Tuesday, July 24, 2012

Patient #8: Max

     "I'm only doing this for you," he tells me, stepping onto the treadmill.  "I'd rather go home."
     "You're doing it for me?  But you don't even know me," I say, looking up at him with surprise.  His height is accentuated by the six inch elevation of the machine.
     "I know you well enough," he answers.
     Max doesn't complain of chest pain--so I shouldn't be doing a stress test.  It isn't "allowed" by any insurance companies if a patient doesn't have symptoms or a condition to justify it.  There isn't a code for gut feeling--but I recall this term being used a lot in medical training, when it was considered a good enough reason for doing a test.  What happened to the merits of a doctor's instincts?  They've been nullified by insurance edicts, but I'm still practicing old-fashioned medicine.  I'm making decisions about patients as though I failed to get my share of indoctrination into the linear thinking of insurance companies.  When the-one-who-knows at the back of my mind whispers, I just don't feel good about that guy, I act on it.  No wonder I'm in trouble.
     Max and I don't have a longstanding relationship--I just met him yesterday.  Despite his protestations that he's fine (his girlfriend made him get a check-up "because she says at fifty-five I need a doctor") he has agreed to undergo a chest x-ray and stress test.  He wouldn't do the stress test yesterday, claiming he needed a shower, but swore he'd come back.
     The chest x-ray isn't good.  It's true he doesn't have symptoms to justify that test either but it turns out the films disclose a spiculated mass in his left lung--a telltale sign of cancer.
     "But I feel fine!" he objects.  "Are you kidding me?"
     We look to the right of his heart silhouette on the viewbox film, and the hazy white star in his left lung is unmistakable.
     "Are you gonna help me?" he asks as I fill out the referral request for a CT scan.
     "Yes, I'm your doctor now, and I will take care of you.  I'm here for the whole ride," I say, placing my hand on top of his.  "Thanks for letting me do the stress test."
     "My heart's okay, but who am I to tell you doctors what to do?" A nervous smile crosses his face.  I remind myself that he hasn't seen a doctor in twenty years, and therefore don't ask him about smoking, diet or exercise.
     The treadmill starts.  I explain the Bruce protocol we'll use for assessing his heart function, and Max walks as though he's raring to go.  His baseline EKG, which is used for comparison during the test, is normal.  But within fifteen seconds three of the tracings look scary.  There is sudden ST depression-- like a floor dropping out from under us--a sign of a cardiac crisis.  I stop the test, have Max lie down, and signal the nurse to call an ambulance and recruit assistants from the nursing station.
     "I'm fine," Max says, but now he is breathless.  Another nurse hooks him up to oxygen and inserts an IV as I put nitroglycerine under his tongue.  Then he swallows four pills meant to limit heart attack damage--an ACE inhibitor, beta-blocker, Plavix and aspirin.
     Max's blood pressure is low, and he has started sweating. "What's going on?" he asks, beginning to panic.  I drop another nitro under his tongue and cast a glance at the defibrillator, just in case.  Max's EKG is not getting better.
     "You need to go to the hospital," I tell him calmly. "Your heart is in trouble."
     "I'm fine," he says.  "Just give me a towel to wipe my face and I can go home."  I have the feeling that he is saying these things out of habit, because he doesn't make a move to get up.
     Then the ambulance arrives and three stalwart men with a stretcher hurry to his side.
     I tell Max that I will be here waiting for him when he gets out of the hospital.  I also say that I think he's going to be fine.  I am aware of his tenuous hold on life, but the little voice that knows pronounces these words anyway.  I think you'll be fine, Max.  He looks at me to make sure I really mean it.
    How has Max been getting by with such complete blockages of three coronary vessels?  How did he survive this morning's shower, which surely required more exertion than his brief time on the treadmill?  Why did he save his heart attack for me?
     Six weeks later he's back at my office with the midline scar of a triple bypass.  "You saved my life," he says, raising his brow.  "The surgeon said I arrived just in time--no damage to cardiac muscle.  Isn't that great?"
     "What about the abnormality on your chest x-ray?" I inquire.
     "You were right," he reports. "The CT scan showed the white thing too, and they said it's cancer--95% likelihood.  I wouldn't let them biopsy it," he adds, shaking his head and looking at the floor.  "It's too soon after my heart surgery--I can't take any more, Doc."
     "I'll arrange the biopsy for a few weeks from now," I suggest, "when you're feeling better."
     "Can't we wait, Doc?" he pleads.  "Can't you recheck another x-ray here in a month or two?"
     I demur, but he is insistent.  He's been through a lot, I reason.  I'll give him some time.
     Three months later the mass looks them same.  He tells me that everyone at his girlfriend's church is praying for him, and so are all his neighbors.  He announces that he has quit smoking.  He still refuses a lung biopsy.
     Another three months go by and the mass looks smaller.  Max tells me that he and his girlfriend have decided, after five years of procrastination, to get married.  The wedding is in two weeks--and I'm invited.
     At his nine-month visit the mass on his chest x-ray is half the size, and a year after Max's heart surgery it's gone.  I am astounded, but Max accepts the information as a foregone conclusion.  "You're the one who did it," he asserts, and it seems unkind for me to contradict him.  "You saved my life and you cured my cancer."
     Eight years have now gone by.  Max has moved to New York, but he comes to Florida once a year to get medicines refilled and visit old friends.  Every year he waits patiently for me to read his chest x-ray and show him the films.  It's a little like "Groundhog Day."  His lungs look perfect.
     I have not stopped relying on my gut feelings, despite their insufficiency as criteria for ordering tests, and despite insurance company reprimands--when my charts are audited--that some of my procedures aren't "indicated."  These audits allow the insurance companies to take back payments for services I have already provided.
     I doubt if my medical colleagues have stopped using their gut feelings either, but we're exercising our instincts underground--and we're looking high and low for solid evidence to justify the studies we need on our patients.  The initial chart note for Max's visit would read:  "No complaints of chest pain, shortness of breath, or claudication."  The stress test would not have been permitted by his insurance company, and my act of defiance could be construed as fraud.
     I live a double life.  I am following a tradition that is at the core of the whole history of medicine:  using my medical instincts.  But I'm also struggling to report my decision-making in ways that make sense to insurance company auditors--people who don't have degrees, and who are awarded coding certificates after six weeks of classes.  I stay up late writing chart notes for these auditors.  I never document the real truth:  I have a bad feeling about this guy... or, He looks like someone with cancer...or, I bet if I put him on the treadmill I'll find something wrong--because who in the insurance world (the only ones who read the charts) would understand?


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