The patient was hospitalized after a week of abdominal cramps, nausea, vomiting and diarrhea. A CAT scan of the abdomen, often ordered by reflex in the emergency department (ED), showed no abnormal findings. In the ED, her white blood count was modestly elevated, but had normalized by the following morning when I met her. My physical examination demonstrated no concerning findings.
I suspected that she was suffering from gastroenteritis, medical jargon for‘stomach flu’. Physicians, lawyers and some bloggers often prefer highfalutin terminology, rather than standard colloquial English, which works just as well. I briefly digress to give a few examples of complicated phraseology used to aggrandize the pompous professional.
Pompous Phrasing........Ordinary English
Pharyngeal injection.....................................Red throat
I advised my patient that I did not advocate additional testing, and anticipated a very brief hospitalization followed by a full recovery.
She was not satisfied with this conservative approach. She had suffered a stomach ulcer nearly 20 years ago, and was concerned that her illness was a recurrence of this condition. She wanted the scope test (EGD) of her stomach to exclude this diagnosis. I spent more time with her to explain why this test was unnecessary, and told her that she might be able to be discharged late in the afternoon. I promised to check on her progress later.
It is more typical for gastroenterologists to coax folks into colonoscopies and other intestinal delights, than to dissuade them from sampling our diagnostic bag of tricks. This patient was an exception.
I called her nurse that afternoon to inquire on her condition. She advised me that the patient’s family had visited and they all insisted that an EGD be performed prior to discharge.
Here were my options:
- Return to the hospital for a family meeting
- Refuse to do the procedure and see the patient on rounds the following morning
- Resign from the case and request another consulting gastroenterologist to see her
- Perform the procedure.
Medicine is not a perfect world and its practitioners are imperfect members of the human species. It was clear to me that if the scope were not performed, that this patient and her family would believe that an essential medical service was being denied. They would be angry. In similar instances in the past, when I had counseled patients against having tests performed that they desired, I had been falsely accused of trying to save insurance company money. I did not return to the hospital to meet with the family as I believed that discussing the futile scope test with them would be futile. As the EGD has nearly no risk, I decided that performing it would serve the greater good. I recognize that other physicians may have chosen differently.
The results were normal. I’d like to think that no one got hurt in this vignette, but this isn’t true. Health care reform took a direct hit from me and my personal integrity was grazed. I’m blowing the whistle on myself.
Interesting. Wonder if this might have worked: "I'll do the test, which I have sound reasons to believe is unnecessary. I do understand your desire to have peace of mind on this, but my professional judgment is that the test is unnecessary and, if it is done, it will show that you do NOT have the condition. Here's the deal: I'll do the test. If you have the condition, I will pay for the test personally; if, as I strongly believe based on the evidence, my experience, and my judgment, you do NOT have the condition, YOU (not your insurance company) will pay for the test. Agreed?"ReplyDelete
I don't think it would have worked, but it would have been interesting. (I probably wouldn't have the guts to say it myself, but one of the perquisites of giving advice is advising things that one would not understake oneself. :)
If at a minimum, doctors were required to indicate, in insurance claims, when they though unnecessary tests were being performed, patients would then be required to explain to their insurers why unnecessary tests were requested. For those who abuse the insurance plans and force rates up for everyone with these unnecessary test, this would at least focus the costs on these individuals. Unfortunately, such a system would likely pit patient doctor against patient over the definition of 'unnecessary'.ReplyDelete
Interestingly, you have illustrated the thesis of the book I am writing, tentatively titled, "What Really Has to Happen to Fix American Health Care", namely that the primary driver of irrational health care spending is driven by unreasonable patient (ie, "American") demands and expectations.ReplyDelete
Linday, I hope you will quote liberally from Whistleblower!ReplyDelete
I appreciate the confession. I have one of my own ... Over Thanksgiving my father-in-law complained of chest pain. I took him to the ER where he got the million dollar work up, and had nothing demonstrably wrong with him. I felt guilty about bending the cost curve in the wrong direction - but would have felt much worse if I'd ignored an MI! :-/ReplyDelete
Thanks Val. Happy to hear about the favorable outcome. I'm sure that your advice was from the heart, since (hopefully) we don't need to practice defensive medicine with our own families! I absolve you of all guilt.ReplyDelete
you claimed to have learned your lesson, then make a statement like "often ordered by reflex in the emergency department."ReplyDelete
oh also- way to perform an egd by reflex, doctor.
I have 2 queries for the anonymous commenter above.ReplyDelete
(1) Based upon the medical data I provided, do you think this patient needed a CAT scan in the emergency department?
(2) From my post, do you really suggest that I performed the EGD 'by reflex'? If so, then there is a colossal misunderstanding as the point of the post was my effort and desire to withhold the unneeded procedure.
Thanks for your comment on my blog, Michael. Physicians certainly are put in a bind, and I agree with Lindsay that a lot of it seems to come from unreasonable expectations on the patient's part. I look forward to reading her book and to your continued thoughts on health care reform and the physicians role in it.ReplyDelete
The insurance industry has done wonders to destroy the doctor patient relationship. It is unfortunate that there is such a lack of understanding on both sides. Patients do not trust their doctors because doctors have been forced to practice medicine in a way that they cannot do their best. And around, and around we go. The insurance companies are laughing all the way to the bank. We have all been duped, in a way that will be nearly impossible to untangle, without losing many lives along the way. The 98,000 people dying estimate is of course wrong. I am sure it is much higher. How can we possibly calculate injury and loss of life, when the health departments in charge are not doing anything! I almost died and spent 9 years trying to recover from my injuries during a fertility procedure, and the health department didnt think it was worth looking into. One of my permanant injuries was massive bowel resection resulting in only 3 ft of small intestine....As a G.I specialist, you must be aware of how serious this is. Well surprise, 9 yrs later I decided to force the health department to do an investigation. They have opened the case, and it appears all parties are quite uncomfortable. Ive written a letter to the CEO of the health system asking him what has changed and what discipline has been imposed on the dear doctor that acted outside of accepted medical standards. I am still wating for his reply. So you see, all we have are the lawyers breathing down the necks of the healthcare system to protect us. Disfunctional yes, but its all we got right now. We didnt get into this mess over night, we wont get out of it easily.ReplyDelete
why did you perform the egd if it was unnecessary, and how are you any different than the ed docs you look down on?ReplyDelete
“Great Post and you absolutely did the right thing. Had you refused the EGD with a family altercation (fancy-schmancy for “fight”), the first time the patient had a symptom they would curse you and get the test from someone else. If the patient developed a disease or cancer in the future, you would be a sitting duck in a courtroom as an aggressive attorney said “So, Dr. Kirsch. Despite her being hospitalized and the family insisting on a test, you just didn’t want to take the time to do it.”. We are dammed if we do and dammed if we don’t. For a gastroenterologist to even go through the process like you did, you should be commended (fancy-schmancy for “atta-boy”).ReplyDelete
Toni Brayer, MD
I enjoyed this post. It hits home. As an electrophysiologist, (aka, as my nurse calls me, "an installer") I am often tasked with NOT placing a pacemaker or defibrillator. Your story illustrates beautifully the difficulty in NOT doing a procedure. The family meeting in which you try and explain that their loved one does not need a pacemaker or ICD can be so draining. There are times when the reasonably reimbursed surgical procedure takes less time and emotional energy than the explanation of why not doing it most appropriate. I come home and tell my wife, a palliative care doctor, it would have been way easier to just do the darn device.ReplyDelete
Nice post. I enjoyed your writing.
The first commenter almost read my mind. Is there any reason why a doctor can't tell a patient, "I don't believe this procedure is medically necessary. It would be against the law and a breach of contract for me to represent to your insurer that it is medically necessary. Would you like to have the procedure performed at your own cost?"ReplyDelete
I wish there was a way to quantify how much of "defensive medicine" is really due to the unreasonable demands of patients, and not due to the fear of litigation.
I appreciate Justinian's comment. I indicated in the post that medicine is not a perfect world. The vignette points out some forces (there are others) that influence physicians to bend their advice and actions. In a Utopian medical world, patients would receive only the care that is medically necessary. That is not the world I live in.ReplyDelete
Thanks for sharing your thoughts and promoting this dialogue.ReplyDelete
In this scenario, it seems to me that cost-sharing is the only way to address the problem. Patients need to have financial incentives to avoid interventions (diagnostic or therapeutic) that have a low likelihood of making any difference.
I'd love to be in the insurance industry so as to be able to address these types of situations, but I suspect it would *not* be simple. In this scenario, suppose that before performing the EGD, you would indicate your estimate of the likelihood that it will change management. For every % less than a given threshold (e.g., 20%), the patient would know that s/he would bear an increasing % of the cost. The cost-sharing threshold could be set at different levels for different tests, based on the risk of complications, the estimated severity of missing a given diagnosis (e.g., PUD, as in this case), etc. (In the case of some tests or interventions, there would likely be data applicable to these estimates, so we wouldn't have to rely solely on your professional judgment for the estimate.)
So, this is not straightforward. Perhaps, however, the bigger problem is that so many of our patients do not have the wherewithal to make good decisions if faced with these complexities.
GU, good points. I agree that if patients had some 'skin in the game', that this would serve as a brake on the system. Others argue that if they have 'too much skin', that they would forgo needed treatment. My experience tells me that the former may be the preferred approach. In most situations, when you're not paying, you get more stuff than you need and you don't care what it costs.ReplyDelete
Clinical claims can be very complicated and it would be unwise to attempt to pursue a claim without professional assistance which should be provided by a solicitor with expertise in this field. It requires medical as well as legal knowledge, and an empathy with the feelings and needs of people who have been harmed by negligent treatment. Specialist solicitors are much more likely to make an informed assessment of the chances of success in claiming compensation for clinical negligence. There are many solicitors who are offering their legal services on the basis of contingency fees which means that you do not need to pay any legal fees to the lawyer unless you have won the case and got the compensation amount. You can also contact the lawyers who offer first consultation meeting free of cost. Visit Medical Negligence Claim for more information.ReplyDelete
I guess I'm not the only doctor who orders tests that patients don't need. http://nyti.ms/bbbLMyReplyDelete
The main concern I have here is that you going against the patient probably would hurt the physician-patient relationship. For a situation like this, where the risk is primarily financial (verses the risk of you attempting to convince the patient to undergo an important procedure later on and them declining) I think you did the “right thing” at the time. The right way to fight these issues is not one patient (vs. one doctor) at a time. We need to alter the system.ReplyDelete
In any case, this is the insurance companies and medicare that are encouraging this with their model. I really thing it's something they are going to have to fix. Though ethical practitioners are appreciated. In a situation like this, where they requested the procedure and it was a relatively low risk I think it's more important to maintain your relationship with the patient than try to fight the system. The ethical requirement that I think you had was to make sure they understood that they were doing this needlessly. Which you did.
I'm just curious, did you by chance go through the details explaining to the patient how you ruled out the need for the EGD or why you didn't think she had a stomach ulcer?
Just as an added note, it has been interesting to see the different issues our two professions (I'm studying to become a pharmacist) face by reading this site as well as KevenMD's site. The grass does seem greener on the other side, but the more that I look, the more I realize that we all have our weeds and brown patches.
@Ed, thanks for your comment. It was not possible to convince the patient that the procedure was not necessary. Had I declined to proceed - an option - she would have hired another gastro physician to do the deed. As I noted in the post, I am not certain that I made the right choice. Do patients have a right to low risk procedures that have very low likelihood of finding something? Radiologists don't refuse to do CAT scans that we physicians order inappropriately.ReplyDelete