Friday, January 19, 2007
Give Peace a Chance
"Peace of mind." In the previous post, that's exactly (as a commenter pointed out) what the ad is all about: trying to create peace of mind as a new reason for having a defibrillator implanted. Get people to dread Sudden Cardiac Arrest, maybe they'll try to talk their doctors into the procedure, even as the typical cardiac indications don't exist. And, when you think about it, it could happen: Doc, if you don't give me one, and I die of cardiac arrest (don't we all, eventually?), I'll see to it that my family sues you for everything you have....
These ads, and many like them, are about creating a cure for a problem that doesn't exist -- at least not to the degree that the makers would like you to believe. Haven't heard much about "social anxiety disorder" for a while? Maybe it's because it turned out the acronym was already taken. (OK, I'm no psychiatrist: I'm sure the condition exists, or could well exist. But the ads clearly were trying to convince a big swath of the population that they have it. Hell, I may have it... Got a drug?)
Getting back to where I began: peace of mind is not a specious goal. Certainly, it's part of what physicians aim for in treating their patients: reassurance, satisfaction that a risk or disease is under control or being attended to properly. The concept comes up in my field in the form of "prophylactic surgery." Breast cancer is a case in point.
For women with a high-risk family history of breast cancer, and/or who carry one of the breast cancer genes, prophylactic mastectomy is a recognized option. And it's more than peace of mind: clearly in this context, it's cancer prevention. I've done it in several women, most often after a long relationship and a few biopsies, counseling about the options of careful followup and stating the degree to which, in an individual case, I'd be comfortable with it; and without reservations. But I wasn't sure what to do when Jane Doe requested it.
Jane was also a long-time patient. She had no significant family history, but her breasts were moderately lumpy and she had some fibrocystic changes. I'd done a few interventions over the years: open or needle biopsies, mainly. One day, she'd had enough. I knew it was very hard for her; she was frequently beside herself when she came to see me, whether it was for a routine checkup, or because of a lump she'd found. Yet as these things go, hers were far from the most difficult-to-examine breasts among my patients. I'd never felt uncomfortable in my ability to follow her along; in fact, as with many of my patients, I frequently avoided open biopsy when a lump felt benign to me, and a needle sample and mammogram were also bland. But Jane was a wreck much of the time, and on one visit she said she just wanted to be rid of her breasts: she couldn't sleep, she cried a lot, she worried about her kids. Her risk was not significantly elevated, I reassured her, and told her I felt we were on solid ground in the followup plan we'd established. It made no difference: she'd simply hit the wall. Peace of mind is what she craved, and bilateral mastectomy was the only way, she implored, she'd ever have it. Absent specific risk, was that a good enough reason?
I told her I wasn't entirely comfortable. In the back of my mind, thoughts flickered about being party to some form of self-abuse, of Munchausen syndrome, who knows? Again, I'm no shrink; I didn't have a name for it. But it was a concern -- facilitating a really big deal for the wrong reasons. Delicately, I told her before considering such a thing, I'd like to refer her for counseling: to see if there were other ways to deal with her anxieties (and, unspoken, seeking an answer to whether her concerns were due to some sort of thought disorder, or whatever a shrink might call it.) She wasn't delighted, but agreed.
The upshot was that the psychologist found Jane to be a generally well-grounded person, and felt there was no specific reason not to do the surgery, felt it was, in fact, reasonable. I was sympathetic to my patient, and after more meetings between us, I agreed to do the surgery. For peace of mind.
Well, it wasn't so easy: cancer-phobia is a recognized entity and has, I believe, its own diagnostic code. Trouble is, it's not on anybody's list of indications for mastectomy. Jane, and I, and my nurse all spent considerable time on the phone with her insurer. I wrote letters to their medical director, assuring him, among other things, that this was not an operation I undertook lightly; I'd not done it before for this reason. But Jane Doe was a special case, whose life had become miserable. I reviewed with him the psych evaluation. No sale; they resolutely refused to pay for it.
We worked it out: reduced fee, payment plan, doing the operation (bilateral simple mastectomy) as an outpatient to minimize cost. She recovered rapidly; soared, really. Neither she nor I ever regretted it. Still, I doubt everyone would agree I did the right thing.