Paperwork.
Spiff, nope, it don’t work that way.
Mayflower, I can’t speak to your doc’s office but I can speak to mine.
Yes, paperwork is part of it. We need to be able to prove we examined all that we examined and write enough to prove that we evaluated you competently. “If it isn’t documented it then it never happened” or so the lawyers tell us. We also have a variety of requirements to meet for governmental scrutiny regarding coding, etc. And QA initiatives from the insurance providers that want to see documentation of very specific sorts. It is cumbersome to say the least.
Review of your chart before we go in the room. Any ongoing issues that need to be followed up on?
Your doc may have handled your room briefly* but the previous room could have been a half hour or much more of a complex problem.
Urgent phone calls from patients or regarding patients. I always have a pile of charts with messages to return over the course of the day that I try to prioritize. Some are important enough to try to fit in between rooms, but it never fails that the one I thought would be a quick’un turns into a twenty minute conversation about serious issues.
BTW, ER’s are a lousy place to get your basic care. Great place for emergencies, lousy for basic care. Also very expensive. It is worth your while to brave a little water to go to your regular doc suring the regualr daytime hours. What are you the Wicked Witch that your are going to melt in the rain?
*Perception is key. Your doc no doubt spent a lot longer than 2 or 3 minutes. But he was clearly rushing, probably stood the whole time, and didn’t conclude with a chance for you to ask questions and by asking you if there were any other issues that needed to be addressed. If he had sat down and focused on you, and concluded with that chance to ask questions, then the same amount of objective time spent in the room would have been percieved as a much longer time period. You would have been satisfied.
Several thoughts to add here.
First, ** E72521**, I join the others in this thread to wish you a speedy recovery.
Second, I’d like to commend DSeid for the portrayal of the flip side to this situation. My $0.02 regarding the effects of lawsuits on physicians is that it unreasonably increases the cost of health care without much impact on quality. Physicians routinely order tests that are unnecessary on strictly medical grounds to protect themselves in the event of lawsuits. Perhaps folks believe that some rare disorders may get diagnosed this way? IMHO, More often than not, the result of an unnecessary test is further unnecessary investigation.
I’m a dermatologist (well, Dermatology resident, but I’m close, real close). I’d like to interpret some of the information in this thread.
Based on the surgical pathology you reported,
the first doctor you saw was at least partly correct. Verruca is doc-speak for wart. And aldara is regarded as a perfectly acceptable therapy for warts like these. You are correct that it isn’t FDA-approved for this indication, but this a widespread, accepted off-label use. Other off-label uses for this drug include treatment of molluscum contagiosum, and a type of skin cancer (I’ve even seen reports that patients with alopecia areata may experience hair regrowth with aldara).
You don’t comment, but I’m certain you contacted the original physician to inform them that the aldara caused undue discomfort. It’s common for an initial therapy to fail and it’s common to miss vanishingly rare diagnoses. I know how I’d react if a patient I thought just had a wart called to inform me that they were experiencing
It would get my attention and I’d have them back for a visit ASAP. Given how angry you are, I wonder if the communication pathway broke down in this case; did the doc not return your calls?
Now to the PA situation. You relate the happening as follows:
This makes me think that in addition to the wart, you have an underlying digital mucoid cyst. This is also suggested in your description of the surgical pathology. These cysts are benign but may be quite painful. However, they do not destroy bone and you relate
Unless this description is innaccurate, I’d shy away from my original thought and consider a bone cyst, a bone cancer or osteomyelitis. Nevertheless a pattern of bony erosion on plain X-ray can be things other than osteomyelitis. I’m curious as to how this became the leading diagnosis.
Additionally, osteomyelitis, unlike shit, seldom just happens. Is there some underlying problem in the finger (trauma, tumor, something more than the wart) or systemically (endocarditis, pyelonephritis, bad diabetes) that provided an opening for an infection to take hold? If not then I doubt the diagnosis of osteomyelitis was accurate. Furthermore, you don’t report feeling ill (fevers, malaise, etc) during this time. Usually these constitutional symptoms accompany osteomyelitis. Anyway, you’ll find out whether it’s osteo or no when the bone cultures return.
Finally, regarding your faith in the hand surgeon. Consider the possibility that it may be misplaced. Medically-oriented folks are apt to wait around and treat with medications to see if a problem will resolve. Sometimes we are faulted, and rightly so, for intransigence with regard to moving to a more agressive approach. Thankfully, however, the vast majority of diseases move slowly enough so that this waiting game seldom results in a net disservice to patients. Surgically-oriented folks, on the other hand (pun unintended), are do-ers, and often (IMHO) do too much. Remember that your surgeon makes more money for taking a piece of you off in the OR then for treating you with antibiotics (probably 20X as much). That’s not to say that this surgeon is guily of negligence or has taken an incorrect approach. It’s only that given the way incentives work, chances are that when you see a surgeon, you’ll get an operation.
In closing, a joke I learned regarding orthopedic surgeons during medical school:
Q: How do you hide money from an orthopedist?
A: Put it in a journal
E7,
Do please give us updates when you are up to it. Definitely your message is valid. Docs need to listen. And we need to behave in such ways that our patients know we have heard what they are telling us. We will make wrong decisions, it is unavoidable that we will since we are always dealing with situations of uncertainty to one degree or another. The key is how we mange and communicate that uncertainty.
choosy,
Your case analysis is enlightening. Thank you. However, E7 probably didn’t need to hear disparaging comments about the idiocy of orthopods immediately after he’s had the end of a finger removed by one of them. I would humbly advise you to very seriously consider resisting the temptation to belittle other specialists in the future. You don’t want to hear the jokes we tell about dermatologists, after all! 
Popping in here, if the tip of your finger was amputated and you do have significant meds and can prove that what the PA and the doctor did wasn’t so much a judgment call as it was an outright failure to perform the types of tests needed and failure to heed your description of pain, you may be able to get a (edited later to add “good”) lawyer to take your case.
Don’t go to the yellow pages as you’ll usually end up with someone who just refers the case to someone else for a referral fee making the case less attractive to your actual lawyer or you’ll get somone who is not familiar with the intricasies of med mal law. Ask around and you’ll probably find a good med mal attorney or try to look at your states bar journals and choose from there based on articles and specific ads which are directed more towards lawyers…
However, although your lawyer might get your meds plus something on top for pain and suffering, be warned your insurance company is going to want that money when you get it… It will be a lot of hassle and likely take some time to see any money, assuming if ever…
BTW, I am not your lawyer, you are not my client. I am not licensed to practice in your state nor should you consider this to be legal advice. You are being unreasonable if you rely on this as legal advice.
Hang in there E! I hope you feel better soon!
Also, some of you are operating under some fucked up legal beliefs and ought to rethink before posting if you are guessing about the law or the results of suing a doctor. But that’s another rant for another day
Sure we do. 
Robin
So I shouldn’t say, red rash, white cream, white rash, red cream?
Regarding my thoughts on the orthopod, allow me to clarify. Since we don’t have real data before us, it’s impossible to know whether the decision to amputate was sound. My personal experience is that surgeons often adopt a more aggressive approach to therapy than I find reasonable. I doubt whether sheilding E7 from this information serves any good purpose.
If your comment is more directed to the joke, then come on, it’s a joke (and a really old one at that). I doubt many take it otherwise.
Here’s my surgical pathology report:
The rest of the report is a physical description of my dearly departed finger that I will spare you from reading.
Where do I begin? I guess a good place to start would be to pull my size 10 1/2s out of my mouth. I’m glad I was able to curb my anger before running to the nearest malpractice attorney screaming “pay me.” Although a more timely x-ray may have helped speed things along and saved me a lot of discomfort, I’m pretty sure the outcome would have been the same.
This afternoon I return to the hand surgeon to get the sutures out. I obtained my pathology report from a third party that has inside access, so I’m not supposed to know that I have cancer. The part about the resection margin being positive for tumor tells me that I still have some cancer in my stump or beyond. This leads me to think that I am looking at even more invasive procedures in my near future. I sure hope I’m wrong.
With the exception of my army days in Europe and college in the New Hampshire, I’ve lived my life in either Southern California or Florida. Having hazel eyes, light hair, and a year round tan is biting me in the ass. Not to mention all of the chemicals I’ve been exposed to at work and in the yard/pool over the years. Let my experience be a lesson to all.
What I find really strange is that the first path report (before amputation) said benign cyst. I hope someone can explain how you go from benign to deeply invasive in two weeks, not that it will matter in the end. I’ll try to get an answer to that one today.
The remedy that I feel is best for all is for me to have a face to face with Dr Derm, even though I only saw his henchmen, even if I have to track his ass down on the seventeenth fairway at Bay Hill. As suggested earlier, he will explain to me how he supervises his PAs, and how a dermatology practice missed SKIN CANCER. If he says he’s sorry and he’ll take corrective action–case closed. If he blows me off, I will pursue every available option with the State Agency For Health Care Administration and my insurance company.
I forgive the first doctor I saw back in November. In retrospect, I can see how he could have discounted my description of pain. At the time, my finger looked normal except for a warty growth on the edge of the nail bed. Maybe he thought I was a Rush Limbaugh wannabe looking for some hillbilly heroine. I will give him the courtesy of reporting the final outcome to all of this when its all over.
I have nothing but good things to say about my hand surgeon. He told me all along that he suspected metastatic disease. I don’t think this is a metastatic process, more of a primary cancer, but he was going by the first path report. His instincts were 100% correct in not starting me on central IV antibiotics for eight weeks and doing the amputation right away. He is now on my x-mas card mailing list.
Again, the sympathies and advice from everyone here at the Greatest BB On Earth is greatly appriciated. I find it hard to pour my guts out to friends and family in real life. You guys are the greatest. Thanks for listening and taking the time to respond.
I am glad to hear an update to this, although I am very unhappy to hear the outcome.
I hope everything goes well with you in the future, and that soon you will be 100% cancer-free.
I hope you realize that there are a lot of people who are rooting for you, hoping you will recover. I know I am.
I see the hand surgeon and he tells me that I have cancer and I act surprised. Then I asked him about a million questions and he was very patient with me and answered everything.
Bottom line is I’m going to see an oncologist to get worked up for metastatic disease. What struck me as kinda weird was that at first he wanted to amputate the second part bone in two parts. The end would have been biopsied and cancer would be expected to be found. The next section would have been biopsied and if no cancer was found–done deal. Then he would send me for a bone scan.
But then he sat silent for a few moments and he changed his mind. He said that based on the fact that I’m an ex-smoker and squamous cell is a common lung cancer, he wants me worked up before any more surgery. He agreed that it is likely a primary in my finger but wants to be sure.
His reasoning sounded compelling enough to me and I agreed. Do any of you MD/DO types out there think that that’s a reasonable approach, out of curiosity and not in the form of medical advice? Or is there a little CYA going on here? (not that I mind). Either way, my stump’s going to get shorter.
I’ve got to say you’re my hero for the day.
You’re facing the fact that your (possible) lung cancer may have spread so far as to get the very end of your pinky finger and you’re here calmly asking questions and updating us on a situation where many people would be so chagrined at their former anger as to slink away and forget the thread?
Good luck with everything, I hope it’s only pinky bone cancer. Your anger might serve you very well in the next few weeks.
E72521, your hand surgeon’s approach sounds very reasonable. The chances that this is a metastasis from a lung tumor are very, very small but not zero, so it makes sense to rule out a lung primary at this point. If you do have metastatic lung cancer, it may not make any sense to remove more of your finger (since the surgery won’t be curative, and will leave you with a less functional digit).
Glad you’ve posted back. Thank you for the update and sorry that there was a surprise on path after all.
I know very little about adult medicine (being on the peds side) but I recall that (presuming it is primary, a very reasonable presumption) squamous is not generally too aggressive. Getting all the facts first with no undue haste and then deciding on the best course seems reasonable to me too.
Total agreement with your plan for updating the other docs. Dr. Derm needs to revamp how his practice functions; his PA is either given or takes too much leeway. No excuse for the PA not calling in Dr. Derm when it became obvious that this was not straightforward. If Dr. Derm blows you off then aggressive action on your part is needed.
Hang in there.