Friday, December 7, 2012

Common Sense

     Most things in medicine are common sense.
     But common sense has been superseded by paranoia among doctors, at least throughout my career.  Now that state caps on malpractice awards are more common, this may change.  There are other motives for bypassing common sense, however, including the habit of avoiding contact with patients, and a reliance on algorithms like the one emergency rooms use for "chest pain."  As it happens, the algorithm is more profitable than plain old common sense.
     Imagine being sued for $120 million because you decided to observe a patient's symptoms before ordering a CT scan (800 times more radiation than a chest x-ray).  This is called "watch and wait" in family practice, and it's perfectly legitimate.
     In this case, however, you tell your patient to return, but he never does--and is diagnosed with cancer a year and a half later.  Unfortunately, you find out about it via certified mail from a lawyer.  (Certified mail is such an effective way to get doctors to open letters that junk-mail companies started using it to trick doctors into reading their advertising come-ons.)
     Sure, you should have called the patient three times, after he failed to show up for his appointment, or sent letters to coax him to return--that's what the lawyers will try to prove.  When big-money settlements are forced on doctors, and they are made to feel incompetent and uncaring, they end up ordering every test in the book to demonstrate forevermore that their patients are getting "the best" care.
     Some patients like fancy tests and treatments.  Sometimes they even come right out and ask for specific tests by name, and a doctor has to be made of pretty tough stuff to refuse, because not doing a diagnostic work-up could mean missing a one-in-a-thousand problem, perhaps life-threatening.  No doctor wants to face a high-stakes malpractice lawsuit--not even one in a thousand times.
     Consider, for example, Mrs. G.  When I met her last year I discovered a cancerous lump in her right breast.  Breast cancer is particularly virulent in African-American women under age fifty, so she was routed through a mastectomy, lymph node dissection, radiation and chemo very quickly.   I hadn't seen her for months, as happens when patients are busy with specialists.
     But today she came to my office, very angry.
     She said she's been having chest pain for five months.  It hurts so badly she can't function at her job in an elementary school classroom.   On a scale of one to ten, she said, it's an eight .  She takes oxycodone, prescribed in a hurry by the oncologist, but she also requested an early PET-CT scan.  After eight calls to her oncologist to request an earlier scan than usual, because of her pain, she felt rebuffed when the receptionist told her, No, your insurance company won't pay.
     True, Blue Cross probably won't pay for a PET-CT, not without an overriding--perhaps invented--reason.  But Mrs. G. wasn't even given an appointment to see the oncologist for an exam, nor did anyone set up a time to discuss her concerns.  All she got was the message from the receptionist.
     I know that Mrs. G. can be a testy,  even quick-tempered and accusatory, and this might be paranoia-making, for doctors, but she has cancer, and people aren't always gracious in the middle of a crisis, and in the biochemical havoc caused by chemotherapy.  She might have deserved extra consideration--and maybe she was, for all I know, hearing only one side of the story.  What most people need in this situation is to be taken seriously, at an appointment.
    Instead, she went to the ER--not once, but three times.  She told the doctors she had chest pain--therefore was admitted, per their algorithm, for a cardiac work-up, and three days of "evaluation."  I read the latest hospital discharge summary:  it might as well have been written by a robot.
     "Did anyone look at your chest?"  I asked, lifting my eyes from the chart.
     "They did a lot of tests on me," she said, "but not the PET scan I wanted."
     "Did they look at the place where you had surgery?"
     "What are you talking about?" she asked.
     "I mean, did anyone examine you--check out the place where you hurt?"
     "They didn't make me take off my shirt, if that's what you mean," she answered stiffly.
     I gave her a gown and watched her change, on purpose, instead of leaving the room to afford her privacy.  Removing her bra was a difficult affair, and the silicon insert fell with a thump like a slippery fish into her lap.
     I checked her mastectomy site, her lymph node scars, and her shoulder.  The trapezius muscle was taut as cords of boating rope, and she grimaced when I pressed on her pectorals.
     "That hurts!" she said.
     "Your muscle is sore," I told her.  "I'm sorry that my exam hurt, but I think muscle strain is your main problem."
     I picked up the prosthesis.  "This is too heavy.  It's making your chest and arm muscles, which have been altered by surgery, work too hard."
     I wrote a prescription for two camisoles with lightweight cotton padding for her to use instead.  Her insurance company probably won't pay, but the cost is low--$30 apiece.
     Mrs. G. stopped clenching her jaw, and I thought she might even have ventured a small smile.
     "I think you might be right," she said, putting her dress back on.
     "What about the PET-CT scan?" I asked.  "Do you want me to pressure Blue Cross for it?"
     "Let's wait and see if this works," she told me.  "Maybe I won't need a PET scan."
     That was a cheap visit, I thought, tossing the hospital discharge summary into the shredder.
     I don't understand the ER and I don't understand doctors in the ER.  What happened to their training?
     Admitting a cancer patient to the hospital and ordering an expensive cardiac work-up on her, when the problem is muscle strain from a too-heavy bra prosthesis, is just not using common sense.


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