In this ongoing series, Dr. Thomas N. Told, Regional Director of Clinical Education for RVU-SU, shares his thoughts and experiences as a family medicine physician of more than 35 years.
It was Sir William Osler, a Canadian physician and one of the founders of Johns Hopkins Hospital, who first observed, “A physician who treats himself has a fool for a patient.” I have heard that famous phrase quoted often since my early days of medical training. In truth, all physicians know it is not acceptable to treat themselves or their families, yet it has been embedded in the culture of medicine for years. According to a survey published in Family Practice Medicine in March of 2005, treatment of oneself or of family and friends is common, especially when it comes to antibiotics, antihistamines, and contraceptives. Another retrospective review of 27 separate studies published in the Journal of Occupational Medicine in October of 2011 found that self-treatment among physicians and medical students ranged from 21% to 96%, with the mean being 56% for all of the studies. The American Medical Association’s Code of Ethics allows self-treatment in only two cases: in emergency and isolated medical situations where no other physician is available and for short-term or minor medical cases. The wisdom behind not treating one’s own self or family is that personal feelings and pressures may unduly influence one’s professional medical judgment and lead to bad outcomes. In Part Two of “Physician Heal Thyself,” I will cover how easy it is to fall into the trap of self-treatment and medical diagnostic “group think” with colleagues, only to suffer the ravages of a misdiagnosis.
A Fool for a Patient
It was the day before Thanksgiving and the first big snow of winter had come early, depositing 18 inches of white in Western Colorado, that would grow to 2-3 feet of snow and permanently blanket our front lawn up to the spring thaw. Our sons and their families had returned home for an old-fashioned get-together and the house was bursting at the seams. Everyone was busy cooking, baking, and decorating when someone remembered that the frozen turkey had not been brought from the garage to the refrigerator.
Reluctantly, I gave my blessing that it would be alright to proceed with cleaning and refrigerating the bird until the next day. My trepidation, or rather outright fear of food-borne illnesses during the holiday season, could be traced back to my college years when I was a waiter for Brigham Young University Food Services. We had catered a large Thanksgiving party for faculty, after which I was given a leftover pumpkin chiffon pie to take home. It was a masterpiece combination of pumpkin and whipped cream, and it had only been out at room temperature for a few hours. As fate would have it, the piece I had selected was loaded with Staphylococci, which wreaked havoc with my alimentary system just a few hours after ingestion; thankfully my wife was completely fine after eating her piece. The days that followed were memorable and miserable enough that I shudder now just thinking about it. Back to the Thanksgiving dinner with my family all those years later, the thought of running into a bout of Staphylococci, E. coli, or Salmonella from an infected turkey weighed heavily on my mind.
The turkey was now completely thawed and it would be another 12 hours before it would be cooked. All the culinary experts in our family, composed of my wife and daughters-in-law, felt that the turkey would be just fine, but I was still skeptical. That turkey was the biggest one we had found, getting another one like it at this hour was out of the question.
On Thanksgiving Day, our guests descended on the lavishly adorned table with vigor. It wasn’t long before empty plates adorned the kitchen and satisfied family members occupied every soft recliner and couch throughout the house, enjoying that postprandial delight that follows most feasts. I, however, had eaten very little and even my most favored dishes seemed to taste like cardboard. Though I had not eaten much of the turkey, there was no off-taste in the portions I had had, and nobody else seemed to notice anything either. In the days that followed I passed up turkey sandwiches and leftover pumpkin pie. I did try some turkey soup as the turkey supply gradually dwindled away. As the days went by, I was becoming more and more convinced that I had yet another bout of low-grade holiday food poisoning. By Monday morning, I still felt under the weather and had a small amount of abdominal discomfort right in the middle of my stomach that I ignored.
I went to work and discussed the long weekend’s events with the Family Medicine resident rotating with me from Denver. Hearing my concerns, he graciously —though reluctantly — agreed it could have been some form of food poisoning, probably Salmonella or E. coli, but remained puzzled that no one else had become sick. I told him I needed to get better quickly. We both knew we had another busy week ahead, but more pressing was that my cousin’s annual Christmas party was happening the coming weekend in Salt Lake City. This was not just a typical family holiday party, but a black-tie affair, with hundreds of important people from government and law enforcement gathering at her estate near the mouth of Little Cottonwood Canyon. This traditionally lavish affair was a highlight of the holiday season in the Salt Lake Valley and was well worth the five-hour drive from Western Colorado to attend.
Throwing me a sample box of Cipro, a quinolone antibiotic that was relatively new on our sample shelf, he said in a hopeful tone, “The drug reps say it will work on all types of difficult infections. Maybe it will work to knock out your stubborn case of food poisoning.” I wanted him to be right so much so that at that moment my better judgment slumped and I took the antibiotics. Because of the urgency of the week ahead, I had allowed myself to take that first step on the slippery slope of self-treatment. I had spent the entire Thanksgiving holiday with classic anorexia (striking loss of appetite) which is the first sign of a developing abdominal infection or inflammation and completely missed it.
The Cipro lessened the pain slightly, lending credence to my food poisoning diagnosis, and I was comfortable for the rest of the week. Curiously, that unsettled feeling in my abdomen truthfully never fully left. While the antibiotic had temporarily slowed the progression of a hidden infectious process, it had further obscured the course of that condition and delayed the true diagnosis.
It was late in the afternoon when the time came to leave for Salt Lake City. I had been double-booked with appointments because everyone was hurrying to get checkups and treatments before the end of the year. Two hours after leaving Craig, we arrived in Vernal, Utah and my abdominal pain had surprisingly returned as intense as it was a week ago. Now, however, the pain radiated from the front of my abdomen and extended around into my back. Driving from Colorado, I discovered that if I bent my right knee and drew my thigh up toward my chest it helped the pain a great deal, but then I could not push on the accelerator to drive the car. I had no choice but to turn the driving over to my wife. Being relegated to the passenger’s seat, I pondered over the clinical reasons for this new development. Perhaps I was experiencing mild dehydration from lack of water or the exertion from the busy day had jarred loose a kidney stone. On the other hand, I thought, I had never had a kidney stone and kidney stones did not run in my family. At this time, I needed a diagnostic narrative that did not involve a hospital or an ER, so those two bits of history didn’t seem to matter and the kidney stone presumptive diagnosis fit just fine.
My wife urged me to go to the hospital in Vernal, but I assured her it was probably a kidney stone and I would be fine once it passed. After all, I explained, passing a kidney stone is the only way a man can understand the true pain of childbirth. She had endured that pain without complaining, so I was sure I could endure it just as well. Not wanting to delay the trip, I promised her I would wait until we got to our family home in Pleasant Grove, Utah before I would go to the hospital. That is, of course, unless the stone had passed by then, in which case I would be fine.
Over a hundred miles later in Heber City, the pain had not let up at all and was gradually increasing. Every bump in the road instantly sent waves of pain into my back and lower abdomen. I jokingly told my wife that it wasn’t necessary for her to hit every pothole in the road. I also vowed to write the Utah State Road Department and tell them that they needed to repave the canyon road for it was nothing but a mass of ruts and potholes.
Forty-five agonizing minutes later – with both my feet planted firmly up on the dashboard of the car –we arrived at our family home in Pleasant Grove. I rolled out of the front seat and slowly stood up; three steps later, I felt like something in the lower right side of my abdomen was released. For an instant, everything felt different and a bit more comfortable, but what followed next was the most agonizing pain I had ever experienced. It was intense enough to double me over and take my breath away. My right leg flexed quickly into my chest and I could not straighten up. It was if someone had opened my abdominal cavity and dumped the entire contents of a barbecue grill, hamburgers, hot dogs, and hot briquettes inside of me. There was no maneuver or position I could manage that would ease the unremitting pain. At that moment, my body reacted by forcefully and involuntarily giving up everything I had eaten that day. In midst of my anguish, my former partner Dr. Raymond G. Witham’s words rang out loud and clear in my mind, “I have never seen a case of acute appendicitis where the patient had not vomited at some time along its course.”
For the first time since my ordeal had begun more than a week ago, I entertained the possibility that I might have acute appendicitis. I, the self-made and self-proclaimed expert on the diagnosis of an acute abdomen, had systematically missed all of the signs of that malady in myself. Yet, even at that point, I had refused to believe it because I had too much to do. The diagnosis of a kidney stone fit my schedule much better, as I did not have time for an operation and a hospital stay. Osler’s aforementioned prediction was manifesting its wisdom once again in front of my family home as I lay in the snow. I was now clearly doing a lousy job acting as my own physician and had acquired myself as that “fool for a patient”. I had no other options left to turn to at this point. Kidney stone or appendicitis, I needed relief from treatments that could only be obtained in an ER or hospital.
Through the years, nearly two dozen physicians have identified specific clinical signs and symptoms of acute appendicitis and many of those clinical signs bear their names today: Blumberg, Kehr, and McBurney. In retrospect, after eliminating the four physical signs that dealt exclusively with diagnosing acute appendicitis in pregnancy, I had experienced most of them over that past week.
One sign I had yet to experience, but soon would in the ER, was Rovsing’s Sign, named after the Danish surgeon Niels Thorkild Rovsing. Dr. Rovsing had observed that when the examiner palpates, or pushes in, on the left lower part of the abdomen and releases, it elicits a rebound pain on the right side of the abdomen. I had always been intrigued with this phenomenon because it relied on the anatomic and physiologic mechanisms of the entire colon to act in concert as a complete organ to elicit the response. Though not always present, in my experience it had proved to be a reliable sign of acute appendicitis when it was present. With the possible exception of a diagnosis of horseshoe kidney, very few other pathologic conditions in the lower abdomen can produce a positive Rovsing’s Sign.
Conventional thought during my training had always been to withhold pain medication until after the preoperative examination had been completed by the surgeon to prevent any masking of those important diagnostic signs. As much as I hurt that night when I reached the hospital, I now fully empathized with all the patients I had made to wait for IV pain meds until a surgical evaluation was completed. I also secretly hoped that my surgeon didn’t live miles away from the hospital so this pain would not go on forever.
Thankfully, I had a surgeon who did not subscribe to the rule of withholding medicine, and IV morphine was administered prior to his arrival and evaluation. That pain medication was like being rescued from the gaping jaws of Hell. It also still allowed me to be comfortable and alert enough to react to any positive signs elicited by the examination. Also, as a physician who had diagnosed many cases of acute appendicitis, I could now experience exactly what my patients experienced during a preoperative examination in relative comfort.
The on-call surgeon, Dr. Sheffield, arrived and reviewed my labs, which showed a markedly elevated white blood cell count and the totally clear urinalysis that I had insisted on collecting at home before coming to the hospital. I was so intent on the validity of the kidney stone diagnosis that I sent my family on a late-night scavenger hunt in search of a suitable vessel with a lid to collect that urine sample. After a brief search, they returned with a small and ornately fashioned holiday jelly jar that somehow added to the other unconventional events of the evening.
That normal urine sample destroyed all of my hopes for a simple solution to the drama that had entered my life since Thanksgiving. I would not be going to the holiday gala and I would not return to work for weeks. All of my patients who had put off their surgeries until the end of the year in order to avoid renewed co-payments in the following year would now have to wait. Suddenly, my insistence on being my own physician had not only hurt me, but it was going to impact the plans of many others who depended on me. A long time ago, I had promised myself that I would do everything in my power not to miss an acute appendicitis as the consequences could be severe or even fatal. Yet I had allowed myself to take shortcuts by not fully treating my own serious condition in the same way I would have treated my patients; now everyone would suffer as a result. I vowed from that moment on, I would strive to never again become Osler’s physician with a fool for a patient.
Dr. Sheffield began his examination on the left side of my abdomen and worked over to my right lower abdomen to a spot known to all as McBurney’s Point. As he pressed down on my left side, I began to feel discomfort rise on my right side, but when he suddenly released that pressure, a lightning-like pain shot to the surface on my right side precisely at Mcburney’s Point. In an excited and almost jubilant tone, I exclaimed, “Oh my word, I have a positive Rovsing’s Sign!” It was unmistakable and every bit as intense as if it had been elicited from pushing on the right side of my abdomen. Dr. Sheffield stopped the examination at that point and gave the order to set up the operating room for an emergency appendectomy. He gave me my choice of an open or laparoscopic procedure. It was now abundantly clear to me that the intense pain I had experienced getting out of the car was the appendicle abscess rupturing. I opted for an open procedure that would allow for post-operative drainage, which turned out to be what was needed. I had an appendix that was positioned on the very back of the lower right side of my abdomen called a retrocecal appendix. It had become gangrenous then leaked and formed a large abscess. In that position, it existed without showing all the more classic signs of appendicitis, and the resultant flank pain caused confusion with the renal pain of a kidney stone.
My recovery was mercifully swift and, within a week, I was back at work and treating my patients. My empathy for my patients had grown immensely and I felt greater compassion for all those who have had to suffer through any and all painful afflictions. My admiration and respect for Sir William Osler’s wisdom had been further strengthened, for I now had real-time knowledge that self-treatment as physicians is very easy to do but quite hazardous. If there was a silver lining in this ordeal, it was being able to experience in real-time the Rovsing’s Sign, and I will never forget that feeling to this day.