“Fire ants on her legs.”
“I’m sorry, but I do not diagnose.”
“But the itch is terrible. Both legs.” This fifty-something woman, stout, but not obese, pulled up a pant leg and showed me her shin and calf. They both were scratched
raw, little red marks like a rash ready to bleed. “Can’t you just give me something to stop the itch?” Her face was distressed like she was about out of her mind. “Please. What is causing this?”
“I may be able to give you a lotion or a cream to help.” I believed that I could actually give her something that would stop the itching like I believed that the moon was made of
tetracycline. “I won’t even guess what is causing it. I am a pharmacist. I am not a doctor. I do not diagnose.”
“It is making me crazy.” She dug her fingernails into the shin and scratched violently.
“It won’t stop no matter how much I scratch it.”
“She doesn’t hardly sleep at all.” Her husband shrugged. “I don’t sleep either.” His face showed it. Gaunt. Worn down with a drawn face and droopy eyes.
“Have you seen a doctor about this itch? You said it is both legs?” A mystery.
“Yes, when I went in for my sugar diabetes check up.”
“You have diabetes?” This was all of a sudden too easy. Careful, Plagakis. Remember.
You are not a doctor and you do not diagnose. You aren’t 150 miles from the closest oasis and the patients do not call you “Doc”. This is the twenty-first century. Not the middle of the twentieth.
“Yes, I do have sugar.”
I drew a deep breath. “Describe the itch to me. Tell me what it feels like and don’t use the word itch.”
She squinted. “I can’t use the word itch?”
“Try,” I urged. I took her all in now. A worn out, but clean plaid shirt. Loose, striped
pants. She wore flip flops on her itchy feet.
“Well, my legs, all the way down. To my feet. Feel like they are burning. Sort of.
But it is very bad. especially at night.”
I asked her if it felt tingly or if like a million pins were poking her skin.
”That’s right! Exactly, I think.” She actually brightened up. Was I the first medical professional to ask her the right questions.? Then I asked her what her doctor had said about the itch.
“To use some oatmeal in my bath water.”
I cringed. “But it did not help did it.” It was a statement, not a question.
She nodded and sighed. “What is causing this itch?”
“How about like if a million fire ants were all over your legs?” This is south east
Texas. She knew about fire ants.
Her eyes grew wide. “This is exactly what my legs feel like.”
Now, I did not diagnose. I am a pharmacist and we don’t do that. What I did was tell her about me. I told her that I had the late effects from polio and that I had been diagnosed
with something called neuropathy. I take a drug five times a day and the tingly, burning, fire ant sensations are much better. The discomfort is tolerable, even on my days of ten hours on my feet at the pharmacy.
“The drug works for me,” I said. “Please go back to your doctor. Who is your doctor?”
“I don’t know his name. He is at the clinic.” She named a health center that specializes in treating low income patients. They certainly had not treated her.
I wanted to tell her physician, “The whole patient, doctor. Slow down. I know that she is poor. I know that she does not communicate very well, but you are treating her for diabetes and she complains about a leg and foot itch so bad that she is almost bleeding from scratching. WAKE UP.” It must have been near his lunch time and she was just another patient, not very sophisticated, not able to navigate the medical care system very well, not very demanding.
Of course, I didn’t even attempt to call out the doctor. What I did was write these two words on a piece of paper. NEUROPATHY & GABAPENTIN. “Tell your doctor that your pharmacist said that he uses this drug to treat the fire ants on his legs. This is what he has and this is the drug that works.”
“Do I have this neuro ……..?”
“……. I can’t say that. All I can do is share with you that I had fire ants on my legs and they almost went away completely after I starting taking this drug five times a day. At least I can sleep very well and the fire ants that I do feel don’t interfere with my life. ”
She promised me that she would see her doctor. Maybe! Fire ants all over your legs is pretty miserable. I sold her a lotion with capsaicin. I hoped that it would help.
What else could I do? If you know, tell me. I need to be educated. After all, I am a pharmacist. I am not a doctor. I do not diagnose.
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Not too sound real schmaltzy, thats why we as pharmacist do what we do! You know deep down that you are probably right on the head and that you took that little extra step and really listened to a patient! Amazing how just listening can really have a positive affect on the well being of someone. If only that still occured in the medical realm any more! Ah I am waxing philisophical !! Ooops!
As long as you aren’t ” Waxing and Waining” ! Seriously, this lady reminds me of a time I had diseminated Varicella. The itching was intractable! diphenhydramine 50- 100 mg QID, Caladryl liberally/literally awash in it.Still the best advise? AAHHH….AVENOO(OATMEAL BATH)That’s right! even today it’s ” the real Quasi-Quaker”
I would of just said to ask her doctor about Neurontin. Then talked really fast about all the possible side effects like the TV commercials do..
Of course I dont understand the whole “Cannot Diagnose” bit. I mean we cant just give her Neurontin or do anything about it. If some uppity doctor gets in your face about the whole deal, scream at him about how he/she could miss something so stupidly obvious as neuropathy.
I don’t know about everyone else, but they are coming very close to teaching us to diagnose in pharmacy school these days. Especially the common things neuropathy and diabetic complications, HTN, and osteoporosis.
Jim:
I’m a semi-retired healthcare admin, who’s husband is a DOP in a hospital and done more than his share of diagnosis in order to CYA an MD, we understand your frustration… This is being said just so you know where I’m coming from…
We can debate until the cows come home whether or not you “diagnosed” a patient. But frankly who cares? What you did was help a patient who came to you and was in a desperately need help, inwhich the clinic RN, PA and doctor had failed to give.
What you really did was give her “healthcare”. You picked up the ball, give her a little attention, asked a couple questions and gave her a few serious suggestions with direction to go see her doctor again as soon as possible.
Personally it’s no harm– no foul. The MD should be damn thrilled someone got an answer out of her that got to the root of her real problem. In the end this will help her. (Neuropathy problems are really painful, I know.) If the doctor cops an attitude, the MD needs to be sent to a Dale Carnegie program and learn to say “thank you.”
Last time I checked we’re all supposed to be on the same team, even if you’re not working in their office. I could tell you about the time another pharmacist sent my Father to his MD via ER and saved his life– but I digress…
In this day and age where MD’s are being rushed to give a 5 minute diagnosis– the patient who can’t verbalize quickly or the MD is unable/unwilling/unskilled to ask the right questions in the timeframe “allowed” gets screwed.
It is not healthcare. I tend to call it diagnosis processing. And because the patient and MD were unable to communicate and come to a diagnosis and successful treatment, the process failed because the root cause of the problem was missed. (Oh FYI: the Husband and I were both trained in diagnostic skills in school over 25 years ago.)
I don’t know about you, but I can’t tell you the number of calls and chats the husband has with friends and family on a regular basis where he (and sometime I) go through the list of their problems (symptoms,) and advise them what to be sure to tell their doctors to insure they get proper treatment and follow up for their problems. Several times our advice has saved a couple people’s lives– so if someone else in the food chain gets bent out of shape because we made a call and helped someone out– then they are the ones who need their priorities and reasons for being in healthcare/medicine straightened out.
Just an opinion!
Jim: You are from Texas. I know you are neutral as I on political issues. I thought you might have a opinion on the Texas Gov’s order on the HPV innoculations. In Calif. All children MUST be vaccinated for Varicella. I ask you, how many die of chicken pox? Is not cancer more important than VZV?
A very good communication with the patient indeed! And yeah, this talk about doctors, again. Hopefully not all of them are like that. Really like your blog =)
Hey JP, I couldn’t tell whether you are saying you do not diagnose because you aren’t “allowed” to or because you don’t want to. It seems from the responses everyone else seems to be saying “go ahead diagnose, don’t worry about what the doctor would say”. I personally don’t want to diagnose. We provide more than enough services that we don’t get paid for. And if I wanted to look at patient’s gross rashes, head lice, infected toes, etc. I would have gone to medical school and become a doctor. I don’t have the stomach for it, seeing tablets removed from patient’s stools has been more than I ever signed up for. I have to admit I am not as bitter since going part time, but I used to really resent the patients that didn’t want to spend the time and money to see a doctor and would get irked when I refused to diagnose their disease that required a drug I couldn’t give. (obviously this lady had at least tried to see a doctor and I would have probably given her the same instructions you gave her.)
As for Tye’s question, my opinion is that if I had a daughter I don’t know how I’d feel about the government telling me I had to have her vaccinated with a new drug. With the removal of many drugs that haven’t been on the market that long, I don’t know if I trust that Gardisil has been adequately tested. I believe it should be an individuals choice. Just my opinion.
You didnt diagnose. Not even close. You suggested a likely diagnosis for her problem. The correct note to have written was “possible neuropathy” and “consider gabapentin”. It sounds like neuropathy from here, too, but it could be a variety of things. Clarifying the patients reported symptoms and telling her to verbalize those to her doctor will help too.
Also, like a typical pharmacist (I fall into this trap too often also), you look at everything as a nail because you have a hammer (drugs). For all you know, this neuropathy may eminate from a spinal cord tumor and gabapentin will just disguise symptoms until diagnosis is too late.
We dont diagnose, and dont want the liability. But we have a RESPONSIBILITY to clarify symptoms and present our thoughts, hunches and ideas to other health care professionals, especially when it comes to a patient requesting an OTC drug for a condition that needs proper medical treatment.
I’m with Rich. You listened! Probably the most underused tool we have. Even in those times when the answer may not be so obvious, it has tremendous impact on the patient to see that you care enough to listen to them about their problem. Don’t we like it when someone listens to us? I rest my case.
An old high school principal of mine used to say, “Nothing sounds so sweet to a man as the sound of his own voice”. He was right of course, but sometimes we just need to be quite and listen to what our patients have to say.
I think the article reminds us again of the simple things to do to improve a practice. I’ve yet to see a doctor (or personally) receive a patient’s anger for being late or bad things happening around the office. Patients yell at just about anyone and everyone except the doctor. So I agree with the Doc being the calming influence around the office.Also, this brings up the consumer vs. patient debate. I don’t know if they are mutually exclusive, but I don’t like the idea of “consumer” because if the company doesn’t give you what you want, you go somewhere else. Well, I’m sure that my refusal to hand out antibiotics for sinus infections, colds, and earaches may cost me a few patients (maybe ones that I wouldn’t want in my practice anyway or maybe it’s just that I do a poor job of convincing people they don’t need them [usually], thanks standard of care!)