I've been seeing ads for butt crack deodorant and I've wondered what societal changes have made that a "thing". I've been soooooo tempted to write an April Fool blog about all the things that could go wrong if sniffing replaces fist or elbow bumps as the way we greet people in an age of pandemic fear. But, I'll leave those imaginings to you. I want to talk about doctors who are clueless about liver disease.

I get many reports from patients of their experiences and I wonder how things can be this bad.

To set the stage, imagine you are a 40ish woman who nearly died 5 years ago because a rural hospital could not diagnose what was killing you. Their advice, have you done your will? By good fortune, though near death, you were transferred to a city hospital with a transplant center, finally got proper management and became a compensated cirrhotic able to go home.

Return with us now to the twilight zone of rural medicine coping with a setback.

ER Doc: Cirrhosis is simply the name of the process. As scar tissue develops, that scarred part of liver has cirrhosis. So a diagnosis of cirrhosis simply means a bad section or two has got scars -- but your arm isn't damaged just because it has a scar or two, right? So since your liver labs are fine, it's silly to worry about old scars. Follow up with your GP

GP Doc: Orders an ultrasound.

Patient: I asked my primary care about my newest liver ultrasound.  I'm a bit of a wild card - so the past several years, most imaging says my liver looks normal. Sometimes they can't tell at all its cirrhosis, sometimes they see a bit.

GP Doc: There's hepatomegaly, and hepatic steatosis with diffuse coarse echogenic texture. Well it looks like you're developing a little bit of fatty liver. Most people do. It doesn't have any symptoms, is pretty harmless. Just try to eat healthy, it'll go away.

Patient: (Sigh, but more exasperated.) I told her that's not correct, fatty liver can progress. And that I already have cirrhosis, so I know how liver damage progression works, I was diagnosed in Seattle.

GP Doc: Well Seattle must be wrong, you are too young for that, and you can't have fatty liver changes if you have cirrhosis. 

Patient: I've had liver biopsies that show cirrhosis

GP Doc: Those have a lot of false positives.

Patient: To herself -- it feels like we need to keep doing so much more to educate patients. But then I think -- patients get absolutely nowhere, if there's such widespread misinformation from actual doctors.

This is me again.  If you would like to know the background of this patient, who today can't find a rural doctor to take her liver disease seriously, Go to this link in our patient stories.. 

We talk a lot about education but our medical schools and management of new doctors is simply failing us. Docs don't often want a rural practice. The big bucks are in the city, but there are many programs that help pay for med school in exchange for a few years serving in rural hospitals.  These docs are transients who rarely get to know their patients and the experience related above is not uncommon. These docs come to us with the view that fatty liver is a throw away diagnosis if they recognize it at all.

We talk a lot about centers of excellence and how to deliver proper care to the NAFLD/NASH community, and a lot of good work is being done, but most of us, in the broader community, are left to the tender mercies of poorly informed docs who don't have time for us.

I only wish this was an April Fools joke.