Wednesday, June 8, 2016

Conundrum

I never know what to do with these.

MRI's and MRA's and all our toys are good. They can see stuff we never could, even 5-10 years ago. So, as they get better, they find more.

But that's not always good

I have a lady in her mid-70's. A few years ago her internist did a brain scan on her and found a small aneurysm.  It wasn't related to her symptoms, but since he didn't know what to do with it, he sent her to me.

I reassured her that it wasn't anything. But, since some small aneurysms will grow into large ones, I'm stuck following it. Otherwise, if she drops dead of a ruptured aneurysm at some point, her family can sue me because I didn't look to see if it was getting bigger. CYA. This is defensive medicine at its finest, and, once you've been sued, you'll practice it, too.

Of course, she could refuse the test, but most people don't. As long as it's covered by their insurance, why the hell not?

So every few years I order a repeat study, though at this point it's starting to get silly. I mean, even if it were growing, surgery at this point would pose a bigger danger to her than the aneurysm. But she wants the test, her daughters want the test, and my personal feelings take a back seat to covering myself.

The repeat study this year was, of course, unchanged. Fine. I sent her a letter saying we'd repeat it in 3 years.

I got a call a few days later... from the hospital, asking me to come see her.

Leaving the MRI place she'd fallen while getting in her car, breaking her hip. Which needed surgery. So now she's in the hospital, post-op, and completely whacked out from unfamiliar surroundings and pain meds. So they needed a neurologist to come see her.

Am I medically or legally, at fault for this? Not really. But I still feel guilty about it. I mean, she could also have fallen at the grocery store or walking to her bathroom, with the same outcome. But, instead, she fell while having a test that I wasn't even sure was needed, but was somewhat obligated to order. Yes, she and her daughters insisted on having the scan, so it's their decision, too.

But I still feel bad. Because of guidelines and defensive medicine a nice older lady had a scan she didn't necessarily need, and in an odd way suffered a complication of it.

Will this change how I practice? Probably not. The culture of defensive medicine is so ingrained into American physicians that it's hard to do otherwise. But stories like this make me wonder what the real cost of it can be.

27 comments:

Anonymous said...

I believe there is a saying: the surgery was a success, but the patient died.

Harry T said...

And what about the place of MRI scans for non specific low back pain which will almost certainly show age related degenerative changes leading to medicalisation of normal aging at best and unnecessary interventions at worst?

Mary said...

I went through weighing the benefits vs costs of test when my mom was elderly. We often opted not to do a test....then again she was not very mobile and that raised the "cost". I appreciate docs who openly discuss the options as I am sure Grumpy does.

Anonymous said...

I feel you. I think the answer is to educate the general population about the nature of medicine as much as possible, that it's about playing the odds in your patient's favor as much as you can, but there's no guarantees. Sometimes you get a shitty roll and your patient has a bad outcome. That's what happened here, a shit roll of the dice. Even in hindsight, you made the right call, odds were not doing the scan was more likely to cause a bad outcome (for all parties concerned), and doing the scan was not going to cause any harm. Just the patient's peace of mind is enough reason in my opinion to do the scan. I think for me personally, if I make it to 80 I'm going to call it good and only accept palliative care. I don't think doing everything that's medically possible is always in the patient's best interest, and goes against the ideal of "first do no harm", but I don't think American culture is ready to accept that notion.

Steph B said...

What a difficult situation to be in. And truly it wasn't your fault that she fell - she could have fallen anywhere.

Packer said...

Mid 70s ---no more test.
80% of medical expense is incurred for last illnesses.
Stop wasting the money. We need to use it elsewhere.
Death Panels.

And lastly stop asking what to we think. Cause we are going to tell you that you are overthinking the thing. Bottom line. Shit Happens, or in the alternative Life is a bitch and then you die.



Anonymous said...

We carefully weigh the risk to the benefit, then wind up doing what the patient and insurance companies want.
The same thing happens all the time with carotid screenings that the community does. What do you do with an asymptomatic 50 % stenosis that probably should not have been looked at in the first place, but now you have an anxious patient with the Dreaded Daughter from Dallas

Bonnie said...

I think this is always a hard thing to call. My mother should have been tested often. She wasn't because the doctor said not to worry - this kind of cancer doesn't grow fast. Which was true for years until it suddenly took off & invaded everywhere. She died too young of that cancer.

On the other hand, my husband, now 81, has refused most tests & treatments. His doctor agrees that they aren't needed. And so do I.

awesomesauciness said...

Let me tell you a story of a woman, late-70's, presents with extreme chest-to-back pain, nausea, etc. and all indications are she's having a heart attack. Except, the EKG and blood tests say otherwise and, nothing's found but she's admitted until they can figure out what the hell's going on.

Fast-forward 18 hours, and she's found unresponsive on the floor of her room.

Not only that, but somehow during the admit process no one asked what to do if she codes. So, hero doc spends a SOLID HOUR resuscitating her before proudly proclaiming he has a weak femoral. A FUCKING HOUR...on a late-70's woman...who happened to be my mother. At no time, during this hour or during the NEXT TWELVE when she was placed on the unit did anyone call any of us in the family to relay the events and ask what to do. We found out, purely by accident, when my sister arrived to an empty bed the next morning and started asking questions.

So, defensive medicine reared its ugly in April of this year, and all because no one could find her living will or DNR.

Mom died on that floor, but her body took another 36 hours to catch up.

And it was an aortic dissection, something they weren't even looking for.

Do I blame the doctors or hospital staff for her death? Nope, not one bit. Mom's aorta was likely damaged in a car accident she'd been in 10 days prior to her admittance...but she didn't tell anyone when they took her in that her chest had been "bothering" her since hitting a light pole at low speed. I'd been trying, unsuccessfully as you see, to get her to go get checked out.

Do I think it was beyond stupid to spend an hour trying to save an elderly woman? You bet your ass I do, and have told the hospital administrators as much. The bills for her stay magically disappeared, and everyone involved apologized profusely. I don't care. Maybe later I will, but not right now.

Bonnie said...

Thanks, awesomesauciness, for the reminder to get that stuff in writing. I had always assumed the kids would be near, but now they aren't.

I've joked about getting DNR tattooed on my chest, now I'm thinking it really might be a good thing.

Ivan Ilyich said...

I had three MRIs (full spinal) to rule out alternative causes and I was glad to have them. I don't know why people object to defensive medicine.

Anonymous said...

I wish you would stop beating yourself up about this, but you won't. Why? Because you're a doctor, that's why. I don't think mine has caught on yet that I quit having Mamos. And I refuse to have colonoscopy. I'm 58 years old, and watched both my father and my beloved mother in law go through chemo. Neither enjoyed what time they had because they were so I'll. Catch it early? Forget it, I've already had enough other surgeries with no help after.

Anonymous said...

I always thought 'they' were researching me, when they asked for follow-up MRIs after the brain surgery. Problem was this was long time ago and far away from the nearest MRI machine and it wasn't practical. My folks just would call the hospital and tell them I was still alive and they followed me all the way through community college, pharmacy school, graduate school, and I'm still alive. Finally they stopped asking, but there's a MRI five minutes away that I could get signed up to take if 'they' still wanted to research me.

Jennette Fulda said...

@Ivan Ilyich - "I don't know why people object to defensive medicine."

If people are getting tests they don't need, it raises the price of health insurance premiums for everyone. This can make health care harder to access for low-income families.

And as Dr. Grumpy said, people can suffer complications from unnecessary procedures that pose a real threat to their lives.

Those seem like two perfectly good reasons. There are reasons to be for defensive medicine as well, as the feeling of reassurance you got from your own MRIs shows. And numerous lives have been saved by people getting tests that might not technically have been necessary. But it's definitely a complicated issue and there doesn't seem to be one clear right or wrong answer.

Ivan Ilyich said...

Jennette Fulda, cost of medical tests is a separate issue, I think. I was fortunate to have excellent insurance so the cost as not an issue. I also had a lot of blood tests which were negative. Was that a waste? I don't think so. A negative test yields information and knowledge is a good thing.

Me said...

I can't imagine anyone blaming you for this woman's fall, Dr. Grumpy. Is it possible the recent death in your family is causing you to be particularly sensitive right now?

Anonymous said...

It used to be that practice of medicine incorporated both an art and a science. The art came in with the experience the physician brought to the practice, a gut feel, a second instinct which took into account personal factors of the patients when dealing with the same one over the years. The 'science' is the basis for understanding the physiological needs of the patient standing right in front of the practitioner. Insurance companies and malpractice suits defuse the good doctor's innate knowledge sometimes in order to fulfill a check box on a paper, turning the process sometimes into a rote in and out process.

When someone talks about 'excellent' health insurance, it usually is in reference to a parson's personal ability to pay for extra, sometimes redundant services. Before there caps to provide consistent, approved, and indicated therapies, the company could get away with charging employers an arm and a leg, so the company ate the cost and the economy when boom! Employees didn't mind that the cost of their premiums went sky-high when companies' bottom lines were turning red, because they had EXCELLENT INSURANCE.

The insurance company company profited off increased number of possibly unnecessary tests, because they could pay the minimum for 'volume' tests and make the company providing the MRI sell their product and service at the minimum charge.

This was especially nice for the insurance company because they could price employees insurance based on such factors as employees being denied insurance in the past for pre-existing conditions.

MRIs have a very high mark-up when considering less expensive methods for issues that may or may not indicate use of the MRI. In this case, the good doctor might feel that the test is not really necessary, but has to practice defensive medicine, otherwise his cost of liability and malpractice insurance increases drastically and sometimes requires time spent in court when patients are waiting.

Mrs J said...

The fact that this bothers you tells me that you are a terrific doctor, wish there were more like you!

Lizard said...

my 88-year old dad said that his doc told him that actually a lot of times the hip breaks and then the patient falls, not the other way around.

I wish it didn't bother you, but of course it does. You are a good, caring, thinking physician.

Moose said...

First, Dr G, in my unmedical and unhumble opinion, you did nothing wrong. I understand your guilt, but I think it's misplaced. Caring is good, but beating yourself up over things out of your control isn't so good.

To the awesomesauciness one: My great-aunt was one of those always-on-the-go types. One day she didn't feel well so she went to the doctor. The doctor thought she was having heart problems and immediately sent her to the hospital, who popped her elderly self into a bed. They did tests. She'd had a mild heart attack. Her heartbeat was slightly irregular, but at that point not worrisome, especially at her age. The doctors laid out plans for her. They discussed how they'd monitor her carefully, having her come in every week for the next few months. They talked about the possibility of a pacemaker if the arrhythmia (if I speled that write) got worse. After a few nights of monitoring, she could go home the next day, after one final check.

She died in her sleep, peacefully, that last night in the hospital. She was gone for maybe a half hour before anyone noticed. My family was sad she was gone, but glad it had been peaceful, and nobody said one word of lawsuit or or malpractice. (And this from a family full of lawyers and doctors!)

The best part of the tale was when they were doing the intake interview. They asked her for her age. My great-aunt looked at the nurse out of the corner of her eye and said, "Ninety... three?" We found out after she was gone and folks went through her paperwork that she was really 96.

She was frikkin' awesome.

Glen said...

The real problem is that there is currently no effective treatment for small intracranial aneurysms. They do run in families, and a single MRI can end up with 7 or 8 family members (parents, siblings, children) needing the same sort of follow up.

That is good science, but really does nothing for the patient or the physician. Until there is an effective and low risk treatment, I doubt the benefit of routine follow up.

clairesmum said...

Gravity happens. Not your fault. You're a good doc, very good.

Ms. Donna said...

As someone who had a stroke and is still dealing with the aftershocks, yes, I wish something like that had been found beforehand (I can't recall what type of stoke, so it may not matter) and was watched.

I do understand. As a good human being, not just a "good doc," you feel conflicted because good care led to an accident. No, it was not your fault. I think you need to "hear" that.

I recall something my 7th grade teacher, Sr. Fluerette, would always say, "The road to Hell is paved with good intentions."

NOT that this is Hell (well maybe a doctor's version of Purgatory.)

Take care.



migraineur said...

Bonnie-

Sadly a tattoo won't work...I've asked EMT's and they'll ignore it. I have been tempted to have a med alert bracelet tattoo, and state my allergies and wishes for end of life care somewhere accessible, but I don't know if that will work either.

Anonymous said...

Won't help in all cases but my parents had all their medical info, living wills and POA in Manila envelope with "MEDICAL INFO" in big red letters taped on back of front door. When they needed ambulance one night for Mom the EMT just had to grab it!

Sandeep said...

An exciting and highly informative read on this topic is "Snowball in a blizzard" from Dr. Steven Hatch.

C said...

I had a test this year- did not think I needed it...specialist thought it was stupid...actually not necessary. Cost $10K, but covered by insurance. In the future, I may not be compliant, and may just refuse.
Would you have felt better if the lady, said "Nah, I don't want to do it?"

 
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