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February 12th, 2012

Impossible Curbside at Medical Grand Rounds

Scene:  Medical Grand Rounds, 5 minutes before the start. Lecture is on coronary artery disease, which may have a link to Infectious Disease even if it isn’t actually caused by Chlamydia pneumoniae or CMV after all.

A well-regarded, experienced primary care physician (PCP) approaches.

PCP: Hi Paul, I have quick question*.

[*Curbsiders often use this exact phrase -- and rarely does it correlate with whether the question is actually "quick".]

Me:  Sure.

PCP: One of my patients has a urine culture that’s persistently positive for MRSA* — I’ve repeated it twice. Should I treat it?

[*Ah, our old friend MRSA. Odds of this question actually being "quick" have just plummeted.]

Me: Hmm, those results could be a sign of systemic infection, with secondary seeding of the GU tract.*

[*We ID doctors are probably -- no, definitely -- biased towards badness. Which makes us worriers. After all, why else do we get involved in a case?]

PCP: But he’s completely asymptomatic*. Do I need to treat it?

[*I am pretty sure, by his giving me this information, that he does NOT want to complicate matters by looking more deeply into the matter. But he's slightly unsure about this approach, so he wants me to endorse his action. Or more accurately, his lack of action.]

Me: Then I bet it’s in his prostate — MRSA can cause prostatic abscess, or chronic prostatitis. You could get a prostatic ultrasound or pelvic CT to investigate further.*

[*At this point, our malpractice lawyers would like me to insert into the conversation defensive boilerplate language, such as, "I've given you some general information about a general patient, but I don't know this case well enough for me to render specific medical advice. At your request or the patient’s request, I would be happy to become involved in evaluating him and see him for a formal consultation." Which makes me wonder: Can you imagine if doctors actually did everything lawyers told us to do?]

PCP: Well, he’s 100 years old, and the family doesn’t want him leaving the nursing home unless it’s a true emergency.*

[*A perfect example of how you don't get the whole story from a curbside consult. "Quick question"... yeah right.]

Me: I see.

PCP: And I’d like to avoid giving him antibiotics, since last year he had C diff twice and it nearly killed him.*

[*See above comment about not getting "the whole story."]

Me: Got it.

The lights dim in anticipation of the lecture. Various doctors, many of them cardiologists, begin heading for their seats, readying themselves for the lecture. Time is running out!

PCP: So, what do you think I should do?*

[*I knew it would come to this. Hey, I'm trying to be helpful! Really!]

Me: I guess you’re weighing the risks of giving him antibiotics — and causing another case of C diff — with the risks of undertreating a potentially invasive infection, MRSA.*

[*Look, I know this is an incredibly obvious thing to say. But what else can I do?]

PCP: I could have told you that, and I’m no ID specialist.*

[*He didn't actually say this, but he was probably thinking it.]

Me: Ask me about evaluating chest pain. That’s much easier.

The lecture starts. It is excellent.  But people immediately take out their smart phones and check their email and Facebook updates anyway.

3 Responses to “Impossible Curbside at Medical Grand Rounds”

  1. Ji says:

    I remember a few cases where residents (and some attendings) just thought that MRSA in the urine or “transient” MRSA bacteremia was soemething that you could just treat with oral antibiotics. Of course these patients came back with full blown MRSA endocarditis or osteo of the spine etc. It became our ID departments policy that we do not take curbsides when it comes to MRSA because of the exact reasons that you stated above. Once it became policy and we made sure that everyone knew of this we just simply said “I’m sorry. Its against our departments policy to accept any curbside questions regarding MRSA due to the complex nature of this infection and potential liability issues.”

    It really did help making this a policy. Of course the fellow (me) became much more busier. Anyway thank you for the post. I’m sure all ID docs can relate.

  2. Howard Heller says:

    The curbside really isn’t about the patient or the MRSA. The answer to “What should think I should do?” is “Sit down and contemplate why you are ordering tests that you don’t want to know the answer to and then have to deal with the consequences of. If he’s ‘completely asymptomatic’ then why on God’s earth did you order a urine culture? More than once. Or is the ‘he’s completely asymptomatic’ another part of an inaccurate curbside history?
    As for this PCP, “No curbsides for you!”

  3. Ben says:

    I’m no doc, but asymptomatic and 100 years old would lead me directly to answer the PCP’s question with the following advice “DO NOTHING”. Seems like the insecure fellow was just trying to cover his ass.

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