RICHARD PLOTZKER, MD, Endocrinology, Metabolism, 11:38AM Aug 23, 2013
As much as I want people to do well, I must admit that extreme lab work has a way of getting me motivated and engaged in my role as a chemistry repairman. I will roam through computerized lab data right from the first encounter to find glucoses >1000, calcium < 6.5, free T4 assays that the lab stopped diluting at >7.7, and TSH > 200. More often than not, these extreme values have a clinical presentation, though some, like unmeasurable 25-hydroxy Vitamin D levels or 5 gram proteinuria or serum albumin of 1.8 g/dl, have little on exam to reveal the extent of the problem. Still, they need to be thought through, assessed with comparisons from previous medical encounters, and explained physiologically.
In many ways, these severe aberrations of normal regulatory systems become the source of understanding the more common presentations of illness that comprise most patient encounters. Most things turn out to be reversible up to a point, often in a surprisingly simple way, leaving a record for the next person to sort through on the next hospital admission.
While people recover from these biochemical crises, their underlying disorder generally becomes manageable rather than truly cured, so something of a movie -- or at least a photo album -- of medical care takes the form of periodic office assessments. As we move from physicians who tend to the patients wherever they happen to be to a more selective parceling out of medical care among intensivists, hospitalists and office physicians, it can be challenging to evaluate a patient under one set of circumstances and realize that what we observe now was not always as we currently see it.
This summer I’ve had a somewhat larger than usual numbers of subscribers to the hospital’s Endocrinology elective, both among our own residents and from the affiliated medical school. Most of the work takes place in the exam rooms with computerized aggregates of lab work from various sources, imaging studies, sequences of medical treatments and the responses to them, and care shared with other physicians -- the whole pageant of medicine with patients going from one place to another only to return for an interval assessment.
Unfortunately for educational purposes, the trainees are really transients passing through the exam room. They see people at one stage of medical management of a chronic condition, mostly doing well, but sometimes they fail to acquire an appreciation of the effort or decisions that it took to have the current assessment appear routine. They get to see individuals on huge amounts of insulin in the form of U-500 R but do not always realize that before the patient can get to that point, there are previous treatment failures, both medical and dietary. People with treated hyperthyroidism look pretty normal but all had some previous time, invisible to people on the elective, when they were untreated and my mind was doing something a little more intricate than moving methimazole doses up or down.
To try to reinforce the reality of Before and After, I’ve gotten a little more determined to let patients tell a more complete course of their treatment and its responses so that the developing physicians whose hospital work takes them from crisis to crisis with no means of assessing the outcome of their decisions can seen the later result of people who were at one time quite ill with extreme lab work that they no longer have. Movies have a beginning, a plot, and a conclusion, as do chronic illnesses. Adventures and misadventures occur along the way, but if you walk in as a show is already in progress, somebody is going to have to recap what came before in order to anticipate what might come next.