• 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.

    • Patients are an excuse to do things.

    • In my limited experience with specialty services, urology does indeed take the cake. After a couple of episodes of kidney stones, I got into a series of visits to a urologist that made me feel ever more like an ATM for the medical group. Even when I was completely asymptomatic, he kept wanting me to schedule visits and precautionary tests, including the dreaded cystoscopy, every bit as unpleasant as described.

      I was finally influenced more by the absence of symptoms than by the MD’s “caution” to cancel an appointment and refuse to re-schedule. But what really got to me was the bland assurance of the MD and staff that, once ensnared, I was theirs for life, since I had insurance that would keep on paying.

    • “It’s unbelievably hard not to follow a doctor’s orders.” Except when it comes to compliance with prescribed medications…

      • There’s a huge difference between a one-time test or procedure and ongoing, repeated things like medications.

    • Thank you for this story. It does make me despair about ever separating quantity from quality in improving healthcare outcomes. The idea that more is not always better but is frequently worse is not a concept easy to relay to the general public.

    • Seems to me to be an example of increased health care costs driven by fear on the providers part. Malpractice fears.

      • There was no fear of lawsuits. Perhaps a fear of professional embarassment (on the surgeon’s part), but there was no worry at all that I was going to sue anyone. I was totally healthy and kept saying that.

    • Aaron, thanks for telling this story. It’s a perfect illustration of the unnecessary creep of “Don’t just stand there – do something!”

      It’s all we’re taught in medical school (I’m currently a 3rd year medical student…). If I wrap up my presentation with “Assessment – no focal findings, perhaps a low chance of (insert two or three possible diagnoses here) but this seems unlikely. Plan – Tell the patient we didn’t find anything and he can go home and if things get worse to call us back” the resident/attending will look at me like I am a fool. It sucks.

      One of the things the Dartmouth Atlas taught me is how much we grow accustomed to the culture around us. Everyone else is ordering these tests, so if I’m not – by God I must be negligent. We all pretend like being motivated by fear of the worst is going to produce the best outcomes. It just isn’t so. Yes, we’re all afraid we’re going to die. Yes, no one wants to miss the unlikely treatable cancer in its early stage. But we can’t pretend like these massive workups are cost free. They suck to go through, they cost a ton and the anxiety introduced is not nothing.

      I haven’t really added anything, just wanted to say this is a great story and although I’m sorry you had to go through it I bet you’re a better doctor because of it.

    • Interesting aside.

      On my current rotation (in Hong Kong – I’m so lucky) I spent about 15 minutes taking a history of a patient and when I started making my differential I realized “Oh shit, this patient could have active TB”.

      I spent about an hour thinking about how stupid I was for not considering this earlier. For not wearing a P95 mask. For traveling to SE Asia without a BCG vaccine. For thinking I could just go out into the world and not expect something bad to happen.

      I wasn’t able to accomplish a meaningful thing in clinic all afternoon. I was paralyzed.

      Some spark in the back of my brain told me to pick up my smart phone and google “Bene Gesserit litany” and read the words:

      I must not fear.
      Fear is the mind-killer.
      Fear is the little-death that brings total obliteration.
      I will face my fear.
      I will permit it to pass over me and through me.
      And when it has gone past I will turn the inner eye to see its path.
      Where the fear has gone there will be nothing.
      Only I will remain.

      Then I started doing some Bayesian math. Thinking about incidence rates, the rates of transmission, the incredible success of rifampin and isionazid in CURING this disease that kills millions even if I did contract it. I got out of a trap of illogical, self destructive thinking that consumes so much of our experience in medicine.

      2 days later the patient was sent home with an atypical pneumonia having ruled out TB.

    • Good nothing happened. On the other hand, if any of those tests had turned out positive, would anyone be surprised? Probably not. The symptoms described by the author are not inconsistent with renal stone, for example.
      The “just-to-sure tests” may be low-valued, but definitely they are no worthless.

    • This post is an instant classic.

    • Fear in any form is a strong inducer of action.

    • I always harken back to Uwe’s apt description of your encounter:

      “Biological structures yielding cash flows”

      Yup. Hate to say it, but your nether region was ATM card slot 🙂


    • I wonder if a good EMR, coupled with a habit of using electronic records, would have helped.

      I have lived in Scotland, where EMRs are in use and can be accessed across the country (and presumably across the entire NHS system). In every interaction with a doctor or nurse practitioner who is not my GP, they immediately call up my record and look closely at it. They often ask me questions about points relevant to the diagnosis. They always appear to base their recommendations for further treatment on the history before them.

      Having and using EMRs really does improve medical care. I find it frustrating that Americans mock the British system, without realizing that in many ways it vastly more efficient.