Not All Doctors Are Created Equal!

From "The Fourth Plane"

I remember that it was a day much like any other at my first job as a Medical Officer. Internal Medicine ward round, longer and more nerve-racking than it ought to have been. My Consultant was a Nephrologist of some renown, but she had a peculiar bedside manner for a practising physician: she could be dismissive, condescending, insensitive or downright incendiary as we went about the business of assessing the patients. As we got towards the last room in the female ward that day, we had a new unclerked patient (let's call her "*Eunice") before us who appeared otherwise normal. Lately, she had been experiencing a recurrent localized right lower abdominal pain; her past medical history was hitherto unremarkable. My Consultant had me assess Eunice briefly,  and the only symptom she had was marked tenderness in the lower right abdominal area of her abdomen. I remember suggesting that it seemed likely that this patient might have been suffering from appendicitis, and that she might actually be more of a surgical patient. The Consultant wasn't having any of it and proceeded to berate me in front of the team, which included medical and clinical officer interns, nurses, physiotherapists, nutritionists and a counselor (and let's not forget the patients that were within earshot):

1. Why would I think it was an appendicitis yet the patient did not have the typical "septic" look of an appendicitis patient?
2. Wasn't her abdominal pain localized, and without the typical progression seen in appendicitis? Where are the other signs suggestive of appendicitis? 

I halfheartedly remember suggesting that perhaps it was an atypical case, but she was having none of it; I was summarily told to stop jumping to conclusions (known more technically as "confabulating") and a plan was made to work up the patient in terms of lab work and some imaging studies.

Getting insulted was usually par for the course, so I just took it in stride. Apart from that slight, nothing else really stirs in my memory from that day. Anyway, the ward round - which spanned 2 wards, and sometimes involved consults in other areas of the hospital - took so long such that the rest of the day typically involved drawing samples and tending to other ward procedures. I was also charged with attending to the Outpatient dialysis patients. A lot of the time, you would end up getting the results the next day, so it wasn't something that you could respond to too quickly. Provided the patient wasn't knocking on death's door, a little waiting wasn't really going to hurt.

The next morning was joyously a Thursday. Thursday was the one day in the week that I got to lead the ward round because it was the day when my Consultant was otherwise occupied running the Medical Outpatient Clinic (MOPC). This meant that we usually finished the ward round a lot faster. As I was conducting a preliminary assessment of patients prior to the ward round, I remember asking one of the clinical officer interns for the list of our patients. When I received the list, I noted that Eunice was unceremoniously missing. When I inquired why, I was told that she had been handed over to the Surgical Team. My interest was piqued and I decided to glance in her file to find out what had happened. The sonographer who performed her abdominal ultrasound had detected a mass in the tender part of her abdomen - an appendiceal abscess. What appeared to be more likely is that Eunice had probably suffered from chronic appendicitis; this inflammation was eventually "walled off" by the body, protecting her from the more adverse effects associated with a leaking/burst appendix.

The irony of it all is that a crowd was present for my ridicule, but my moment of vindication was mostly a private affair. Dear God life can be so unfair!

I must admit that I have been reading and watching a lot of news concerning Covid-19 lately. Part of the reason for this is that so many medical updates keep on arising concerning testing, and many of my colleagues on the front-line worldwide are providing a lot of useful advice that might prove helpful in our local battle with the disease. Another reason is to see how countries are dealing with the economic push-back from the virus, and to get a sense of what stimulus measures might be needed to protect the citizenry from the economic ravages of the virus. However, the last bit consists of the debacle-prone US response (with all its bells and whistles) and, surprisingly, tales of conspiracy theories and what not. Just recently, I caught a segment on Fox News whereby Dr. Oz was talking about possibly getting children in the US back to school after a Lancet (Medical Journal) study had shown that such a move came with a 2-3% chance of increasing the total US mortality statistics. This is of course par for the course when it comes to Fox News recently, and though they keep on emphasizing how precious human life is, it a repetition of their stance that some amount of human life sacrificed for the sake of the economy might not be such a bad thing. However, policing a news media outlet is not my duty; as a trained medical practitioner, my job is to at least make sure that people are getting sound medical advice wherever they choose to consume it from, and especially that is being delivered by a sound medical professional.

Now, rightly so, Dr. Oz drew a lot of condemnation for his comments and ended up having to apologize. This is not the first time that he has been forced to walk back his comments as he was actually brought before a congressional hearing to account for claims he had made on his television show about certain weight-loss regimens. For those who may not know it, Dr. Mehmet Oz is a renowned Cardiovascular Surgeon who is a media sensation who got a big push by being endorsed by Oprah Winfrey. His skill is unquestioned in the field of cardiovascular surgery where he is known to be an innovator; however, it is his media sensationalism that typically gets him into a lot of trouble.

I remember chatting with a group of my high school alums on Whatsapp and I remember being peeved at a suggestion by one of my friends that they needed to be hearing more from doctors in the national discourse during this period of Covid-19. That remark set of a powder keg in the group that drew the ire of the health practitioners. This came against the background of disdain and distrust that Kenyans have continued to hold towards doctors and nurses since a massive 100+ day strike in 2017 which was meant to address issues of poor renumeration and working conditions, and inadequate functional capacity. The politicians of course turned things around and made it seem like it was purely a salary push by a money-hungry lot, and consequently medical professionals and institutions were lambasted by the citizenry. Long story short, hearing my friend calling on the medical professionals to start waxing lyrical was like opening up an old wound. In retrospect though, having had some time to calm down, I can admit that my friend was right. People do need to be hearing from sensible medical professionals at a time like this. The amount of sensationalism, hoaxes, "miracle-cures" and conspiracy theories is proof of that.

I think that people understand even less about the practice of medicine these days. In the old days, people were awed about the profession, but nowadays the prevailing sentiment might be that the internet has bridged the divide between clinicians and patients. It is therefore useful to understand the typical career path of your typical medical doctor. In Kenya, there'll be 5-6 years of medical school (post-secondary), followed by a 1 year internship rotating in 4 major departments; from there you can expect 3 - 5 years of specialty training, and after that you add on as many Fellowships as you want, and you can aim towards being a professor, etc.
Now, since I am going to discuss Dr. Oz, I'll give you a glimpse into the American path of ascension.

• 4 years of a pre-medical degree
• 4 years of a medical degree
• *Residency Program
• Fellowships

*The 1st year of the residency is pretty much just an "internship" (semantics). Unlike the Kenyan experience, American doctors do their internships specifically in their field of interest. Surgeons have a surgical internship, physicians do an Internal Medicine internship, etc.   
    

The aim of medical training is to start you off with as wide a base of medical knowledge as possible, and then whittle that down to the things required only for your area of specialty. Back in the day there were people who dabbled across the field of medical specialties, but nowadays - short of someone being a genius - such broad focus is discouraged. True Story - I remember being blasted for showing lack of focus during a surgical specialty interview at a local medical university. Why? you might ask. Because I had listed that I had performed independent research on Phytoremediation on my curriculum vitae (CV); the same CV further states that

"I aim to become an experienced doctor specializing in surgery, with a view towards
practicing and teaching medicine while infusing my practice with environmental
consciousness to enhance the focus on preventive medicine."

The Plastic Surgeon on the panel had a look of disbelief on his face; it was like this was blasphemy!

Therefore, applying this logic to Dr. Oz, who got his joint MD and MBA degree in 1986, the man has been a PURE SURGEON since 1986! This is not the kind of individual you want to be getting your principal Covid-19 findings from (media sensation or not).

The above 2 images have been part of a meme sent out by many of my medical colleagues, but I think that only the medical field is in on the joke. This is the grim reality: most of the specialist medical professionals do not have the skills to deal with this Covid-19 pandemic; but if we cannot keep the numbers of severely sick down to a level where the healthcare system can adequately handle the numbers, then every medical practitioner will eventually need to be drafted to help with the situation. They'll just have to be retrofitted and adapted to the situation.

If this post wasn't already too long I would've delved into the reasons why medicine is not the homogeneous field most people tend to think it is. There is a lot of direct antagonism going on that is the subject of much comedic gold.

• Surgeons vs. Anaesthetists, where surgeons believe it is the joy of an anaesthetist's day to cancel a scheduled surgery for the flimsiest of excuses. Anaesthetists in turn believe that surgeons will steam-roll through any procedure without considering the risks. (It's the relationship portrayed in the title cartoon!)
• Orthopedic surgeons being of questionable IQs (despite the research)
• Those who are not good enough to be surgeons become... (I once remember a surgeon toss this gem in jest at his accompanying scrub nurse)
• Doctors vs. nurses
• A surgeon only sees a surgical solution to a problem. A physician only sees a medical solution to a problem (typified by my experience with my Consultant)

All this aside, the best results in our profession (and its allied fields) are usually achieved when we have a healthy dose of respect for everyone and their training. The best approaches are always multi-disciplinary. Therefore, next time your relative with Diabetes/Heart Disease/Lung Disease etc. shows up for an elective surgical procedure and another doctor gets called in for a specialized consult, please understand that the hospital is not simply trying to pad your hospital bill; what they are trying to ensure is that the elective surgical procedure doesn't end up degenerating into a complicated affair with death as an outcome.

This pandemic is stressful for everyone, more so the medical fraternity which finds itself faced with a new enemy for whom our typical treatment regimens don't seem to be working. Despite that, we are soldiering on, and we are looking for our fellow (not-so-flamboyant) colleagues to provide answers. We are listening to the Researchers (Virologists, Pathologists, Epidemiologists, Biotechnologists), Infectious Disease Specialists, Intensivists, Critical Care nurses, Respiratory Therapists, Psychiatrists/Counselors etc. to help us chart the way forward. Their work will eventually filter down to the other medical professionals and inform our practice, and finally down to the general population.   

Now, more than ever, it is important for people to interrogate their sources of information. It has taken the medical field forever to get down to the level of Evidence Based Medicine wherein we have to let the efficacy of the science guide our practice. We are not witch-doctors after all! This level of supervision has not made its way to streaming and social media, and thus all manner of dubious claims are being made about this disease and its treatment. We have no way of policing all these dubious claims, but I would ask people to exercise restraint in dispersing all this pseudo-science. Sars-Cov-2 is out in the open and it will be studied intensively for many years to come, then we will finally have the truth; until then, for all these medical pundits making all these claims, remember to assess their backgrounds with the following lens

1. Researchers trump Classical Doctors
2. Internal Medicine specialists trump Surgical Specialists
3. Alternative Medicine specialists are pretty much at the same level as the typical civilian
4. Not every PhD has the acumen to discuss medical issues
5. Always look for conflicts of interest. The person is certain to be selling their dubious miracle cure as they tear into the conventional medicine, i.e. Miracle Mineral Solution (MMS) which is just INDUSTRIAL BLEACH; otherwise, look for them to be espousing a particular agenda
6. Check for reports about them being called out by their professional peers or censured by medical regulatory boards. This kind of behaviour is always a continuum       

This current sensationalism of medicine reminds me of that time when "The DaVinci Code" movie graced the movie screens. I remember that it was touted to have made a lot of people lose their Christian faith, and I wondered if watching it would have been detrimental to my own; then I watched it and I felt bamboozled. I remember at one point the author (Dan Brown) randomly included "The Peace of Westphalia" and used it to make a nuanced argument. I wouldn't have known anything about that incident if it hadn't been for the boring "Church History" lessons (my apologies Mr. Borruso) that I'd had to take while I was in High School, and thus I could see that the author was merely sensationalizing historical incidents that most people are not aware of.

The same exact thing is playing out with medicine right now. To tell you the truth, medicine - just like History - is very boring! Let me clarify, studying/reading medicine is extremely boring! You better thank a scientist who is able to take the time to truthfully summarize a lengthy research paper into snippets that you can digest because reading them is hard work! Being boring notwithstanding, it does not give us practitioners of science the right to mislead people. Always remember that

"The most dangerous untruths are truth slightly distorted." 

Therefore, as a medical practitioner, I will do right by my patients or anyone who needs some clarification. Honesty, Discipline, Empathy and fortitude will get us through the rigours of this pandemic. However, despite the readily available stream of information from social media and video streaming services, we all still have a responsibility to practise patience and critical thinking. There is no need for panic.

God Bless