibiotics for a swollen tonsil. A resident and two medical students walk in the room to take a history and do a physical exam. During the history they ask the parents if they would excuse themselves so that they may ask some personal questions.

Mom thought they were going to ask about alcohol and drugs.

The patient later reveals to the mother that they asked him about firearms in the house. Despite the fact that they do not own firearms, the mother and son felt violated and confused as he was admitted for tonsillitis, not for psychiatric reasons, or anything remotely related to firearms. Advocate spokesman Mike Maggio told the mom that asking about guns is not standard practice but the pediatric residency program director Dr. Mark Butterfly said it was.

So, Dr. J. is going to filter through the BS to give you the real scoop.

Advocate’s spokesman is right, it isn’t standard practice hospital-wide, but the Pediatric residency program director is equally right that it is standard practice in his corner of the kingdom.

If you are a medical student, your hospital rotations are your first opportunity to develop your newly minted history taking skills. You are expected to ask anything and everything with an exausting level of detail. You are then asked to formulate your differential diagnosis (Ddx), and develop a plan.

A Ddx is the list of all the things it could be organized by likelihood and system. In other words you don’t say Mr. Jones has tonsillitis, you say that your differential diagnosis includes bacterial tonsillitis, mononucleosis, lymphoma, head and neck cancer , HIV, sarcoidosis, lupus (it’s never lupus), and a bullet lodged behind the tonsil from a previously unknown gunshot wound to the neck. The medical student then states that it is most likely bacterial tonsillitis because of this element of the history of present illness, those findings on the physical exam, these lab and imaging findings, etc…etc…etc…

This medical student, wanting to get an A+ and recently made aware of the AAP recommendations, probably asked every question possible under the sun, including those about firearms. The history and physical has a standard template. Despite this, however, the students are typically asked NOT to do a full physical exam, deferring unnecessary rectal, genital, pelvic, (Oxford comma, Czar) and breast exams lest they be considered harassment.

They are the chief complaint, history of present illness, past medical history, past surgical history, medications, allergies, family history, social history, review of systems, physical exam, lab data, imaging data, assessment and plan.

The social history is the part where firearms were presumably asked about. In this section, we ask about education, occupation, smoking, alcohol, drugs, sexual activity, etc…

Before beginning the social history, Dr. J. would have said, “These are questions we are asked to ask everybody in order to make sure we aren’t missing anything. Some of them may not be relevant in your case, but to be fair to everyone, we ask everyone.” That usually puts the patient at ease that Dr. J. was checking off some check box for some useless bureaucrat, rather than being a nosy parker.

Dr. J., now a seasoned specialist takes a fairly focused history and does a focused physical exam in most patients. But when he was a medical student he would take a thorough history and exam, but he would steer clear of any irrelevant areas, sometimes to the annoyance of his professors. He would gloss over the sexual history, unless it was absolutely relevant.

Now if this medical student were appropriately thorough, however, he would have taken a rather pointed and personal and possibly offensive sexual history on this young man, leaving virtually no stone unturned. This tonsillitis, while most likely to be streptococcus or staphylococcus could have been neisseria gonococcus, the germ behind gonorrhea, and requiring a different antibiotic strategy, conceivably. This young man should have been asked, in private, regarding his sexual proclivities, especially with regard to oral sex. Now he may have been asked, but that wasn’t mentioned in the article. It’s embarrassing enough being asked those personal questions as a teen, but even more embarrassing for the patient to answer, either in the affirmative or in the negative for that matter (uh, yeah, I’m still a virgin #headdesk).

Asking about firearms in this case is irrelevant. And while the medical student (or resident) was probably being thorough for the sake of being thorough, he should have been more sensitive. After all, he did upset and confuse the patient. He also made the patient distrust him when trust was the most essential of all elements in this therapeutic relationship. When a patient is admitted to the hospital, the residents and medical students act on behalf of the patient’s outpatient and inpatient attending physicians.

On more than one occasion, Dr. J. has had to do significant damage control. One time he admitted a patient for multiple expensive and invasive tests in a run up to a possible valve replacement. Addressing code status was in vogue, and Dr. J. got a phone call from the cath lab saying, “why did you send us a patient who is ‘do not resuscitate?'” Dr. J. was stunned, his patient was not DNR, as we say, especially given we were thinking about open heart surgery. He went to talk to his patient, and asked him why he was listed as DNR, and the patient said, “The residents made it sound so good!” SIGH! Those residents were re-educated on the difference between discussing code status and ‘giving up’ on relatively healthy individuals.

At a time where doctors need to be thoughtful, thorough yet efficient, asking about guns is irrelevant 99.9% of the time. Furthermore, young doctors in training need to learn to be more politic and judicious regarding guns in the inpatient setting just as they typically defer unnecessary personal parts of the physical exam. In this case, these young doctors have hopefully learned a lesson that will last a lifetime.

Dr. J.