One of my pet peeves is when a patient or colleague speaks ill of another health care provider. I find it unbecoming behavior that often (though not always) speaks more to the character of the speaker than that of the object of anger/derision/dissatisfaction. I recently had the misfortune of interacting with a nurse practitioner who behaved in this manner. (The evidence of my hypocrisy does not escape me.)
A patient had been having some vague complaints for about 5 years, including myalgias, headaches, and fatigue. She remembers a tick bite that preceded the onset of symptoms. She tested negative for Lyme disease and other tick-borne illnesses multiple times, but after seeing many different doctors she finally saw an infectious disease doctor who often treats patients for what he diagnoses as a chronic Lyme infection. The patient was on antibiotics for about 5 years. But because she didn’t really feel any better, she started questioning the diagnosis.
I explained to the patient why I thought that fibromyalgia might explain her symptoms. She looked this up on the Internet and found that the disease described her symptoms completely. She was happy to stop antibiotic treatment. However, in the interest of leaving no stone unturned, I referred her to a neurologist for her headaches.
The nurse practitioner who evaluated her sent her for a brain single-photon emission computed tomography scan that showed “multifocal regions of decreased uptake, distribution suggestive of vasculitis or multi-infarct dementia.” The NP then informed the patient of this result, said it was consistent with CNS Lyme, and asked her to return to the infectious disease doctor who then put her back on oral antibiotics.
The patient brought this all to my attention, asking for an opinion. I thought she probably had small vessel changes because she had hyperlipidemia and was a heavy smoker. But I was curious about the decision to label this as CNS Lyme, so I thought I would touch base with the NP. What ensued was possibly one of the most disturbing conversations I’ve had with another health care provider since I started practice.
She didn’t think she needed a lumbar puncture to confirm her diagnosis. She hadn’t bothered to order Lyme serologies or to look for previous results. “We take the patient’s word for it,” she smugly told me. She had full confidence that her diagnosis was correct, because “we see this all the time.” When I said I thought, common things being common, that the cigarette smoking was the most likely culprit for the changes, her response was: “Common things being common, Lyme disease is pretty common around here.” On the question of why the patient was getting oral antibiotics rather than IV antibiotics per Infectious Diseases Society of America guidelines for CNS Lyme, the response I got was again, that she sees this “all the time, and they do respond to oral antibiotics.”
I think the worst part was that when I pointed out that the preponderance of other doctors (two primary care physicians, two infectious disease doctors, another neurologist, another rheumatologist, and myself) did not agree with the diagnosis, her reply was to say that “the ID docs around here are way too conservative when it comes to treating chronic Lyme.”
Of course, she could very well be correct in her diagnosis. However, the conceit with which she so readily accused the ID specialists of being “too conservative” when she clearly did not do the necessary work herself (LP, serologies, etc.) just rubs me the wrong way. Lazy and arrogant make a horrible combination.
I politely disagreed and ended the conversation, but I was so worked up about the situation that I decided to write about it, thereby demonstrating the same bad behavior I claim to dislike. I am afraid at this stage in my professional development magnanimity is not a quality that I yet possess. Hopefully, I will not have many opportunities to demonstrate my lack of it.
Dr. Chan practices rheumatology in Pawtucket, R.I.
