Tuesday, 2 February 2016

Too smart to get ill? - think again.

BMJ Case Rep. 2016 Jan 28;2016. pii: bcr2015213845. doi: 10.1136/bcr-2015-213845.

Multiple sclerosis in a postgraduate student of anaesthesia: illness in doctors and fitness to practice.

Reyes AJ, Ramcharan K, Sharma S.

Abstract

A 29-year-old previously healthy woman, a doctor, was diagnosed with remitting relapsing multiple sclerosis after fulfilling McDonald's criteria for the diagnosis of definite multiple sclerosis. Despite 22 months of immunomodulatory treatment, the feasibility of continuing to train in a stressful specialty of medicine became an ethical and practical dilemma. Fitness for practice and career advancement among doctors with illnesses or having cognitive and physical decline from disease and/or ageing is a global problem. The need for addressing this issue in a compassionate and comprehensive manner is discussed. Cognitive and physical fitness are required in doctors and other healthcare workers since medical errors/adverse events are commonplace in medical practice. The public welfare is equally important in this global problem.

House MD: "Are you comparing me to God? I mean, that's great, but just so you know, I've never made a tree."

Dr Greg House (played by Hugh Laurie), is an egotist medical genius who entered into our small screens and changed the way we think about the medical profession, something which ER and Grey's anatomy have failed to achieve.  But, even House is not infallible to the ravages of illnesses, and his fitness to practice comes in to question in a number of episodes.

But, are we ready to accept a physician or surgeon suffering from a long term condition? The answer is an emphatic no (to paraphrase "the public welfare is equally important..."), and in this case study written from Trinidad and Tobago addresses this uncertainty in medical professionals life when they themselves are diagnosed with an illness, in this case multiple sclerosis. I have witnessed this on several occasions, as a trainee and as a qualified doctor. There is nothing worse in a medical or surgical professionals career when the roles are reversed - you now sit across the table, really not listening to a word that is said (since you already know what it means), as you re-evaluate your career options, on who to tell, whether to take time off...

It is such a taboo, that clinicians discuss such matters only when trust has been established and in hushed tones. And, if they choose the most aggressive treatment option who am I to argue with them?

30 comments:

  1. So are you saying no person with MS is competent to practice medicine ultimately?

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  2. Reminds me of an article I read a while back.

    https://www.msconnection.org/Blog/November-2015/How-becoming-a-patient-made-me-a-better-physician

    I wish the doctor in the abstract all the best with her career.

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  3. Can relate to the above. 27 male, international rugby player and a doctor on postgraduate, kinda autodiagnosed 3 months ago when got lethermites, first symptoms 6 months ago. Got MRI and lumbar punction that came positive. JC stratify is negative. Got offered tysabri or lemtrada. Decided to hit MS early and hard, today's my second lemtrada infusion day, 1 day was fine. Guess farmacovigilance will be my new friend :D

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    1. Good luck with the Lemtrada, as you probably guess we're big supporters of the hit hard and early strategy here. I'm also a huge rugby fan so all the best.

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  4. Spot on Doc. Our work was initially in fact inspired by a head nurse of many years who then got DX'd with MS by colleagues. Head Nurse was her identity, who she was, purpose, all of it. BAM. In fact, next Monday we will see her again. First time since we set up shop back in August 15'. She's now an author, artist, has her own gallery. But her story, oh my gosh what a journey.

    I could relate sort of. I was on my way to becoming a nurse when I was DX'd. I was an A+ student, Ace'd everything including microbiology which I did not think I would. Then when in the hospital doing mock clinical BAM. My cognition blew out a bit, took memory with it, anxiety came frothing forward. I ran out crying. My professors wanted me to go back. I'd had funding given me for doing so well in classes as well as being a inspiration to the younger students. Here is this 44 year old babe making learning a lot of fun, helping others, study groups and more. But I knew what MS meant. Thought I was past it at 44. I knew there was no way I could work in a hospital. It "broke" me. But I arose, I am still a caregiver but really... As much as I hate thinking about it. As much as I HATE MS for what it has taken from me. As much as I am a shell of that brain that ace'd the classes... I want help others with MS.

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  5. I usually say that there are two "things" and democratic in this life: illness and death. They not care or want to know for example what profession you exercise, or what social class you belong to, whether you are rich or poor, what is the color of their skin, etc., they just "come" and overall we are never prepared for their arrival ...

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  6. Well that post cheered up my morning!

    I'm a GP and know a few Dr's with MS. Yes we are unlikely to be working to 67 and we have to be very honest about where our condition is and where it is heading but I'm only 33 and have many valuable years ahead of me (I've had campath so not planning retirement any time soon). There is a silver lining in everything and you say we should we be thinking of a different career I say I've learnt more about how to be a good Dr since my diagnosis than 6 years at med school ever taught me. I've met the best and worst of the nhs and have so much more compassion, understanding and empathy with my patients now.

    You could argue there are far more 'healthy' health professionals making decisions when exhausted/depressed/hungover that I imagine make far more mistakes than those with MS.

    Just another side of the argument :)

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    1. That's a great post with a silver lining. Thanks.

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  7. Good to see both sides of the story, the introduction of highly active therapies has definitely changed our take on MS - the future is looking bright. Now it's time to change societal views. The health service needs to lead on this, because if we don't how do we expect the public companies to do any differently?

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    1. Yes and no - I just wish the drugs had fewer risky side-effects.

      I am still quite sceptical unless one finds a specific MS target without driving the whole immune system (and its good bits) down.

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    2. That's what we've spent a large amount of our time researching on (specifically turning off immune system response to CNS antigens). Works like a dream in the mice but prospects for MS some way off yet. Preliminary trial (serously flawed IMO for a variety of reasons) unsuccessful.

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    3. The problem lies in there being many targets for the autoimmunity, so one solution doesn't fit all. Which explains the domestos (bleach) approach to MS.

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    4. I worked in the private sector and there were a few of us that had MS. None of us had DMTs, but we all had fulfilling careers.

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  8. Dear NDG,

    I enjoy reading your Monday 7 pm post on the subway home.

    As mentioned before my brother was a doctor, first attack stopped his surgery training. He started on another specialization, three year later he literally sat down after final aural - never got up.

    I have hit it hard with tysabri and do fully intend to work until am 70 and dance at my 3 year old daughter's wedding. That's what my neurologist said.

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    1. Hope high efficacy is hight enough and you can fulfil your life goals, as I posted above I decided to go lemtrada as dmt naive. Only time will tell, but all the evidence supports stacking hard and early, maybe give us more time for the next breaktru teraphy and better symptom control.

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    2. Thanks Aidan, hope you have every success and that your brother is doing OK now as well.

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    3. Dear Pedro, I hope that the highly effective therapies will work for us all. I have real hope in upcoming treatments.

      Dear NDG, brother is EDSS 8.0 to 8.5.

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    4. I wish him the best, hopefully the Barts MS Team and Raj! get cracking with their neuroprotection trials.

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  9. There are several MS patients who are beating the odds and continuing with their careers and dreams.

    Kayla Montgomery - http://mobile.nytimes.com/2014/03/04/sports/for-runner-with-ms-no-pain-while-racing-no-feeling-at-the-finish.html?referer=

    Jamie Lynn Sigler - http://www.today.com/health/jamie-lynn-sigler-today-show-why-i-kept-my-multiple-t69311

    These women are great examples of strength. Whether you take aggressive treatment or not, you deserve dignity and respect and freedom to pick the career you have always wanted.

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    1. Jamie Lynn Sigler kept her MS hidden from the public eyes, was it a wise decision at the time - probably. It's easier to disclose once you have made it, ergo Michael J Fox and Parkinson's disease.

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  10. To continue with my comment above...MS may one day overpower me, but till that day I will call the shots. I won't accept an empathetic "No".

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  11. I have heard so many MS patients say things along the lines of what would THEY do and I wish a neuro would get diagnosed with MS, then things would change. While I don't exactly agree with those sentiments, I'm now seeing where they are arising from - "There is nothing worse in a medical or surgical professionals career when the roles are reversed - you now sit across the table, really not listening to a word that is said (since you already know what it means), as you re-evaluate your career options, on who to tell, whether to take time off..." While I appreciate the honesty, I'm very uneasy about what it means for patients.

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    1. The point being that at the end of the day we're all people.

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    2. I think it means sometimes ignorance is blessed, as a practitioner with ms you probably have seen enough patients to make yourself an idea of what's going to happen, you don't need the Neuro to tell you everything will we fine, because you know most neuros don't even bother themselves looking for bad prognosis profile, they'll put some methilprednisolone, and luckily start interferon/g acetate then wait and see

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    3. cept the doc has all the power in the world and the patient very little... it is not an equal relationship in the first place. if the shoe turning makes docs feel uncomfortable then we are not all people because some people have more power than others :)... please do not misunderstand this comment as an aggressive attack, it isn't intended to be, just an observation that i think docs should keep a check on in the interest of doc patient relationship. i watched my gf be attacked by a neuro once.... the neuro's ego got a little too big, i guess the neuro was busy that day blah blah blah...

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    4. Never had a problem with neurologists, only Physios and Occupational therapists. They really don't understand us. Once they've spent some time seeing how we live, they change their preconceptions. We all have MS, but our challenges are quite different. Something you can't teach in university you have to listen to us.

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    5. Anon 7:19

      So true, my Physio had good intentions and taught me a lot of great exercises however he did not truly understand what pwMS go through on a daily basis. I don't think many know what its like unless you're going through it or the spouse or children who are living with those who have it and see it on a daily basis.

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  12. I enjoyed a 34 year career as an echocardiographer, and had MS for most of it. I wasn't diagnosed until only 7 years ago when I could no longer ignore the waxing and waning symptoms. I've been on Tysabri since. I was doing much of my work in the OR, doing perioperative transesophageal echos with 3D rendering. The last year I worked, I was having serious cognitive and "word searching" issues. The surgeons I worked with knew what I was dealing with, and loved me well, and cut me a fair bit of slack. But there was a real, live human being in the table about to have his/her chest cracked open for a mitral valve repair or ascending aorta replacement, or (insert big operation here). I just couldn't do my work anymore, or be a disservice to our patients. I'm so grateful I was able to do my work for as long as I did. My MS got too unmanageable 10 years before retirement age.

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  13. Role reversal is enlightening. I'm a social worker and when I got diagnosed with MS I became acutely aware of the oppressive terminology we throw around in everyday practice, the blow to ones identity, self doubts around competency. You name it I felt it yet I'd worked in the disability field for a number of years. I too have experienced first hand the good and not so good care system. There was a time I felt too close to work in that area and actually changed my role because of it. Now I consider myself a better practitioner for my experiences.

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  14. I notice that everyone's experience is slightly different, but there is also a common theme running through here - life is unpredictable, it is how we deal with them that makes these stories different. I wish all who have divulged their MS stories here the best of luck.

    On a positive note, everything is again right in the world, the Trumpster has met his match - the public!

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