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Intuition

There is an obvious difference in the way I practice medicine compared to most of my professional colleagues. Many of my patients have asked why. Some seem to believe that I have special gifts from some universal Divine power. Others have a sense that I listen. Still others believe that I actually learned something in medical school and post graduate training. All of these ideas or beliefs might be true, but I believe there's a bit more to being different.

An adolescent girl came to the office an evaluation of her psoriatic arthritis. Most of you reading this article probably do not know what psoriatic arthritis is. Psoriatic arthritis (also arthritis psoriatica, arthropathic psoriasis or psoriatic arthropathy) is a type of inflammatory arthritis that will develop in up to 30 percent of people who have the chronic skin condition psoriasis. Psoriatic arthritis is classified as a seronegative spondyloarthropathy and therefore occurs more commonly in patients with tissue type HLA-B27. Human leukocyte antigen (HLA) B27 (subtypes B*2701-2759) is a class I surface antigen encoded by the B locus in the major histocompatibility complex (MHC) on chromosome 6 and presents antigenic peptides (derived from self and non-self antigens) to T cells. Seronegative means that the patient is Rheumatoid Factor negative. If you understood the above paragraph, you can probably practice medicine in your back yard or basement.

The diagnosis was rendered by a specialist at either at medical center in Jackson, Mississippi or University of Alabama, Birmingham. Both places wanted to prescribe biological response modifiers to treat her for her illness. Biological response modifiers (BRMs) are substances that modify immune responses. Humira® is the humanized monoclonal IgG antibody that is advertised most often on television and the most likely one recognized by my readership. Her mother refused to commit her daughter to the therapy so an alternate was prescribed: methotrexate. When I performed my first examination on her, she was taking fifteen milligrams of methotrexate per day (not a big dose). Her treatment was ineffective, she had sore, swollen, achy joints and psoriasis. She had some gut issues, but she regarded them as mild when comparing them to her joint pain and skin conditions. She also had not had a menstrual cycle for several months. She was not pregnant.

As I reviewed all of her blood work over the past eight months, I noticed that she was profoundly anemic. Normal hemoglobin and hematocrit for a non-menstruating adolescent girl would be roughly 13 and 39% respectively; her counts were 7.6 and 24%.
She had a low iron, but a normal ferritin (iron binding protein in tissue). Perhaps this finding was a red herring. Perhaps not. I asked her several questions about her ability to perform in school activities and extracurriculars. She related she was on a dance squad and was able to perform several routines, but over all felt fatigued and exhausted all the time.

After our first encounter, I gave her strict instructions for her therapeutic adventure, and repeated her complete blood count to evaluate her anemia before she left the office. When the results confirmed her profoundly anemia, I discontinued her methotrexate. Her mother asked if her daughter could travel to Chicago for a dance competition. I was baffled. How could dance with such a profound anemia? Her daughter told her mother that she felt tired but could do her part in the routine. I gave permission for her to make the trip, but on returning, she needed to have another complete blood count performed.

After the Chicago dance competition, her complete blood count dropped even further. When I called her mother, she related that her daughter could no longer finish her limited dance routine without extreme shortness of breath. Her mother was worried. I was concerned that her blood counts had dropped to an extreme low. My intuition told me her daughter was suffering from something other than psoriatic arthritis. Several other blood tests were abnormal which supported my intuition.


Enter St. Jude's hematology clinic. I contacted St. Jude because they have an incredible reputation for caring for children with catastrophic medical conditions, not just cancer. I referred patients to St. Jude for consultation in the past. There was always prompt, accurate communication between the St. Jude practitioners and me. So, I felt that she should be evaluated by the experts quickly.

I was able to talk to a nurse practitioner in the hematology clinic late afternoon Thursday of last week. The nurse practitioner initially thought I was over-reacting since the patient was not symptomatic. I was not sure where she got that understanding from since I had related that my patient was exhausted and was not able to perform her daily routine without extremis. At one point in the conversation, she suggested that my patient go to Le Bonheur's Children's Hospital's emergency department for evaluation and have one of their hematologists evaluate her. I was surprised to hear those words out of her mouth. I told her I wanted St. Jude to evaluate her as soon as possible since my intuition told me she needed a bone marrow biopsy.

The nurse practitioner finally agreed to see her Friday, twenty-four hours after my call. I was grateful. I contacted my patient's mother. She agreed to come to St. Jude even though they lived five hours away. I called St Jude back, spoke to the nurse practitioner, and she wanted to speak to my patient's mother. I gave the mother's cell phone number to the nurse practitioner and thanked her for her compassion.

The next morning, Friday, I asked Tammy to contact my patient's mother to give us a rundown of her itinerary. Well, to my surprise, the nurse practitioner decided to put off her visit to St. Jude for two weeks. All she wanted was a blood draw in their home town. The nurse vowed to call her mother with the orders when she got time on Friday morning. However, my patient's mother stated she had not received a call from the nurse practitioner and it was well after the noon hour.

Tammy called the nurse practitioner at St. Jude, spoke to her, and the nurse related she would be calling the orders in on Monday. The nurse practitioner related that our patient was not an emergency. Her mother misunderstood their conversation. When Tammy relayed the information to me, I realized that the nurse practitioner either had no idea about the urgency of the situation or she was waiting for our adolescent girl to go into congestive heart failure to label her an emergency or she was just plain incompetent. So, I called in orders for the iron studies myself and by Monday morning, the results would be available. I am not sure it will make a difference to St. Jude, but it made a difference to her mother since she and her daughter felt abandoned by every practitioner who had evaluated her daughter.

My intuition tells me that her daughter is suffering from an anemia that is not related to her psoriatic arthritis directly. Then it dawned on me. I listen to my intuition when almost every other physician I know denies theirs. They take great measures to out think what they know through their intuition, some to the point that their intuition is absolutely dead. There is no question that medicine is an art, and to know art, one has to listen to their intuition.

Perhaps I am intellectually gifted, or have a great memory, or I learned something during my medical training and from my experiences over thirty years of practicing medicine that separates me from the herd. I believe it's my medical intuition that distinguishes me from my peers and I am unafraid to listen to it. I hope in her case, I'm wrong.

I'll continue to pursue caring for this wonderful adolescent girl as if I am right. Although I called in the orders on Friday, the young woman didn't get her blood drawn until late Monday (Yesterday) afternoon. I wonder what will happen next.

Doc

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