Friday, April 07, 2006

A Doctor's Smell-emma

As soon as I stepped into the exam room, I could smell it. That distinctive odor, called "feet" by lay people. Tinea pedis. Fungal infection of the feet. You know what I'm talking about. We all know (or are) someone with "stinky feet". These are the people that get stuff thrown at them if they take their shoes off in the car, who have to leave their tennies outside the back door, who balk at the request to remove their footwear in Japanese restaurants or sensitive homes.

There was a guy on the exam table, fully dressed, shoes firmly on feet. He was here for a sore throat.

Now, here's the dilemma. Do I address the foot issue or not?

A confounding factor is the structure and flow of the Walk In clinic, where I was working that day. We have several exam rooms, several practitioners, and a steady flow of patients. The practitioners don't have assigned rooms. Once I finish in one exam room, I move on to the next waiting patient, whatever room they're in. We just go along, taking turns and going to where we're needed next.

I had no idea who was in the room before this guy, nor how long he had been waiting there. Maybe it was the patient before him who had stunk up the place, and my patient's feet were clean as a whistle. Maybe I was making a false accusation, and would just anger the patient and make the clinic look less than pristine by calling attention to the choking fog.

Setting that aside as the lame excuse it is, the real question remains. Assume that I know that this pharyngitic person (big word for sore throat) was the odorous culprit. What do I do? He didn't ask to have his "foot problem" addressed. He's here for a sore throat, feels miserable, wants to get help and get back to bed. Should I say, "By the way, I'm noticing a distinctive, um, odor in the room, reminds me of limberger cheese..." Just kidding. I'd be more professional, of course! I would!

But should I? Do people expect their docs to address every health issue at every visit? Or do they want us to stick to the subject at hand, particularly in an urgent care setting? Would I be rude to mention someone's terrible acne, or remiss not to, when they're here for a sprained ankle?

As a Family Doctor, trained to view the patient as a whole organism, I tend to err, if you will, on the side of addressing rather than avoiding. Certainly if the "other issue" contributes to the problem at hand (like smoking when they have a respiratory infection) I feel compelled to mention it. It's bad medical practice if I don't. But something like smelly feet with a cold? I can't concoct a connection there, so addressing it is in the realm of "unrelated other".

What should I have done? What would you do if you were me? What would you want me to do if you were the patient?


Sylow_P said...

I have to get my ears flushed every couple years. The last time I went to urgent care for a serious cold, they checked my ears and noted the build up. The Doc kindly said "Would you like us to flush that out for you while you're here?"

I can't tell you how happy I was that I didn't have to ask. Having the nurse tell me that mine were the third set of ears she had flushed that morning, that was nice too.

I vote for pointing out what you can do for the patient. They probably have no idea how many of their problems you could solve...

Jon Mikel IƱarritu, M.D. said...

Integrative medicine. You said "As a Family Doctor, trained to view the patient as a whole organism".
That's the best way. Here in Mexico we are trained to numerate all the clinical problems in a patient, for example:

1. Pharyngoamygdalitis.
2. Obesity.
3. Tinea pedis.
4. Dental caries.

It's always better to sin of been detailist rather than been on the line just to to make the minimum effort to get the job done.

marybishop said...

Yes, do speak up.

You could say, "I want to check your feet for fungus as I can smell it in this room, might have been the patient before you but I have a very sensitive nose"...who would mind such a sincere non-judgmental statement?

Heather said...

I would think that inhaling the stench of his own feet is probably what caused the rawness in his throat, so truly, they could be tied together.

I had no idea you could treat stinky feet. So he probably didn't either. We all just assume it's one of those things, some people sweat, some people have stinky feet. I'm guessing he would have appreciated knowing he could do something about it.

anafaran said...

You could say anything you want to say to a patient, as long as you wear a smile on your face, and you think fast on your feet, and it sounds authentic. Say something really funny, like just what Heather mentions.
Dr. Peg: Patient, it just so happens in this issue of Harvard Men's Health magazine, a doctor researched that the most recent connection with the common sore throat is the airborn microbes that seem to have emanated from your sock or your jock, so let me have a look. Which place do you think is most likely the source of the problem?
He'll get the hint and you'll both have a laugh and you'll fix both of his problems in one visit. He'll love you for saving him future embarrassment not to mention valuable time and excrutiating pain with his other problem.

Kim said...

I would want to know, although it would be embarrassing. Better to hear it from the doctor than from anyone else.

But...first you have to make sure that the olfactory problem is coming from that patient. Because he had socks and shoes on, can you really tell if the odor was his.

We had a rule in one ER I worked in. If a homeless person had shoes on, they stayed on for as long as possible, unless it was a foot problem.

Found you through "Doc Around the Clock"; I'd like to link you on my blog if that is okay!

minnie said...

i vote you say something.

PaiDojo said...

I would not mention the feet. I would instead ask if he has had a check-up in the recent past, stress its value and even offer it, if your clinic allows such appointments. Or even offer to do it then and there. Your review of systems and physical exam may uncover things of even greater significance than the cause of the odor. You might, for example, discover that diabetes is a facilitating factor in his fungal infection. I remember once when a politician friend of mine was running for re-election, going door to door in his district. I invited him in. He had the foot odor you describe, but I knew he had diabetes and had been pounding the pavement all day. (I was not his physician.) Your dilemma, in other words, may be not a dilemma, but a constraint of your clinic. It's a matter of episodic versus comprehensive care.

pegadoc said...

Thanks to everyone for your comments! I figured I'd get a range of opinions, and I did.

kim - I've never heard of "doc around the clock" but will check them out for sure now, and yes, you are welcome to link to my blog. I'm honored!


Doc NOS said...

I stick to what I do, and taking care of the hygiene of others isn't it. BTW, if you've ever done a stint in a general hospital ER, then and only then can you appreciate the odors the human body is capable of hosting: vomit, blood, pus, stool, mouth, underarms, feet are just a few.

neuroticillinifan said...

I don't know. I'm torn on this issue. I had one doctor who, no matter what the reason for the visit, brought up my weight and the need to lose it. Drove me crazy. I am more than willing to discuss my weight if it has a bearing on the condition I'm there to see the doctor about (back pain, for instance). However, when I come in with a fever and raging sore throat suspecting strep (turns out it was), it is not the best time to expect me to happily discuss my weight. It was soon after the strep throat incident that I changed to a doctor that agreed to stick to the issue at hand.

Perhaps, you could ask the patient, "Is there any other issue you'd like us to deal with today?" That gives him the opening to either say yes or no, and then you can proceed accordingly.

pegadoc said...

Doc NOS - I agree re personal hygeine, but this was an infection. Makes a bit of a difference.

neuroticillinifan - I'm so glad you brought this up. Weight is another one of those issues that falls in this category. It IS a health issue. And yet, if someone is here for something totally unrelated, the same questions apply to weight as to the foot fungus. If an overweight person comes to me for a sore throat, I'm not going to mention their weight. As you say, it's unrelated. On the other hand, if they have chronic knee pain or back pain, or if their blood pressure is up, or if their chief complaint is anything else that weight could affect, I'd be remiss not to mention it.

Thanks for commenting.


Dreaming again said...

As a wife and a mother of 2 teenaged boys ... I say ADDRESS IT!

My own feet have never been stinky ...until this spring. I have no idea what's going on! I've noticed wearing open sandles! I've got stinky feet. Driving me insane. Nice to know it's an issue that can be addressed! Doing a search on it now.


Dreaming again said...

neuroticillinifan ... I have a neuro who brings up my weight at every single visit for 14 years ... It's gone up and down widely ... and still he brings it up ...however, he also struggles with weight ...and he comiserates on the struggle too (sometimes, I wonder if he doesn't do so obsessively (grin)..)

pegadoc said...

dreaming again - Try an over-the-counter anti-fungal cream, like clotrimazole. Rub it in twice a day.

Giovanni said...

I sympathize with 'sylow_p' above.

My preference is certainly for a technically skilled physician, but equally certain is my desire for a physician who is 'looking out' for me; that is, who will create a relationship with me over the years and initiate health suggestions like: 'I know you've come here today to have your ears irrigated but it looks like it's been a long time since you've had your prostate examined. Let's check that out too.' (The exam I love to hate).

I know...I'm asking for too much: Idealistically, I'd like a physician with the qualities of Dr. Ben Casey (60's TV series) and Dr. Welby. :-)

pegadoc said...

giovanni - You're not asking for too much. You're describing a good primary care doc. Although, if you're being seen in an Urgent Care type setting (such as the situation I was describing here) you might be more likely to get, "I see you haven't had a prostate exam in a while. Why don't you make a regular appointment and we'll do a complete physical, when we have more time and when you're over your current problem?"

That's how I do it, and I know I'm far from alone on this. A good primary care doc does consider the whole patient.


Sallysis said...

what DID you do?
And, what can be done about stinky feet?

peg said...

sallysis - What did I do? I didn't address the stinky feet. Chickened out, you might say. Next time, thanks to these comments, I'll buck up and deal with it.

Stinky feet are usually caused by fungus. What you can do is get air to 'em by wearing socks that wick moisture away and changing socks frequently. Kill the fungus with anti-fungal cream on your feet. Try spraying any stinky shoes with anti-fungal spray, but often the shoes need to be discarded, cuz it's really hard to get fungus out of shoes.

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