Imagine this….

A little thought experiment:

Suppose you are a guy, pushing the edge of middle age, and have been diagnosed with a reasonably aggressive brain cancer. You work in a menial job and can barely afford your rent, let alone health insurance. You travel 2 hours each way to see your neuro-oncologist, just about the only one in the state who sees people without insurance. You undergo a extensive surgery to take the cancer out — what they can see of it, anyway — and then rounds and rounds of radiation. A follow up MRI shows your disease is progressing despite all that. Your oncologist recommends chemotherapy in the form of a little pill every day for 5 days out of every month. Sounds good, you say, except you can’t afford it. Enter the bureaucracy of charity care, weeks and weeks of paperwork to convince the drug company to let you have a few pills for free.

In the meantime, you start getting headaches, right around where the cancer is growing. They respond to Tylenol, mostly, but you worry about taking too much at once. You call the oncologist’s office for advice, and a nurse tells you to go to the emergency room. So your brother drives you 2 hours to the emergency room at the hospital affiliated with the oncologist, where they can see all his records and the results of the brain MRI you had done 3 weeks ago.

Your headache goes away completely with a little tramadol. The emergency department doctor decides to get a CT scan of your head (“to look for bleeding”) even though you haven’t hit your head or anything. The CT scan shows there’s something abnormal — hardly a surprise in a patient with a brain tumor! — and the report recommends MRI to get a better look. So the ED doctor comes back to you and says, “maybe we should get another MRI.” And you say sure, you’re the doctor, you know what you’re doing. So back to the scanner you go, this time for an extensive scan which shows that your untreated tumor is, well, acting like an untreated tumor — a bit bigger than it was 3 weeks ago.

At this point, it’s 1 in the morning. You’ve been in the emergency department for over 12 hours. Your headache is still at bay. The emergency department doctor wants a neurologist to come evaluate you for possible admission to the hospital. You agree, because they are the doctors, they know what they are doing. Reason for the consultation: “I don’t feel comfortable sending this guy home because he might have a complication. I just want to do what’s best for the patient.”

Those are weaselly words, “I just want to do what’s best for the patient.” Because this is where I got involved, as the neurology resident on call. I was consulting on a man with a known tumor, with known tumor progression, now with … more tumor progression. The chemotherapy he needed could not be provided as if he were admitted to the hospital. The box with the charity pills was being delivered to his house in two days. The last thing he needed was to be admitted to the hospital. What’s best for this patient would have been some recommendations about headache management, and being sent back home from the ED in a timely fashion. Instead, he ends up having to pay several thousand dollars for unnecessary imaging, not to mention wasting hours of valuable sleep. (Realistically, he’s not going to be able to afford that ED visit, if he can’t afford his chemotherapy; to recoup the loss, the hospital will artificially inflate the cost of services to those who can pay their way.)

We failed this patient at nearly every step of the way. First, he should have been given headache recommendations in clinic or over the phone, instead of being sent to the emergency department for a non-emergent (though annoying/troubling) symptom. When he did show up in the ED, neurology should have been called early for recommendations — certainly before 6 hours into his ED course. (I do complain about bullshit headache consults, but if someone with an established neurologic problem develops a new neurologic problem, we’d like to know.) The imaging should never have happened at all — there was nothing clinical to suggest a bleed, and the CT and MRI told us nothing that we didn’t already know.

Moral of the story: think a little before you order a test. I know it’s fun sometimes to shotgun your way through medicine, and there is an academic curiosity in a lot of what we do. And be real careful about using the phrase “I want what’s best for the patient” — it makes you come across as a condescending asshole.


One thought on “Imagine this….

  1. Thanks for that. Put yourself in the shoes of the patient. We are going to change how we do things. Your blog will be a small but important cog in the wheel. Keep it going.


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