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.

I am.

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.

An Opinion Opinion

My para-previous post mentioned getting second opinions. I think it's a concept worthy of separate rumination; and because I'm not entirely coherent on the subject, I'll be interested to read what I have to say.

So it doesn't get lost in the morass, let me be totally clear: whenever a patient wants a second opinion, for whatever reason, s/he ought to get it, and I'd never ever discourage or disparage it. Being comfortable with whatever medical intervention is at hand is essential, and if the first doctor resists it or gets huffy, well, that's probably confirmation of the need. But it has always bugged me when the reason is a requirement by some insurer or another, or when it's because someone (an agenda-driven talking head; a relative; a BFF) has made the patient feel guilty or inadequate if they don't demand it. It's possible -- and I always made a hell of an effort -- to establish a relationship of trust based on being fully informed, respectfully addressed, and carefully listened to without the need to run off.

At some level, when a patient requested a second opinion I felt like a failure. Drawing diagrams, writing booklets, soliciting questions, I succeeded nearly always. Many is the time my patients told me they'd never had a doctor explain so thoroughly and understandably. So to me -- ever self-critical -- a request for a second opinion said, somewhere in my lizard brain, that I'd not done something well enough. I recognize that many people simply see it as due diligence: taking control of one's health includes exhausting every avenue to information. But in that evanescent and impossible best-of-all-worlds, that fantasyland, I like to think doctors could be good enough, and patients open enough, to justify the idea that one opinion can suffice.

Patients have the right to feel right. They are entitled to full disclosure, to thorough explanations, and to complete answers to all their questions. And people have senses. If they feel uncertain or dissatisfied; if there are warning bells ringing in their heads; if for whatever reason they are left uncomfortable with a physician encounter, they should absolutely positively get another opinion and/or another doctor. But what's wrong with feeling OK in the first instance? If what you hear makes sense, if you think the doctor in front of you is being honest and thorough, must you be made to feel like an idiot for standing pat? Some people show up broadcasting distrust from before the first hello; or bring someone who glares dares from the co-pilot seat. It ices the wings of the encounter before it ever gets off the ground. That attitude comes from giving too much credence to crap. Don't cheat yourself, says I. Don't close the barn door before the horses are in. Or something.

Of course, it's not always simple, and doctors are imperfect. I'll examplify.

There was a time when, because of insurance demands, I saw lots of people in need of second opinions before hernia repair; and had to send them for same, as well. (After looking at a few years of predictable data, most companies have dropped most such requirements.) Usually it's a no-brainer: you can see the hernia as the pants are coming down. But I've had a couple of people in whom, for the life of me, I couldn't confirm the hernia for which they were scheduled to be operated. It's uncomfortable. Often, because the mandated need for a second opinion was realized at the last minute, I'd be seeing the person within a day or so of the operation. In part, it (the non-finding) happens because you can't always feel a hernia, even when it's there. They don't always pop out on command, with office maneuvers. I'd explain that to the patient, and tell them the fact that I can't feel it doesn't mean it's not there.... Unpleasant, mutually. When the patient had symptoms, and described what surely must have been a hernia, I always explained that it was a probably a safe assumption. But sometimes it was a person in whom the "hernia" had been found on a physical exam, and there'd been no signs or symptoms at all. When such a person was sent to me directly from the primary doc, I'd generally recommend against surgery until things were more clear, trying also to avoid any implication that their doc was wrong. But what to do when it's a second opinion referral from a surgeon who had them on the dotted line?

With breast cancer, some aspects of treatment are extremely complex, and changing nearly daily. Along with the good information available, there's lots of bad, sometimes leading to distrust as the default position going in, which makes the job of explaining even harder than it already is. I still get upset when I think of my patient who went for a second opinion and died a couple of years later, very possibly as a result. She had a very large cancer in her breast, and for several important reasons I told her she ought to have mastectomy despite her hope for breast preservation. She accepted what I said and why I said it, but saw another surgeon anyway. A young guy fresh out of training, sure he knew way more than the old guy, he told her she could safely have lumpectomy and radiation. He convinced her, signed her up, and went ahead. As I was sure would happen, he ended up cutting through tumor at all edges of his large lumpectomy, operated again unsuccessfully, and not very much later, operated once more to do a mastectomy. I can't say with certainty she would have been saved if she'd had it at the outset, but cutting through tumor that extensively may well cause direct seeding into the bloodstream, if it hadn't already happened; and three major operations on incompletely treated tumor seems less propitious than having only one.

So there you have it. Second opinions aren't necessary except when they are, and they're good for you except when they aren't. Have a nice day.

I'm Aware

Since it's Breast Cancer Awareness Month, I should point out that I've done a series here about breast cancer and related issues (one, two, three, four, five; and this about breast lumps.) My "memorable patient" series included this lady with advanced breast cancer; and there was a post about Elizabeth Edwards and her recurrence. I've admitted some outdated views on immediate reconstruction, and lamented my near miss with national notice regarding outpatient mastectomy. None of it does justice, perhaps, to the fact that over my career, by far the greatest number of patients I saw was women with breast problems. In fact, I'd have to say that one factor in my eventual burnout was the increasing number of young women with breast cancer that I was seeing; those office encounters are much worse for the woman and her family, of course. But they took a heavy toll on me as well, time and again, nearly daily.

It was the appearance on NBC news, a couple of nights ago, of a person who has annoyed the hell out of me in the past that reminded me of my recent silence on the subject (which is only because I think I've said most of what I have to say.) This love-ly person is mentioned in one of the above-linked posts. She'd gotten early fame by appearing on various shows claiming that the only reason mastectomy was invented is because men like to mutilate women. Sigh. It's hardly worth responding to something like that. Upping the ante, she also liked to say that if your doctor tells you you need a mastectomy, find another doctor, because no woman ever needs one. Complete and utter bullshit, then and even now. I'd like to believe she wasn't dumb enough actually to have believed it, but was just trying disingenuously to get attention. I do give her credit for having written a quite good "breast book," and I've seen her, more recently, being generally reasonable. But last night she did it again: questioned by Brian Williams about the most important thing a woman can do regarding breast cancer, her answer was always to get a second opinion before embarking on treatment.

I have no problem with the idea of second opinions: when there's any reason at all for uncertainty, I encourage them. ("Always" is a little dogmatic, though.) But what got me was her reasoning. As complicated as the field has become, she said, it's impossible for any one doctor to "keep up." So see two? Like if no one person knows enough to be trusted, getting another will magically fill in the holes? Two wrongs make a... what? I question the math. Anyhow, it's not really a big deal. Getting a second opinion is perfectly sensible, no matter the issue at hand. It's just that, after those years of listening to the woman's crazy rants back then, I have a hard time giving her much credence now. Even when she's right.