Sunday, May 23, 2010

Necessary Medical Tests

After Josh staggered across the finish line, he collapsed on the track. He was taken to the medical tent. He was pale, light headed, and very tired. He said he just wanted to sleep. The paramedics were called over to check him out and they recommended he go to the Emergency Room and get some fluids in him. There was no way he was going to make it to my car so he went in an ambulance and I drove to the hospital.

At the ER I found that the ambulance crew had started an IV and Josh was beginning to look and feel better. Blood was drawn for testing and they ran an electrocardiogram. Then the doc told me they'd also like to do a chest X-ray. Curious about that, I asked what he was looking for.

The doc asked if I had ever heard of athletes who suddenly drop dead. Yes, I had. He said there's a rare heart condition that affects about three or four athletes every year. I remarked that there are a lot of athletes to which he agreed. (Let me note that I was looking at the rationale and logic for ordering a test to rule out a very rare condition, but I apparently didn't come across that way. I need to work on explaining myself better.) Misinterpreting what I was getting at, he asked if this was going to be an extravagant personal expense. Not at all, my insurance was going to cover this ER visit and all tests the doctor felt were necessary.

"No," I said, "I wondering if this is a necessary test." Again, I'm not explaining myself well. The doc's demeanor iced over. He got defensive and said he was not trying to churn tests to generate revenue. I missed the clue to reassure the doctor that I did not think he was trying to rip me off.

Here's what I was thinking but not saying: If this is something that affects three or four out of millions of athletes, then we're talking about minuscule odds. Heck, even even if we're only talking about athletes in Eastern Washington, the odds are still extremely small.

I (poorly) explained again that I was questioning the need for the chest X-ray since the purpose of it was to rule out something that's extremely rare. To that he replied, "Well, maybe I overstated the rareness of it." And to that I left unsaid, "If you're not sure of what you're talking about, how can I be?" But I thought that.

The doc reassured me that if it was his child then he'd want the X-ray done. Dang! He nails me with the guilt trip. Because "What if..." and "just in case..." The scene of explaining to Kathy why Josh suddenly dropped dead when I could have had that X-ray done popped into my mind. Totally unfair. But the deal is, I wasn't stopping him from doing the X-ray. I was trying to get a clear and logical reason for doing it. After all, the evidence we had before us was that Josh was very dehydrated and had obviously overexerted himself. The fluids being pumped into him were obviously bringing him back to a normal state. His color returned and he was alert and pretty much back to his normal self.

But now the doctor had to have me say "uncle" by asking me to allow the X-ray. I did. After all, what if, right? Unsurprisingly, the X-ray showed nothing wrong.

Set aside reactions to my side of the story--I'm not looking for validation or anything--and ponder this instead. Do we evaluate and respond logically to the risk factors in our lives? With or without the X-ray and even with all the safety features built into vehicles today, Josh has a far greater chance of dying in a vehicle accident than of this rare heart condition. And yet I allow him to drive a vehicle as well as ride in other vehicles. Instead of three or four athletes, we're looking at over 40,000 people dying every year. Would it be just as prudent, if not more so, to keep Josh off the road as it is to have that X-ray done? Maybe, but hardly practical.

And there's the conundrum we're faced with. At the hospital we often want everything done regardless of the likelihood of success or failure. It's easy to see why when you consider the leading causes of death. All of them involve a disease or some type medical condition except for accidents. And when you think about it, that's normal.

But how do you know when you reach the point where you say stop? Whether it's a test or a procedure, regardless of the expense, do we look at the need or likely result and recognize the odds are so small that there's really no sense in having it done?

11 comments:

Anonymous said...

"Whether it's a test or a procedure, regardless of the expense, do we look at the need or likely result and recognize the odds are so small that there's really no sense in having it done?"

But what if you were wrong?

Would you logically rationalize it was worth the risk (to save a little money) if your child had signs of the problem, or worse, that rarely happens?

Sorry, but I think you are just plain wrong in this case.

That's the problem with people who think they are smarter than everyone else.

I hope you aren't on the government board deciding health care decisions best left between a doctor and his patient. You provide the best example of everything wrong with the looming health care fiasco being forced down our throats.

Jason Gilman said...

Glad to hear that Josh was just shy on fluids. The one thing that occurs to me is that for statistical purposes the pool of athletes that collapse on the track is hopefully much smaller than the overall total of competitors. It seems likely (and perhaps where the doctor was coming from) that the odds for a competitor that collapses during an event to have the condition (though still incredibly slim) are far greater than if you picked from the full pool of track athletes.

Hank said...

Very good point, Jason. And that leads me to question if any of the athletes who have collapsed and died suffered a warning collapse beforehand.

Rachel said...

And here is one of the reasons that healthcare costs have skyrocketed.

But of course, just as one of your other commenters pointed out, there's a .003% chance it might be something serious, so of course because we all have insurance and don't have to feel the expense of necessary tests, it's somehow negligent to forgo the things.

And, should a doctor thing this way, and not have a test run, hello lawsuit city.

The whole thing is such an awful monster.


Of course, the other thing people forget is that tests can have side effects, and an x-ray is definitely one of them. So the question is no longer about money but risk. Is it a higher risk that you'll have side effects from the test, or that you'll have this rare condition the test might reveal?
Oh, and how accurate is the test? And how many false positives are there? And what's the treatment for the condition?

And then the doctor pulled out the guilt trip card? It isn't just obstetrics anymore? The guilt tripping as a way to get you to undergo unnecessary tests and procedures is throughout medicine now, isn't it?
Actually, I already knew that, when I had a doctor tell me about how he wouldn't let his child go without vaccine X. (And then he told me that sharing a bed with my baby was going to give her SIDS, because she could suffocate from the blankets.)

Let's also not forget that apparently it was very important you make this decision right now. Like he was at any more risk by waiting for you to go home and do some research (or get a second opinion) and come back again before his next athletic event.

And how people get so defensive, like the commenter above, when people make choices for their own treatment. Like somehow you're dictating what choices they should make?

Rachel said...

*expense of unnecessary tests

Hank said...

Rachel,

I don't know that it's a purposeful guilt trip, although it's probably true for some. The doctor's explanation for requesting the X-ray reminded me of much of what I read in The Science of Fear. There's a good review of that here.

Anonymous said...

Rachel you prove the folly of a national board making our health care decisions for us.

I give credit for asking questions of a doctor as long as it is between the patient (and parents in this case) and the doctor. It should remain so.

However, under the new health care about to be thrust on us, health care decisions will no longer be between the doctor and the patient. You will have your health decisions made for you, you won't have a choice on your treatment. To me, that is extremely scary.

No level of logic will make a difference in the decision of the national health board. Their decision is final and you will have to live with their decision...even against your will.

The clear majority of Americans are against the new health care plan with more joining their ranks daily.

Rachel, there are a lot of things in life that have unintended consequences, not just in the medical world.

So, in hindsight and with humility, I applaud Hank he still has the ability to question treatment for his son/family/himself. But enjoy it now, because it won't last.

Elections have consequences and I believe you won't be happy with your new health care when you lose choice in treatment you believe you should have.

Hopefully, this health care fiasco never see's the light of day. (The majority of Americans agree with my hope...).

Lucas said...

Anonymous -

The kind of comparative effectiveness that is proposed in the recent healthcare law will lead to more stories like this:

http://www.time.com/time/health/article/0,8599,1871759,00.html

All they did was adopt a uniform standard for pre-surgical preparation and it reduced mortality by 50%. While each person is unique, we are all built on the same frame with similar parts. There are many, many cases in which having a treatment course whose effectiveness has been borne out by data would not only reduce the cost of treatment but also provide better results. It is true for fixing cars, and computers and for people as well. What's wrong with developing a commonly accepted starting point for treating medical issues?

Ultimately it will be up to the doctor to decide to use them, but there is no harm in really doing to work to find out what actually works, not just what the local pharma rep tells us will work.

Anonymous said...

Lucas.

Not talking about pharma reps, talking about the doctor patient relationship.

There is a lot wrong with the government controlling and determining our health care needs. Will it cut costs? Every day we are finding it will not. We will be paying more in premiums. Also, it is not a surprise the CBO came out and added another 150 billion plus to their estimates...and low and behold...the cost will be over a trillion dollars. Oh, don't think there isn't another 2 trillion when actual costs come out.

So, will you get better care when your physician will be "forced" to add hundreds/thousand of people to his patient list? Well, let's say the number of patients he see's every day doubles. That means he will see each patient for less time and for less money (government mandates) on each patient, so he breaks even...maybe. So, since he is forced to see double the patients will the patients be getting the best treatment possible? I highly doubt it because he can't spend enough time with a patient. I won't even get in to how long it will take to get that appointment.

Don't be fooled by this new health care mandate. It won't improve the care you get and it won't be less expensive. No government program has ever been less expensive than what they "promised" you.

Rachel said...

Doctors already barely spend any time with their patients. You show up, on time, for your 1:30 appointment (which they will cancel AND bill you for if you're more than 10 minutes late), so you can wait 15 minutes in the waiting room, then 10 in the exam room for the nurse, and then another 25 for the doctor. Then zie spends all of 10 minutes with you and gets annoyed AND tacks on another $75 if you weasle an additional 5 minutes out of zie.

The system is already broken. It's so broken I really don't know where we can even begin trying to fix it. Of couse, big pharma sure isn't helping one bit. Patent expired for your ointment? Throw in a cleansing pad to use before the ointment, patent the package, and then you can tack on $650 beyond the $50 generic and bill those insurance companies!

As for basing you treatment off of everyone else's... That has two sides. Evidence based medicine reduces unnucessary tests and procedures and gets people treatment that actually works. It gets rid of those scare tactics. American obstretrics crumbles when you throw a little evidence based medicine at it. Get rid of all the unnecessary inductions an ceserean sections, and you save BILLIONS.
But, doctors do always need to listen to their patients and consider each case individually (something they do NOT currently do, if you ask me).

Sorry for any typos, iPhone-typed comment.

Anonymous said...

Rachel.

The system is not as good as it can be. Agreed.

I guess I am wondering how you will get better care if your doctor has double the patient work load every day than he/she does now? It seems to me, if you don't like the time you get now, you will really hate it later (it might even take you six months for that appointment).

I know risk sounding selfish and self-centered (I am sure someone will pick up on that comment...lol). But I have good health insurance which I have worked very hard for in order to provide for me and my family. I am very concerned it will be taken away when government health care (remember the president and congress said this is just a starting point...) comes into full force. No choice, I get to be in the same category as everyone else, even those who won't do anything for themselves....That isn't right either.

I also guess my point is that the government should not mandate what tests and care we get and what tests and care we don't. I am willing to pay extra for it if I think it is the right thing to do for my me and my family. But to have that choice taken from me is a very scary thing. Sorry, just the way I feel.

If you want to forgo a test your doctor thinks you should have, then you should be the one who makes that decision, not the government. You have that choice now, but you won't later.

Anyway, thanks for the discussion. I appreciate it. :)