Self Titled

I describe to my preceptor the perfect viral pharyngitis. Not one single symptom of strep throat. No fever, no lymphadenopathy, no “painful swallowing”, not in the age range that would increase suspicion, no tonsillar swelling or exudates. There is the perfect history for post nasal drip with cough and no contacts with strep. My description of the throat rivals a text book of what Strep Throat Doesn’t Look Like. I won’t bore you with details.
“So we’ll just do a rapid strep test and send them on their way.” says my preceptor, apparently unconvinced. He is unsure of why, so I help him out. I validate the possibility of a strep test, noting this could be a “therapeutic” test. In other words, a lab test that may help assure the patient that a bacterial organism is not causing her pain. It may provide some relief to know that we did everything possible to find a reason to give her antibiotics, even if she walks home empty handed, despite the evidence that gives her a next to zero chance of having strep throat. He then needs a glass of water so we spend 10 minutes in the kitchen while he lectures me on the point that I just made for him. It is a cheap test and if everybody sleeps better tonight then so be it. But, in order for her to sleep better tonight, we have to get her out of our office before midnight. Put the water glass down and let’s do something, even if that something includes doing a test that I can guarantee will be negative.

I gag the patient with a swab and send it to our lab. Alas, it is negative. (If it had been positive for strep, I would have been devastated and probably too embarrassed to relay this story to you.) I then wait, and wait some more, for the preceptor to be ready to go see the patient. A 15 minute visit turns into 45. He’s been frustrated all morning, slow in his pace and deliberately making things like being put on hold, or logging into his computer seem overly dramatic.


We shuffle into the room and I listen to my preceptor describe viruses, post nasal drip, and the lack of need for antibiotics. The mother of the patient tells the tale of being prescribed antibiotics in the past for similar episodes. Not today, honey. We offer symptomatic relief.

After we’ve left the room and the patient was left with her salt water gargling instructions, my preceptor turns to me and in a demeaning tone says, “I certainly hope you won’t be one of those providers that prescribes antibiotics for that in the future.”

“You got it, pal,” I think as I watch the family leave, well over an hour after they should have.
Funny moment when you realize that, despite not knowing it all, or even not knowing a lot, you still develop your style of practicing medicine. Mine is different than his. Or maybe I just don’t like him.

New Guy Once Again

First week of 3 months in Hood River completed. I'm renting my own house close to downtown. It has a wood burning stove but no WiFi, so I bought a 1/4 cord of wood and will likely spend more time stoking the fire than surfing the web.

A very different feel here compared to Cheha-town Peds. There it was fast paced, 2 minute dictations, crack-the-whip, sort through the viruses medicine. My patient presentations eventually got boiled down to: "It's diarrhea. They look good." Even in Scrippsville, if they walked in the door they got a Statin. A door prize that didn't require much thought or reason.

My preceptors here expect a much deeper and wider differential diagnosis. They also expect a little more evidence based approach. We actually use things like Framingham's Cardiac Risk Score. They want my notes to say things like "...due to lack of abd pain and blood in stool, we ruled out bacterial etiology of this patient's diarrhea although if symptoms persist we may order fecal leukocytes and occult blood studies." Their ortho exams entail more than their fingers hitting keyboards to order an ortho consult.

It's refreshing. And difficult at the same time. It's easier to practice loose and fast medicine and blame everything on how busy your schedule is and how the "real world" doesn't include a legit review of systems and lengthy differential. It's easier to keep the patient's sweatshirt on and call a specialist than to actually examine their shoulder.

And at the same time 85% of my patients speak only Spanish. So my brain is doing a bit of spinning right now. I am being humbled on multiple levels. From basic communication skills (come se dice 'blister' en espanol) to detailed pimping (what are the guidelines for phototherapy in newborn hyperbilirubinemia?)

I'll keep you posted. But for now, I'll be stoking that fire with a textbook on my lap. I've still got a lot to learn.