Monday, March 30, 2009

CAT Scans - Lighting the Fuse!

The superscan in the prior posting, which showed a ‘freckle’ in the right lung, has now created an anxious patient and family. This patient’s worry will be heightened when he is sent to a pulmonologist, or lung expert, to evaluate the ‘abnormality’, which was found entirely by accident. The lung specialist will then advise the patient to have periodic CAT scans over the next 2 years to assure that they lesion does not enlarge. Obviously, this exercise diminishes quality of life and costs plenty of money that could be used to help truly sick people. And, if the nodule does increase in size – which even benign lesions can do – then the doctor may recommend surgery just in case it is cancerous. Consider what tens of thousands of Americans endure evaluating abnormalities that should never have been discovered or investigated.

Millions of us are walking around with innocent imperfections in our internal organs. In other words, if any of us were to undergo a CAT scan, many of us would have abnormalities described by vigilant radiologists.

Sure, some folks have been saved by having cancers discovered early. If I or a family member were one of them, I might have a different view of this issue than I do now. However, these occasional accidental rescues must be balanced against the enormous financial expenditures, anxiety costs, radiation exposures and direct harm from medical complications that result from these medical cascades. I am convinced that the harm outweighs the good.

So, when your doctor recommends a CAT scan, you may feel that there is no risk from a non-invasive study. Think again. The CAT scan may be the match that lights the fuse.

Monday, March 23, 2009

CAT Scans - Friend or Foe?

I am astonished at the diagnostic accuracy of today’s radiologic technology. CAT scanners today, for example, can detect lesions that were invisible 5 or 10 years ago. As a gastroenterologist, I am routinely referred patients with subtle abnormalities seen in their livers, pancreases and digestive tract. Indeed, every medical specialty has been similarly affected. Pulmonary specialists see patients with tiny lung nodules that would not have been seen with older technology. Oncologists see patients with borderline abnormalities that can only be detected with the latest generation of scanners.

Shouldn’t we celebrate this futuristic diagnostic accuracy? I’m not so sure. I believe that these phenomenal technologies harm many more patients than they save. Follow my reasoning.

Most of the abnormalities that scans detect today are innocent lesions that will never make a patient sick. Our internal organs are not smooth and perfect. New scanners, like the satellites in space mentioned in the prior posting, reveal ‘abnormalities’ with their incredible resolution. Healthy people are told every day about internal irregularities, which doctors will then pursue. CAT scan abnormalities create an undertow that drags patients into medical deep waters. Consider a hypothetical example that happens every day in every city in America.

A concerned patient comes to the emergency room with chest pain. The ER physician properly considers a diagnosis of a pulmonary embolus, or a blood clot, and orders a CAT scan. No clot is found and the patient’s symptom resolves. However, the radiologist reports a tiny nodule in the right lung and states in writing that malignancy cannot be excluded.

This patient has just involuntarily entered the medical labyrinth. On the next posting, I will share what his sojourn there will be like. It’s a journey that patients are forced to take every day. It’s a long trip, but it’s no vacation.

Monday, March 16, 2009

Trapped in the Medical Labyrinth

We’ve all seen satellite photographs of the earth that show a portion of the globe from afar without any details of the earth’s surface. Google Earth allows even a computer neophyte like me to zoom in from space to image my own backyard. I’ve even been seen a satellite image of our red family car parked in our driveway! Using this technology, major rivers and mountain ranges, invisible from space, can be brought into view. The closer you zoom in, the more details you will visualize.

Look at the skin on your own hand. Now, bring your hand closer and closer to your eyes. With closer inspection, the topography of your skin comes into sharper focus. From a distance, your skin seems smooth and unblemished, but with closer examination, surface irregularities, small scars, pigmented spots, freckles and veins will come into view. Don’t rush off to see a dermatologist STAT! These are the normal imperfections that every physical object has if it is studied at high magnification.

What do mountain ranges and freckles have to do with medical quality? Everything. The medical profession is increasingly devoted to finding ‘freckles’ in every organ of the body and then demanding that they be investigated.

In the next posting, I will explain how innocent and healthy patients are pushed into medical labyrinths every day and then spend years there searching for a way out.

Monday, March 9, 2009

Abnormal CAT Scans - Not Always Bad News

One of the most vexing events for patients is when they are told that there is an abnormality on a radiology study. These discussions in doctors’ offices create palpable anxiety for patients and their families, even when physicians try to reassure them that the abnormalities are likely to be trivial. Patients today are frightened that they have cancer. They all know anecdotes of individuals who were falsely reassured and were ultimately diagnosed with a malignancy. I have heard fears of cancer related to me by teenagers who have seen me as a gastroenterologist to evaluate a few drops of blood they observed on the toilet tissue. Their fear is not rationale, but it is real.

A few weekends ago, I was asked to see 2 patients on my hospital rounds to offer an opinion on abnormal CAT scans. The first patient’s scan showed an abdominal mass the size of a grapefruit that the radiologist suspected was related to the patient’s prior diagnosis of colon cancer. The second patient’s scan showed multiple lesions in her liver, which the radiologist suggested could represent metastatic cancer.

No physician looks forward to relating these ominous findings to patients and their families. Such devastating news provokes legitimate anxiety and worry, in contrast to the exaggerated concerns that patients feel after being advised of minor radiologic abnormalities.

I am not a radiologist and have only rudimentary CAT scan interpretation skills. Yet, I was able to advise both hospital patients that all would be well. How was I able to do this? Was I in a deep state of denial and issued false hope to minimize my own discomfort? Was I reclaiming the paternalism of my medical predecessors who routinely withheld serious medical information from patients? Was I so sleep deprived from phone calls through the night that I was too stuporous to function properly?

On the contrary, I was well rested and clear minded. I was able to dismiss the ominous CAT findings using a technique taught to me as a medical student over 25 years ago. Afterwards, I politely chastised the radiologists for neglecting the fundamentals that they also were taught in their training.

It only took a few minutes for me to determine that the scan findings were harmless. I simply looked through the prior medical records and in both cases found CAT scans from years ago that showed the exact same ‘abnormalities’. While I couldn’t offer a specific diagnosis, I knew that the findings were benign as the lesions had not changed.

If you are told that a radiology test is abnormal, make every effort to determine if a similar study was done in the past. Comparing the recent test with the previous one can be the cure you seek. These prior films may be in hospitals across town or in other states. These records can be hard to get, but the payoff can be enormous.

I advise patients to maintain a master file of their lab results, radiology reports and other medical records. Now you know why.

Tuesday, March 3, 2009

Finding the Good Doctor!

Here are some pointers in how to choose a good physician. Remember, while these tips offer guidance, there is no guaranteed method to rely upon.

  • Ask friends and coworkers who their doctors are and why they like them. Keep in mind that they may like their doctors for the wrong reasons. If a neighbor recommends his doctor, because “he prescribes antibiotics over the phone whenever I want them”, then you may have learned something important – choose another physician. Conversely, a person may be dissatisfied with a doctor who truly performed well. For example, a patient may complain because his doctor wouldn’t give him a refill on addictive sleeping pills. While I encourage canvassing opinions about local physicians, use these recommendations cautiously.
  • Ask hospital nurses for their advice. They see physicians working when doctors don’t know they’re being watched. They are an unrivaled source for obtaining a candid review of medical professionals. They know who is caring and conscientious, who spends time with patients and families, who communicates with consultants, who returns to the hospital when necessary and who puts patients first. Contact a few nurses at your local hospital and ask for 3 physician references. They will be delighted to speak with you. This is my hottest tip, yet, nearly no one follows it.
  • Generate a list of 4-6 physicians to consider. Contact their offices and find out when the next available appointment is. If it’s in 3 months, then this physician might be too busy for you.
  • Ask how much time the doctor allots for a new patient. If it’s 15 minutes, and you have chronic medical issues, then this might not be the right choice.
  • Find out the logistics of the practice. Does the doctor see patients in multiple offices some of which may be far away? If a patient needs an urgent appointment, does one of the physician’s partners or a nurse practitioner see the patient? Does the doctor treat his patients in the hospital or does he refer them to other physicians?
  • Who takes the doctor’s calls after hours? The doctor who will be taking your emergency call at night might be much more important to you than your regular physician.
  • Narrow your list to 2 or 3 doctors and interview them. Get a sense of their style and manner. Does the doctor listen? Do you feel rushed? Is the office staff courteous and attentive? Can you picture yourself as a patient in this particular practice?

These tips will take you far, but not necessarily to the goal line. You may not get it right on the first try. Nevertheless, this is likely a better strategy to select a doctor than flipping through the yellow pages or resorting to eenie, meenie, miney moe.

Remember, you are not just trying to find a good doctor. You want to find one who is right for you.