The epidemic of low-value care – ctd.

Austin’s post made me think about my own story. I don’t think I’ve ever told it on the blog before, so here goes.

During my third year of medical school, I woke up one day with terrible abdominal pain. I have a reasonably high tolerance, so you’ll have to trust me it was pretty bad. I started walking to work, but couldn’t make it. Instead I went to student health.

They were pretty frightened, and wanted to admit me to the hospital. The pain was bad enough that I agreed.

There were three surgery services at the University hospital, and there was an unwritten rule that one of them was for more indigent patients. This was the one on which I was placed. No one came to see me for a long while, and when someone did, I was actually starting to improve. By the next morning, when an attending surgeon laid eyes on me, I was nearly better. Obviously I was not a surgical emergency any longer, and I was stable for discharge.

The surgeon was very upset. I imagine he knew my father, who had also been a surgeon in the city for most of his life. I think he feared that I was angry no one had really talked to me until morning, or that I would get my father involved. Neither was true. But he was determined that we would get to the bottom of my abdominal pain, even as it was disappearing. I stressed that I was completely healthy before this incident, and I was already starting to feel better. But he “wanted to be sure.” They ran a number of minor laboratory tests, and did a thorough examination. For the most part, everything was normal. But two things were slightly off. I had a minor heart murmur and a small amount of blood in my urine.

The surgeon convinced me that I needed to see some specialists. The abdominal pain needed a gastroenterologist. The murmur needed a cardiologist. The hematuria needed a urologist.

And so my adventure began.

By the time I saw the specialists, I was completely back to normal. No pain, no issues, just good health.

The GI doc thought my physical exam was normal, but he wanted “to be sure.” He ordered an upper GI and an abdominal CT. The upper GI involved drinking a ridiculous amount of what tasted like liquid chalk followed by a number of scans. It was thoroughly unpleasant. The CT, on the other hand, was quicker and less intrusive. But both were expensive. They found nothing.

The cardiologist confirmed that I had a murmur on physical exam. He ordered an echo with contrast. If you’ve never had contrast before, it was like I had been injected with liquid fire. It was terribly uncomfortable. They confirmed I had a murmur about which they would do nothing. He recommended I take prophylactic antibiotics before a dental exam. Since I’m allergic to penicillin, he recommended azithromycin, which gives me horrific abdominal pain.* So going to the dentist had an extra wonderful bonus now. Otherwise, they found nothing.

Oh, and that recommendation for antibiotics has now been debunked and rescinded, so I took all those painful antibiotics for nothing, as well.

Urology won the prize, though. First we got an ultrasound. That showed nothing. Then, they recommended an intravenous pyelogram. That meant more contrast and some x-rays of my kidneys. That showed nothing, too. That left cystoscopy.

For the uninitiated, cystoscopy involves sticking a camera up your penis to take a look at your bladder. Take a minute to reread that last sentence; it’s not a joke. Usually, they give you some conscious sedation for the procedure, since no one – and I mean no one – wants to remember it. There was one problem. I was actually on a urology rotation as a medical student at the time.

The thought of my colleagues, and all the nurses, and everyone else watching them put a camera up my penis while I was out was too much to bear. I was too embarassed. The urologist said he’d do it in the office, but I had to forego the anesthesia. That’s how I found myself popping a valium a half hour before coming into the office for the procedure. Next, he shoved lidocaine gel up my penis so the camera wouldn’t be too painful to bear. You’ll have to trust me that the gel didn’t feel so good either. The penis really is meant to be a one-way street.

But once I was numb, up the camera went. I remember every second. I even remember when the urologist offered me the eyepiece of the flexible camera so I could look directly up into my own bladder. Good times.

What did they find? Nothing.

When I recounted all of this much later to my mother, she said, “Oh yeah. You had that hematuria as a kid. The pediatrician worked it up a long time ago and said it was nothing. You didn’t know?” Evidently I also had this benign heart murmur my whole life that no one had ever discussed with me either. I imagine that a good EMR might have spared me some of this, but I’m still not so sure. I’ve seen many, many tests repeated even when patients insisted they had already been done. Doctors just “want to be sure.”

I can’t remember the cost of the workup, but it was astronomical. I can remember the pain and frustration. At every step, there was a doctor I trusted telling me that they thought I needed further tests.

This is me talking here. I’m as skeptical as they come about spending money in health care. I always err on the side of minimalism. But even I got caught up in this diagnostic odyssey. It’s unbelievably hard not to follow a doctor’s orders. I fear these adventures are more common than many believe.


*Yes, I’m aware of the irony here that I wound up getting more of what started all of this in the first place.

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