Wednesday, March 28, 2012

Boutique Doctoring

Admittedly, there are some things I don't like about this job, or specifically, this specialty.
One concept I try to get across my medical students is that hormones, by their nature fluctuate. Sometimes more than others especially in extenuating circumstances. To top that up, while there are MANY tests available, there are good reliable tests, and there are some not-so-good tests. Add to this that there are so many symptoms that the public attribute to hormones that can be nonspecific. Weight gain. Weight loss. Hair growth. Hair loss. Low libido. Erectile difficulties. Mood swings. Lack of stamina. Muscle strength.
Take your pick.
And so, many a times I feel like a boutique doctor.
You know, the kind of physician who hands the patient a menu, and say, "Ok, what tests would you like today?"
And follows that with "What medicines would you like? Something to make you more energetic? Or perhaps you'd like this libido enhancer? Also I strongly recommend this medication to help you shed weight; it's one of our bestsellers!".
Maybe I'm being too cynical and am exaggerating. But the issues (bad, and good I suppose) with modern medicine are that my generation of doctors are taught not to be paternalistic and make decisions for patients; rather I see my job as to provide the patient with the information to make an informed healthcare decision for the better; in addition we now have the wonders of the internet and Wikipedia. Plus, big pharma now is using direct-to-consumer advertising (notice how many more TV and magazine ads we are seeing?).
So, often I have patients coming to see me because the are convinced that they have either Cushing's Syndrome or Addison's or Hashimoto's or Hypogonadism or Carcinoid or whatever else. Asking for a hormonal panel to be tested up the wazoo.
And couple that with the guy whose  total testosterone is a mere 1 ng/dL below normal (with a normal free level) who is demanding to be put on expensive testosterone replacement.
What does one do? Help him make an informed decision. In most cases if they really wanted a therapeutic trial, I hesitantly yield.
Not really being surprised when I see them for follow up 3 months later only to hear that it didn't help them feel better one bit. (though I still fear for the safety of one guy who refused to believe me and at last test had overdose his total testosterone to 5000 ng/dL, the highest I have ever seen. He refused to come back for follow up and has since been getting some Wellness provider to write him the prescription. I hope his prostate isn't the size of a melon).
And at the same time hating the idea that I am contributing to the exploding cost of healthcare and the billion-dollar pharmaceutical profits.


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