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An observation.

Discussion in 'Military Medicine' started by Number41, Mar 26, 2007.

  1. At the risk of sounding ignorant, i've made a few observations. Background about myself: I'm Active Duty Air Force in a non-medical job. I'm also in pursuit of a Degree in medicine. Now, on to the observations.

    Judging by the many places i've been, and varied environments, it seems that Diagnostics in military medicine is lacking. I can't be certain if this is due to lack of autonomy or just the historical EM perspective. Should chronic joint pain or the like be treated with less care or focus than a battle wound? Granted prioritization is a deciding factor, but let's face facts... At 8:00 AM on a Monday morning, there's not much more than the standard cough, follow-ups, and prescription refills.

    Here's a scenario.

    Monday morning, I walk in to the clinic with knee pain brought on by a lengthy run. I have a history of knee pain and it's well documented. So, the doctor in the clinic... New Chief of Medicine... asks me all pertinent questions and I respond with symptoms. During the consultation she glances at the clock every minute or two. Having to repeat myself a few times due to her lack of attention/interest and obvious preoccupation, i'm now annoyed. I ask her if she'd like to refer me to another physician. She puffs and offers a less than cordial remark and pokes at my knee. She then writes me a prescription for viatamin M "Motrin", and tells me to be on my way.

    Now, regardless of her administrative obligations, and in conjunction with two prior surgical procedures on the affected area, was that a sufficient diagnosis? (Inflamation)

    Thoughts?

    Caveat: Because of this diagnosis, i'm now seeing a physical therapist... to rehabilitate my knee after a more serious injury stemming from the original.
     
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  3. The White Coat Investor

    The White Coat Investor AKA ActiveDutyMD Physician Partner Organization 10+ Year Member

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    What were you expecting, a STAT MRI? Take the motrin for a couple of weeks, if it doesn't get better, go see ortho. Perhaps they'll inject it with roids. If it isn't better after a couple more, your PCM or ortho can get an MRI to ensure there isn't a surgical problem. There is nothing wrong with your doctor's current treatment plan, especially given the chronic nature of your problem. Have you considered taking up swimming, biking, or an elliptical?

    P.S. On Monday at 8 am there is a helluva lot more than runny noses going on, there is also bogus knee pain coming in to avoid being in PT. :) Not saying you're one of them, but we see a lot of it.
     
  4. I think my overall issue was the attitude in which the diagnosis was conveyed. Knowing that it has been an issue in the past, I feel I should have been refered to Ortho. I've had the same feeling of being marginalized more frequently where I am now. I suppose I was expecting a bit more "patient care" and some sign of concern rather than Motrin and a shove out the door. I could have medicated myself if that were the case. I do appreciate your reply though. I know there are many people trying to avoid PT on Mondays, but our Clinic is only open Monday through Friday, so if it happens on a weekend, I have to wait.
     
  5. BigNavyPedsGuy

    BigNavyPedsGuy Junior Member 10+ Year Member

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    The first thing you almost always do with knee pain is ibuprofen and rest for a week or so. If the pain persists, then you try cortisone shot or ortho referral. Sorry your doctor wasn't what you had in mind, but the diagnosis seems right to me.
     
  6. kzjonez

    kzjonez 2+ Year Member

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    Further thoughts about your scenario . Physicians can not just send you to ortho just like that simply because the patient wants to be sent there .For knee pain as per "TRICARE" for what is worth, you are required to have failed "conservative therapy " which includes Motrin and PT, that is if the physical exam does not point to something serious like a ligamental tear or the likes.It seems to me that the course of action taken by the physician is perfectly adecuate.
     
  7. Very well could be, but i've done the injections and surgery in the past. As for "rest", you know that the military doesn't always permit that. I also didn't get any sort of PT limitations or profile, which, as stated, made the condition worse. I can't say that it was do to a lack of treatment... but I think there could have been much more done.

    I suppose I was just wondering if this rush'em out thing was common, or just an anomaly that I had the misfortune of seeing.
     
  8. The White Coat Investor

    The White Coat Investor AKA ActiveDutyMD Physician Partner Organization 10+ Year Member

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    Uhh....both.

    If it makes you feel any better, I would have given you a 1 week 4T profile so you didn't have to run on it. But then again I'm a big softie.
     
  9. kzjonez

    kzjonez 2+ Year Member

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    MEB if it was me !!
     
  10. backrow

    backrow 60% of the time it works everytime Lifetime Donor Classifieds Approved 10+ Year Member

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    I'm going to go ahead and get it out there and be the jerk who says it:

    Quit your whining, your treatment was appropriate for what you have described. Just because you didn't like the way it was given doesn't mean it wasn't the right pathway.

    Sorry if this sounds a little harsh, but I have a feeling that is what the posters above me were thinking.

    Okay, so after reading the thread again it's a little harsh, but I'm going to leave it.
     
  11. For clarification purposes, i'll go ahead and say that i've seen Iraq and most of the CENT theater during the rough times. I've been through a lot of programs that have turned my knees to gelatin. Now, the only thing i'm expecting is to be treated. Motrin, as illustrious and exalted as it is, is temporary. The now chronic pain certainly warrants a more thorough treatment... not even cure. That being said, i'm not seeking protection from a dead man's profile, just a bit of relief. I see and have seen many with the same argument. The critical care elements within the scope of Military medicine are some of the best. Again, my mind goes back to history. "Patch'em up, get'em fighting". I think complacency would be an unfair term, but i'm wondering if it's just the environment i'm in. I've had some great Military physicians, but there are certainly no average docs on the spectrum. Either great or terrible. I'm also stationed on an installation operated by another branch of service, so perhaps that has a lot to do with these thoughts. Not sure. In any case, I do value the opinions of all that responded.
     
  12. kzjonez

    kzjonez 2+ Year Member

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    I may not give patients what they want, but I always will give them what they need, that is my pledge. Welcome to Milmart.:rolleyes:
     
  13. Heeed!

    Heeed! On target, On time! 10+ Year Member

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    It seems like anytime I saw the flight doc I would walk away with Motrin. Granted, I was on flying status so the hard stuff was off limits. But can we give our fellow brothers and sisters in arms some real pain medicine in addition to the vit M? How about some Lortab? or at the very least, a week/few days of Vicoden? Sheesh. It has been my experience that we vastly undertreat pain in the military. There is so much proctalgia fugax we should all get some opiods!
     
  14. USAFGMODOC

    USAFGMODOC Attending physician 7+ Year Member

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    I agree with some of the previous comments above, conservative therapy with Motrin/rest/PT is recommended... Reason is-- no significant new trauma, just pain after running ---- OVERUSE/inflammation or whatever...

    I can't tell you how many patients I've had demand their way into orthopedics with a "non-surgical" problem, but if the patient persists, they get an MRI-- (usually negative or have non-surgical findings) and low and behold they get a knee scope for some ridiculous reason and end up WORSE!!!

    Despite your docs lack of attentiveness, I think you were given the right course for now... Follow up, if not better the PT's I've had are usually pretty good at telling when something "more" is wrong or your treatment is not following the expected course/outcome...

    GOOD LUCK

    The above information especially applies to Low Back pain.... Hey, I'm not letting anyone operate on me unless there is a true indication or a significant limitation on my lifestyle!!!! Patients need to realize that if they doctor shop around enough, they can find a surgeon who will operate on just about anything--- let the patient beware!
     
  15. All valid points. Unfortunately, it did get worse. It seems the consensus is that the physician was correct. My mind still makes a connection of stereotyping in this case. I had several people in my family that were in Law Enforcement. These people would see someone and judge them by their appearance. They had a keen ability to "know" that person was a criminal simply by a glance. Unfortunately, because they only deal with the criminal element of society, these associations were made. I imagine a physician that constantly sees nothing but knee and leg injuries on Monday mornings would tend to get tunnel-vision and forced conclusion of "He/She wants a profile". I don't know. I do agree that surgery will probably only further deteriorate my knee, but I guess it's one of those lose/lose situations that are omitted from my jobs recruiting brochure.

    /rant off :)
     
  16. BigNavyPedsGuy

    BigNavyPedsGuy Junior Member 10+ Year Member

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    Nobody's saying you're done with treatment!! Try the motrin for a week, if it doesn't help (which you've already decided won't). Then go back and they'll try Phys. Therapy, or maybe an MRI. Then, if indicated, you might get sent to ortho. I know you think that nobody's listening to you. We believe you that it hurts. The problem is that we can't send every guy with knee pain straight to the MRI machine. There are limited resources. The system would be more bankrupt if we did that. So, please put your weak law enforcement analogies away and let the docotrs who went to school forever do their jobs.
     
  17. Gastrapathy

    Gastrapathy no longer apathetic Physician Lifetime Donor Classifieds Approved 10+ Year Member

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  18.  
  19. Every time i've been to Ortho in the past, i've needed a consultation with the Flight Doc. It's one of the stipulations of a program that i'm in. Aside from that, to see a specialist in my area, I have to drive two hours. So you can imagine all the paperwork has to be in order. As for the treatment route, i've started to see that there is no cure in the forseeable future. I was merely looking for thoughts on the diagnosis. Sounds like the diagnosis was accurate from above replies.
     
  20. kzjonez

    kzjonez 2+ Year Member

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    This is a prime example of the type of battle I face every single day.I see patients demand being seen by a specialist when I can handle perfectly what ever they have. Everytime I see an add on TV about the newest latest best drug /device etc... on the weekend, sure enough, monday there is someone asking me for it.The problem is ,that at least in my mind, there is a complete lack of trust on what the physician is doing for you.People don't realize that we uphold to the maximum promise that we can make as a doc and it is primum non nocere.I will be hesitant to try the latest greatest drug on you because guess what I dont trust it is safe for you!! this until enough time has elapsed of it being on the market.People think we don't like making our patients to feel better, but guess what I want to keep you safe also.If I send you to the ortho/surgeon you will most likely get a surgery because that is what they do.So I better be sure that what you need is surgical because contrary to what the media has lead patients to believe surgeries are not quick fixes and are not a walk in the park, even the so called "simple ones". :scared:
     
  21. Please don't misunderstand. I'm not so much questioning ethics or moral obligations as I am diagnostics and treatment. I understand that the stress of a physician's job is insane. Pain creates a clouded view and in some cases doubt. I have the utmost respect for all of our physicians, but I don't clearly see both sides of the issue... hence the sound of complaint.
     
  22. Droopy Snoopy

    Droopy Snoopy 7+ Year Member

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    I just want to throw in for anybody reading this after googling "chronic knee pain" or something that SDN shouldn't be used as a source of medical advice. Schedule an appointment with your physician if you're having knee pain.

    This public service announcement is brought to you by Tic and our sponsor Taco Bell (eat great even late).
     
  23. kzjonez

    kzjonez 2+ Year Member

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    You are absolutely right. I was just generalizing. But if I send you to a surgical specialist it is because I think surgery is a possible route of treatment.
     
  24. DNA Helicase

    DNA Helicase Let's do this! 2+ Year Member

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  25. colbgw02

    colbgw02 Delightfully Tacky 10+ Year Member

    Bingo.

    As others have said, it would have been inappropriate for a generalist to just turf you off to ortho for relatively uncomplicated knee pain at the first visit.

    This would be a lot easier if you lived in Podunkville, USA, for your whole life with one family doc. It's a frustrating fact of military medicine that both the physicians and the patients are continually having to re-establish care after PCSing.
     
  26. West Side

    West Side 5+ Year Member

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    I'm surprised this aspect of the case hasn't been addressed more fully. No doubt the OP is suspicious that he's getting a Motrin and a push out the door because during the diagnosis process, the doctor acted dismissively and didn't seem as concerned as she "should" be, in the eyes of the pained patient.

    Put this behavior at your local car dealership. Would you be interested in returning to buy a car if the salesperson was constantly checking his watch while you were telling him what you needed out of a car? Of course not.

    It seems part of the issue was the diagnosis, which sounds like the correct one. But part of this falls under lack of bedside manners and customer service. Now, does the root of this come to the culture of metrics, an environment of brusqueness, jaded and unhappy physicians...or was this an isolated incident? From what I've read of this board, it could be any combination. Simply put, though, if the patient had been made to feel like he was being cared for, and not simply processed, he probably wouldn't be writing this post.
     
  27. GMO2003

    GMO2003 Senior Member 10+ Year Member

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    when you've got 30-40 patients to see in a 3 hr sick call period, you don't have anytime for pleasantries and alot of "bedside manner" the active duty joes that come into sick call are mostly routine sports medicine, musculoskeletal issues that can be diagnosed and treated by a monkey...whether or not the OP thinks he received good customer service is secondary to the primary role that sick call accomplishes....this is to make sure that all the freakin' malingerers and sick call jockeys are given a swift kick in the behind with a RTD stamped in big red letters on a DD689...frankly I don't have a problem with doing just that:thumbup:
     
  28. West Side

    West Side 5+ Year Member

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    I don't doubt what you say is true, but how, precisely, does appearing attentive and being congenial take more time than the alternative?

    Vocations I've dealt with in the last month that have a similar, if not higher, turnover rate than 1/6 minutes, are economically dependant on high volume, and still managed to be very pleasant and made me feel good as a customer:
    • Dealers in Vegas
    • Servers at McDonald's
    • Cashiers at the supermarket
    • My asset managers and stock brokers
    • Retail salespeople
    If it's the volume of slackers and malingerers, how do you square your attitude towards them with the oft-repeated title "greatest patient base in the world"?
     
  29. orbitsurgMD

    orbitsurgMD Senior Member 10+ Year Member

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    Welcome to institutional-grade "socialized" medicine, all you think you can eat at one low fixed price.

    If you are scheduled tight and run like a rat on a wheel, making nice-nice doesn't get a lot of time. That is the system through which care is delivered.
    No, it isn't real personal or high touch. What I am not understanding is why this poster, who ought to have a clue since he is in the system, finds this so surprising.
     
  30. i want out

    i want out Member 10+ Year Member

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    I have tried the path of least resistance a few times in the past, when someone like yourself comes in and says that they 'absolutely have to see ortho'

    I go ahead and put the consult in to ortho, and almost before my enter key has been hit, I get back a nasty gram from ortho demanding that I try at least one course of NSAIDS (Motrin) and at least 6 weeks of physical therapy before I waste their time again with a needless consult. They are usually nice enough to include that if the patient actually has clinical evidence (on physical exam) of instability in the knee, then I could reconsult once I had MRI results, but without fail, if you read between the lines, they are also yelling "DON'T WASTE OUR TIME" or your patients by sending them here before you have at least tried the above.

    That goes for long term knee pain, as well as acute.



    Now for something else you need to understand about medicine.

    Socialized medicine works differently than consumer based.
    In the Military system, E-3 whoever thinks that MRI is the first step in diagnosis, and since it doesn't cost them a dime, they don't care that it has a value of almost $1000 (old numbers, may not be truly current). Just like they don't care if Valtrex is about $200 for a single course of treatment, vs $20 for acyclovir.

    Now, if your in the civilian world, and I saw you, and you wanted to see Ortho, I would have written your consult, but I also would have informed you and documented in your record that you were told that your insurance company may not pay for either the consult, or the MRI that you demanded because they weren't truly medically needed, and even the high school drop out that the insurance company has reviewing records can tell that after the first visit for knee pain without any other attempts at treatment, YOU DON'T need an MRI or an ortho consult.

    And after your insurance company denies the claim, and you get stuck with about $1200 worth of bills for the MRI, and Ortho consult, you may listen to me next time I suggest ways to treat something that aren't immediately the way you want to go.

    i want out
     
  31. R-Me-Doc

    R-Me-Doc Now an X-R-Me-Doc 10+ Year Member

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    Not to mention the 3 month wait to see the ortho doc . . . There ain't no sick call in the real world.
     
  32. Mirror Form

    Mirror Form Thyroid Storm 10+ Year Member

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    Sorry, but patients like you are incredibley annoying. So you have a history of chronic knee pain, and then your knee hurts after a lengthy run . . . big surprise! If it's an on going chronic problem for which you'd like a chronic treatment plan: then call and schedule a routine appointment! Don't walk into sick call where the doctor has tons of other patients (who unlike you may have truly urgent issues) and expect them to spend all day listening to your long sad story and spend lots of time setting up a good long term management plan. No, in sick call you get treated for your ACUTE issue. In this case the appropriate treatment was motrin and rest.

    BTW, you have no idea how unlucky many patients are that get sent to ortho inappropriately. Ortho is famous for doing unnecessary procedures and frequently just making things worse. For example, i had to stop my mother from getting a total knee replacment a few years back b/c she got a knee injury that caused knee pain over a few months. The retarded orthopod told her she had arthritis and needed surgery. Of course the pain got better with rest and aspirin over a couple months. No problems since. That's a personal anecdote, but I saw the same thing all the time when I've rotated in orthopedics.
     
  33. GMO2003

    GMO2003 Senior Member 10+ Year Member

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    there are bad apples in every bunch...the vast majority of active duty enlisted and officers alike don't abuse their access to medical care...for those that have truly legitimate and acute medical issues I am more than professional and accomadating to their medical needs...who are you exactly..are you a military physician or health care provider??
     
  34. BomberDoc

    BomberDoc ex-BomberDoc 2+ Year Member

    There are a lot of valid points here on both sides of the coin.
    - As a patient, it sucks to be shuffled in and out quickly and not having an attentive doctor listen to your problems.
    - As a doctor, it sucks to have appointments booked every 15 minutes all morning AND sick call to deal with, not to mention that it takes 5 minutes to see the patient and 10 minutes to do the damn AHLTA note. This is immediately what I think of when you mention she was looking at her watch.
    - The only on-time appointment is the first one of the day. After that, each additional minute spent with one patient is a minute waiting shared by all the rest. Consider how unfair a few long appointments can be to the waiting room full of people. The last guy gets hosed.
    - It sounds like the doc did a good job diagnosing and treating the problem.
    - When people question my diagnosis, I usually ask them where they went to medical school. I remind them that I don't go to their shop and tell them that they're doing their job wrong.
    - Even if she did consult ortho straightaway, it would have been refused by the Tricare ghouls because that isn't an appropriate first step. They may be highschool dropouts, but most of them can read the treatment algorithm and they have more power than the doctors.
    - Military doctors are bitter and angry because we're in a sh1tty system and sometimes we don't show a lot of compassion. Sorry.
    - That MEB is right around the corner if you get too demanding. Since you're seeing the flight doc, I'm sure there is a DQ-ing diagnosis in there somewhere. We know how to use 48-123. Be careful who you piss off.
    - MRI is not a magic bullet. Neither is every specialist.
    - I appreciate very much an informed patient. I cringe when I hear the words "I did research on the internet"
    - Not only at the doc do you get long waits, short visits, and lack of compassion. Have you been to finance lately? or MPF? or TMO? or Readiness? The list could go on all night...
    - Would you have gone to the doc if you had to make a $5 co-pay?
    - We care about our patients and we really do want you to get better.
    - Often the problems are simple and so is the treatment. Most people don't need the million dollar workup, but a lot feel entitled to it.
    - The majority of military patients are awesome. There are a few whiners and malingerers and we HATE them. Consider that the negative experiences stick out in our minds much more than the average experience. 95% of the problems come from 5% of the population. We bitch about the problems more than we celebrate the good experiences so things look skewed.
    - No doc worth his or her salt would knowingly undertreat you.
    - Agree with above post that in the civilian world you would still be waiting to be seen AND have to pay for it.
    - Did I mention that we really do want you to get better?

    I've been writing EPRs lately, if you can't tell by the style.
     
  35. kwiggo

    kwiggo Junior Member 5+ Year Member

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    ultimately you only get surgery if a surgeon decides you need surgery, but you only make it to the surgeon if an internist/PCP decides you need to see a surgeon. The difference between a good internist and a bad one often revolves around how he/she bears the responsibility of referral. A strong internist with good clinical judgment accepts the responsibility of diagnosing rather than throwing his hands up and letting the surgeon decide whether surgery is appropriate. I am inclined to think the surgeons have greater respect for an internist who consistently sends patients who are good surgical candidates, rather than a lot of "rule out surgery" referrals that fill the surgeon's clinic schedule and keep him out of the OR.... any surgeons or internists with thoughts on this subject?
     
  36. Mirror Form

    Mirror Form Thyroid Storm 10+ Year Member

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    You're thinking of military orthopods. Frequently people are referred out to the civilian world where there is a subset of orthopods (not the majority) who practice so that EVERY PATIENT that can in any way be justified to have a procedure gets one. This is very unfortunate for some people who get spine surgery when they probably didn't really need it (it's basically the beginning of the end). I like how you call these procedures "definitive" too. Sure, overall on the the appropriate patients ortho procedures are great. But a knee replacement doesn't last forever, and everything doesn't always go well. And oh yeah, hardware can kill you.
     
  37. kzjonez

    kzjonez 2+ Year Member

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    I am very good friends with the ortho/surgeons and believe me they get anoyed if you send them something that they might consider non- surgical in management, specially since cases are hard to come by in the military.A good clinician in my mind is the one that can distinguish when something is no longer medical, In other words knows his limits and knows when to call our surgical colleagues.Just my 2 cents.
     
  38. g293

    g293 2+ Year Member

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    You hit the nail on the head. I am a surgical subspecialist and I will turn back a consult in a heartbeat (gotta love socialized medicine!) if the primary care guy has done nothing to evaluate and treat the problem. More often than not I get consults for a problem that wasn't even addressed in the progress note where the consult was made. No labs, no films, no basic meds, just consult. I'm not asking that they are experts in my specialty, but at least send some basic labs and try a course of conservative medical treatment if you possibly can.
     

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