Sunday, August 7, 2016

Overtreatment and Unnecessary Medical Testing? You Make the Call!


Ok, readers.  I know how many of you fantasize about being part of the high drama and glamor of the medical profession.  Believe me, it’s even more exciting than the medical TV shows that have been part of pop culture for generations.  Remember Ben Casey?  Marcus Welby?  Dr. Kildare?  Dr. Seuss?   Rescuing folks hovering over the Grim Reaper was just another day at work for these guys.


The Grim Reaper

Here’s your chance to play doctor for the duration of this post.

A patient wants a colonoscopy, but it is not medically necessary.  Assuming he cannot be convinced to withdraw the request, should you perform it?

A physician wants you to perform colonoscopy on his patient, but it is not medically necessary.  Assuming the physician cannot be convinced to withdraw the request, should you perform it?

An elderly patient’s son wants a colonoscopy performed on his father, but it is not medically necessary.  The patient is ambivalent and delegates the decision to his son. Assuming the son cannot be convinced to withdraw the request, should you perform it?

A nursing home requests that a feeding tube be placed on an elderly resident.  While the tube would be much more convenient for the staff with regard to administering food and medication, the tube could be avoided if a staff member had sufficient time to assist the patient with meals and medicines.   Should you place the feeding tube? 

An anxious mom (please forgive the sexism here) demands an antibiotic for her child’s sore throat, which is not medically necessary.  Assuming she cannot be dissuaded from her request, reinforced by prior physicians who prescribed antibiotics under similar circumstances, should you acquiesce?

A man is critically ill in the intensive care unit and is nearing the afterlife.  The consensus among the treating physicians is that additional care would be medically futile.  There is no advanced directive or medical power of attorney.  The next of kin insists that the patient be placed on life support.  He is not persuaded to withdraw his demand and suggests that there would be consequences if his relative is simply allowed to die.   What would you do here?

So, ‘doctors’, any thoughts?


7 comments:

Anonymous said...

I'm not a doctor; I don't even play one on TV. But I've been steeped in the healthcare field for the last 7 years and have some thoughts. To me, it comes down to benefit vs harm. For the colonoscopy, there's at least the possibility of a benefit to offset the potential complications & costs - perhaps a treatable issue will be found. For the feeding tube and antibiotics, the balance seems to be in favor of harm done. The patient receives no benefit from either; the tube could cause discomfort and complications; the unnecessary antibiotics are a societal/microbial harm. The last seems to be truly ethics. Although I don't personally want extensive life-extending interventions, if the one person in the patient's life who's in a position to decide does, then I wouldn't think it's my place to disagree. Though I'd want to set a timeframe for a re-evaluation with the caregiver; at some point, there is the potential for harm (pain for the patient, costs to society).

Michael Kirsch, M.D. said...

Appreciate your thoughtful comments. What's your connection to health care?

Anonymous said...

I work at a health care software company, which hopefully doesn't take "thoughtful" out of the running. :-) I sit between business and technology, and have spent a lot of time trying to understand as much as I can about our customers' world, from the clinical aspects, to the regulatory, to the operational, to the emotional. I've been in software for 20 years and health care is the most complex industry I've ever worked in. It's incredibly rewarding, because it really means something.

Mike Recktenwald said...

The various dramas that you have presented are very similar to the daily melodrama that takes place in your local pharmacy! The majority of these patients are delinquent in their requests, present with unrealistic expectations of physician and pharmacist both and will simply lie to your face, in the miniscule chance that they may develop a lawsuit against anyone and everyone. After 32+ years of pharmacy practice and having a son that holds a PharmD degree and owns and manages an independent pharmacy, in addition to my oldest niece who practices ER/Trauma medicine and her husband who holds a Ph.D and MD in Oncology/Hematology, all share the same stories you have. Don't worry about changing the names, none are innocent !

I entirely enjoy reading your blogs. Keep them up, it helps to get thru the day.

Respectfully, mtnmikerx BSPharm, RPh.

Anonymous said...

1. Give him the colonoscopy. Maybe something unexpected will show up and if I denied it, and it wasn't caught people might be mad. If not, clean bill of health for his ass, literally.

2. Ask the patient about their health issue. Maybe ask the other doctor what symptoms or test results warrant it. Probably do it anyway, unless the patient objects, especially if the other physician is my superior.

3. Tell the dad first, alone, that it isn't medically necessary and it's ultimately his choice, go into possibly complications of a colonoscopy if there are any. Then tell the son too. If the dad is still indecisive and the son still wants it then let it happen.

4. Screw the nursing home. It's one thing if an adult makes an informed but still terrible decision, but it's another when it's imposed upon them because they're too sick to represent themselves. Maybe recommend a personal care assistant if that's in my power though I guess PCAs are what people have before they need full time care.

5. Torn between giving her a lecture of antibiotic resistance, maybe twisting the knife by implying her son will have to live in a world where even the most mild infection can once again kill. Or I could sweet talk her by saying that he's very fortunate to have a mild viral infection instead of a bacterial one because it will likely clear up quicker, and on it's own. Also tell her that half his class probably has it too and she might too because while it's mild, it's contagious too and that she might catch it too soon. (I'm assuming it's just a cold with sore throat) Then give some info about otc symptom relief. This is where I wish it would be like TV and I could be rude about the facts to her and then pay all the other patients in the waiting room 50 dollars to go away.

6. Too bad the guy isn't in a situation where he was really sick but still talking for a bit before the coma. Next of kin could still probably impose being alive upon him but that'd give me grounds for a solid guilt trip. Ultimately I'd give him the life support. We have 0 opinions from the almost dead guy and 1 from the guy threatening me.

My jobs have been food and customer service. It's pretty much the (partial) opposite of being a doctor. Doctors care about their patients' wellbeing but won't just give them whatever they want. I'll give someone anything I'm allowed to but I don't care about the customers at all beyond what they're ordering most of the time. We both wear gloves, sanitize/wash frequently, know how to avoid cross contamination and get disrespected on a regular basis, sometimes for no apparent/relevant reason, by customers/patients+loved ones, so we aren't TOO dissimilar.

Maybe you were sarcastic in the beginning with "Here’s your chance to play doctor for the duration of this post" but if you're reading this, can you please tell me if I got any of them close to what you would have done?

Michael Kirsch, M.D. said...

Excellent comments! There are no right answers as those of us who live in the real world can't be zealous purists. While there are lines that we won't cross, there are some that we will traverse. When purists have insisted on various zero tolerance policies, we have all seen the absurd consequences of this. Great comments above! Why remain anonymous? Step up!

Anonymous said...

Fun hypotheticals -

1. yes - as a previous poster said, if you found something, good for you both, and if you didn't perform it, and it turned out something was there, you'd be up $#^* creek (well, without actually having been, but you catch my drift)

2. unclear why another MD asking for your consult cannot be convinced the procedure is not indicated but if the patient is not having any symptoms, and is not personally attached to having the procedure, I would say no. If something were to go wrong, that's on you, not the referring physician.

3. This is a tough one. Your patient is the dad, not the son. I would say don't do it. Not to go all Machiavelli, but if you miss something, dad might die before whatever is missed kills him anyway. If you perf him or he dies under anesthesia, devoted son is coming straight for you.

4. this I do not know. Is the quality of the NH such that the patient will not get adequately fed if you place the feeding tube? what about other attention? If you put the feeding tube in, will they not pay other attention to the resident, like T&P and cleaning? Sounds like a garbage NH if they can't make time to even feed their residents.

5. Yes. Explain to mom that her child probably has a viral infection, or whatever reason you think it's not indicated. Give her the antibiotic anyway. At least she's taking her child for medical treatment. That means she's not an anti-vaxxer, right? Reinforce good behavior. Let her sit on it when she's less distressed about her child's condition.

6. You don't mention whether the patient has any ability to weigh in. Assuming he does not, and the next of kin will not withdraw his demand, you have a meeting with him and the responsible physicians, explain why the treatment is futile, and if he won't back off, and if he truly is next of kin, get him to sign the POA/advanced directive and you have to do what he says. you obviously can't just pull the plug on the patient. btw, i am always curious about how hospitals verify who is the "next of kin," in these types of situations. I guess they figure if you show up during business hours for two weeks straight you get to make some decisions. They must err on the side of caution. now, if the patient is refusing treatment, things get a bit dicier and people have to start showing ID.


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