phynedyning

Paging, Inspector…err…Doctor Gadget

In Editorial on October 3, 2012 at 11:58 am

 

Where’s the doctor?

 

“The art of medicine consists of amusing the patient while nature cures the disease.” Voltaire

 

 

My morning meal is constant: exactly one cup of long-grain rice, a teaspoonful of Vietnamese chili paste, and a dash of ‘lite’ soy sauce, washed down with a tiny cup of Bosnian espresso. I had just stirred my morning feast when the telephone rang.

It was my sister-in-law. Her voice had a faint catch in it; that little quiver that often heralds the coming of tears. I assumed she was calling to talk through the flotsam that her life became after the recent suicide of her husband of nearly thirty-five years.

“It’s Mom…and I don’t know what to do and I was wondering if you can help…I don’t understand what’s going on…and she’s starting to get scared.” She sniffled as she waited for me to reply.

My mother-in-law is a saintly woman in her late eighties. Growing up in any era upon the buckle of the poverty belt in America’s Ohio River valley is never a bowl of cherries. Doing so during the Great Depression would have been an epic task. Consequently, and despite her mild exterior, she’s a tough old bird who seldom needs doctors.

“What’s wrong?”

“She’s had a few dizzy spells and she told her doctor that her heart “skips” once in a while. She sent her to a cardiologist who told her she has ‘atrial fibrillation’. He put her on warfarin (a blood thinner). Her feet and legs started swelling and she says she’s tired all of the time. Then, she went back for her blood test and they increased the blood thinner dose and told her she might have kidney failure. Now she feels even worse and she can’t even get shoes on her feet. She says she’s not hungry or thirsty and the doctor said she may put her in the hospital. Even though she has Medicare, she’s paying the twenty percent she owes the doctors and her doctor bills are starting to worry her. I was wondering if you could look at her labs and stuff. Something’s not right.”

I eagerly agreed. It would give me a chance to use a medical education I put on the back burner when the American healthcare delivery system stopped delivering health care and became the “Great American Money Suck” for physician groups, medical corporations, and insurance companies.

My sister-in-law provided me with a list of medications and dosages. That was simple. There were only two and the warfarin was her only new medication. She had been on a thiazide diuretic for mild hypertension and, until her new symptoms developed, had been doing very well. The symptoms that had resulted in the spasmodic flurry of physician activity had arisen in mid-December. My brother-in-law had killed himself about a week after Thanksgiving.

It was now April and my mother-in-law’s health appeared to be in a downward spiral. I asked my sister-in-law to fax me her recent lab work, ECGs, and her physician’s notes since the preceding October.

The records arrived a few hours later. I was both stunned and unsurprised by their content.

Despite the severe emotional trauma caused by the suicide of her son-in-law, her doctor had not even recorded the event in her notes. She had listened to my mother-in-law’s heart and noted, “slightly irregular rhythm”. There was no notation of heart rate or the nature of the “irregular” rhythm. Her physician immediately jumped to request an “immediate cardiology consult, CXR (chest x-ray), and comprehensive metabolic panel (blood work)”.

Two weeks (and $8000) later, the results were in: “Paroxysmal supraventricular tachycardia and early renal failure”. The patient was put on a starting program of warfarin with follow up INRs (a test for blood coagulation) every two weeks and her diuretic dose was almost doubled. She was to follow up with her family doctor every week for more blood work, adjustment of the warfarin dose, and to monitor her “failing” kidneys.

I looked at the ECG. There were no missing (or irregular) “P” waves that are classical for atrial fibrillation and there were no irregularly irregular ventricular beats. The “heart strip” was one any reasonably healthy forty year-old would be proud to claim. Across the top of the strip, the computer had printed, “Atrial fibrillation”. There were physician initials and a date accompanying the machine’s declaration. The computer simply followed its programmed algorithm and the doctor signed off in agreement…with “Doctor Microsoft”.

The labs were normal, except for the measurement of nitrogen in the blood. It was slightly elevated, as was the sodium level and creatinine. The lab computer had dumbly noted, “early renal failure” in bold letters across the top of the page. A physician assistant had put her chop next to the declaration, concurring with “Doctor Dell”.

Far from being absolute indicators of early kidney failure, the lab values suggested mild dehydration. Frightened or anxious people don’t eat or drink as much as the rest of us. There were no physician notes about her food or beverage intake…or if there had been any changes in them. There had been no dietary counseling about possible food interactions with warfarin or dietary sodium and protein consequences for kidney disease. And nothing was being done about her increasing anxiety.

I dialed my sister-in-law’s number.

“When does Mom see her doctor again?”

“Tomorrow. Gosh, I’m glad you called. She’s really upset and scared about going.”

“Tell her not to worry. She doesn’t have a heart problem and the other symptoms are related to the blood thinner and the fact that she’s not eating or drinking normally, while her kidneys are being forced to give up water she cannot spare. Her body is trying to compensate and heal what the doctor is damaging. Under no circumstances should she consent to being hospitalized. She doesn’t need a second opinion. Her doctors need to ignore the machines for a few minutes and take a look at the patient perched on their exam table.”

I explained how stress affects blood pressure and that swings in the pressure, caused by anxiety, can result in dizziness and disruptions in normal heart rhythms. I doubted there was ever anything wrong with her heart. The last thing an otherwise normal geriatric patient needs is over-thinned blood and overworked kidneys. I told her that I would email her a copy of the latest treatment algorithm for protective blood thinning that favored simple aspirin over warfarin and reassured my sister-in-law that, with a little anxiety medication or counseling, the heart ‘palpitations’ would go away. She would have to be a bit forceful with the doctors and be careful not to step on their (typically) very fragile egos.

A few weeks later, my sister-in-law called and reported that the swelling feet and legs had resolved, there were no ‘skipped’ heartbeats, and that all lab values were “normal”. My mother-in-law had been given two weeks of a low dose of lorazepam (a “tranquilizer”) and she was her normal, happy self again. The warfarin had been discontinued and she was now on a daily dose of enteric-coated aspirin. The doctor had peered suspiciously at the copy of the journal article I had sent, shrugged her shoulders, and scribbled into her notes to reduce the diuretic to its original dosage.

I hung up the phone, shaking my head.

The total cost of my mother-in-law’s care had now topped $10,000. There had been months of anxiety and hours of her life had been wasted commuting to doctors in distant cities.

It had played out typically, as it does for too many Americans.

Seniors usually get passed hand-to-hand from doctor-to-doctor. Doctors are eager to share in the lucre generated by these fearful and gullible seniors who tend to be easily manipulated through the health care system.

The share the wealth mentality among doctors is much of what ails American medical care. Most of today’s family practice docs quit practicing real medicine as soon as they get access to “The very expensive machine that goes ‘PING’”. (Hat tip to Monty Python!) Patients get tossed onto a medical merry-go-round where each provider they encounter as the wheel spins takes a bite from their financial apple. Pretty soon, they forget about the patient, the medicine, and everything they learned.

One of the first lessons a student doctor learns is, “Listen to your patient. They will provide you with a diagnosis.” The second lesson is, “Use labs and tests only to confirm your diagnosis.” And finally, “When you hear hoof beats. Think ‘horses’…not ‘zebras’.”

The total cost of care for my mother-in-law should have been in the neighborhood of $100. Fifty, or so, bucks for a “problem focused” physician encounter (office call) where the doc would have learned she was dealing with the stigma and tragedy of suicide and about $30 for two weeks worth of anxiety medications and/or a brief visit with a grief counselor.

Instead, she was treated to a guest appearance on “House”; the popular television ‘doctor-drama’ featuring a misanthropic doctor wielding all of the latest medical technologies. The technologies were intended to help physicians in their decision-making processes but they have all but replaced decision-making by doctors. Consequently, most doctors have become mere technicians, responding to this dial reading or that flashing light on a computer screen.

It has been the death of doctoring.

At some point, usually in post-graduate training, new doctors forget the three basics they learned as first year students. Batteries of labs get ordered and patients are hooked up to the latest gizmo because the doctor has no motivation to think things through. Every minor problem becomes an excuse to play out an episode of “House”, where cost is no object and a flick of Dr. House’s pen orders a myriad of obscure and costly “investigative procedures”. If you ask a physician how much a “needed” test or procedure costs, he will almost invariably say, “That’s not my department.”

But, it is their “department”. Someone ultimately has to pay Dr. House; a small detail left out of the television show. Costs of care are important to those who pay them. Even my veterinarian can provide me with an estimate of costs when my dog gets sick. (It explains why it is harder to get into vet school than human medical schools and why a veterinarian’s office is uncluttered by diagnostic gizmos.)

(Editor’s note: I know from past experience that a good percentage of continuing medical education seminar time is devoted to reimbursement issues and not medical care.)

If handymen practiced like doctors, a scenario covering a broken kitchen cabinet hinge would go like this:

“Hi Mr. Smith. I’m your handyman. While I was looking at the cabinet, I noticed some water on the floor in front of your dishwasher. I’ve asked for a plumber to come and look at it. He’s here now, pressure testing the hot and cold water lines and inspecting each connection. He mentioned sending off a water sample to check for signs of pipe corrosion, just as a precaution. When he turned on the light over the sink, the light flickered. So, he’s asked an electrician to run load tests on all of the house circuits. He just finished. I didn’t have a replacement hinge, but I sent my courier and he brought me a chromium-titanium model that will last for decades. Of course the rest of the hinges should be replaced as well, but that can wait until my next visit. The appliance guy is also finishing up to make sure your fridge is at the right temperature. Is there anything else we can do for you today?”

A few weeks later, the handyman’s bill for $8500 arrives. Remember, the homeowner’s original need was only a $5 hinge and $20 worth of handyman labor. If the handyman bothered to ask, the homeowner would have told him that the water on the floor was from a spilled glass of water and that the “flickering” light was the normal start-up of a compact fluorescent tube. Finally, the homeowner had already purchased a replacement hinge at Wal Mart, but had simply not had time to install it.

Oddly enough, every time I have taken my aging truck to my mechanic, he gives me an estimate of the charges that are usually within $20 of the final bill. It’s a bloody miracle, that. Doctors usually just mutter and walk off.

A friend of mine says going to an American doctor is like going to the grocery store where there are no labels on the cans and where the prices aren’t posted near them. Then, when you get to the checkout line, the prices are determined by a chicken pecking the cash register.

It’s enough to make you sick.

[Editor’s note: My readers (all three of you) may recall my own, recent encounter with the American medical establishment. After being bitten by a (probably) rabid bat, my blood pressure took its own stress-related leap. My doctor, a former classmate at the medical college I attended, provided me with some excellent, patient-focused, care. Still, he could not resist the “Doctor House Syndrome” and he cajoled me into some pricey lab work…that ALL came back dead square in the middle of normal values. When he relayed the information to me, he sounded a little disappointed and I reassured him that those feelings would pass. There were still plenty of folks still in his waiting room. He smiled broadly. I went home. I meditated and then sat down to my supper of curried vegetables and brown rice…and two glasses of cheap, red wine. It was my turn to smile broadly.]

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