Friday, February 22, 2008
Ripoffs or Reticence?
Couple of months ago I read an article about a guy who did a three or four simple un-fixes to his Subaru, took it to a bunch of repair places, and reported the results. Bottom line: only about twenty percent found the problems and provided the appropriate and easy repairs. The others suggested all manner of unneeded and very expensive work, and missed some things. Not a surprise.
The article analogized to medical care: experts who have a stake in providing the care and charging for it may not always be trusted to give the best advice. It's not an entirely specious proposition. I was reminded of it recently.
I get ongoing comments on posts from long ago; most particularly the gallbladder series. "I'm so glad to have found your blog," they say, and then proceed to tell me their saga of problematic diagnoses and/or recommendations, and they ask my advice. At some level it's flattering, until I realize they're probably pretty desperate to trust some guy on the other side of their computer whom they don't know from a bag of groceries.
Anyhow, I try to help when I can, within the parameters of my disclaimer over there on the right. Recently there was a description of a symptom complex that was quite typical of gallbladder pain, with confirmatory ultrasound which even showed some thickening of the organ's walls -- pretty much diagnostic of active problems. Her gastroenterologist had her scheduled to have upper endoscopy to "rule out ulcer," and then she'd be sent to a surgeon. Her question was less about the need for the scoping than about how to approach the upcoming surgical consult. (The preceding link is worth checking out, by the way, because the doc appears to be using an invisible scope and looking at a lampshade.)
So here's where it gets complicated. Unlike a Subaru, the human body doesn't have a shop manual. Doctors sort through incomplete, conflicting, and inadequate data (because all of our tests are fallible) in order to come up with a diagnosis and recommendations. On the one hand, I can't judge from afar the need, in this case, for endoscopy; on the other, from the little info I had, it seemed a waste of time and money, with at least a small amount of risk.
I didn't say anything.
In my series on the appendix, I told the story of a call I got from a family doc, asking me to see a young man he suspected of having appendicitis. A twenty year old with a day and a half of abdominal pain, starting near his belly-button, moving to his right lower quadrant, he now had point tenderness, associated with loss of appetite, nausea, fever, and an elevated white blood count. Which did I want ordered, I was asked: ultrasound, or CT scan? If ever there was an appendicitisoid duck ("if it walks like a duck, quacks like a duck, has feathers and feet like a duck, it's a duck"), this was it. But here's the point: in this case, the doc had no financial stake at all in the imaging studies he'd have ordered. (I operated with no further tests, removed a hot appendix, and the guy lived happily ever after.) So yeah, it's complicated: it's not just about self-interest, at least in the purely financial sense.
I've been referred many patients over the years, all teed up by their docs and expecting an operation. For a variety of reasons, it wasn't an intergalactic rarity for me to tell them it wasn't needed or advisable. I can say with near certainty that I never did an operation where I let monetary considerations tip the scale. But I'm sure nearly all docs would say the same thing about any procedure, even the ones that did. Is it conceivable that an ulcer could cause severe colicky right, upper abdominal pain, intermittent, radiating to the shoulder blade, and not be related to the proven gallstones and gallbladder wall-thickening? I guess it is, although she might also have been struck by lightning on her way to the test.
If the patient were seeing his/her family doc instead of a gastroenterologist, would s/he have been referred first for endoscopy before an appointment to a surgeon? I'm guessing not. If the patient were seeing a surgeon who did endoscopy, would that procedure more likely be done, pre-operatively, than if it was a surgeon who referred such patients to a gastroenterologist? And if not, would there be any back-scratching involved? I'll defend my profession vigorously, and I'll argue as hard as possible that caring for humans will never be subject to binary decision making. But in this I can't claim we, as a group, are pure as a virgin's smile.
Were it possible, liability-wise, and avoiding-being-burned-at-the-stake-wise, it'd be interesting to consider an on-line business wherein one provided prospective (as opposed to working for lawyers) second opinions or general guidance through a problem. Obvious preclusive limitations and dangers and presumptions aside, I bet it'd be eye-opening.