Some patients won’t accept a conservative approach to medical treatment

by Michael Kirsch, MD

Who says one person can’t make a difference? This past week, I personally set back health care reform. No, I wasn’t attending a ‘tea party’ or decrying Obamacare in a venomous letter to the editor. I single-handedly bent the health care cost curve in the wrong direction. I performed an unnecessary medical test on a hospitalized patient, which exposed her to risk and cost the system money. Why did I do this? Personal enrichment? Fear of litigation? None of the above.

The patient was hospitalized after a week of abdominal cramps, nausea, vomiting and diarrhea. A CAT scan of the abdomen showed no abnormal findings. In the ED, her white blood count was modestly elevated, but had normalized by the following morning when I met her. My physical examination demonstrated no concerning findings.

I suspected that she was suffering from gastroenteritis, medical jargon for “stomach flu.” I advised my patient that I did not advocate additional testing, and anticipated a very brief hospitalization followed by a full recovery.

She was not satisfied with this conservative approach. She had suffered a stomach ulcer nearly 20 years ago, and was concerned that she her illness was a recurrence of this condition. She wanted the scope test (EGD) of her stomach to exclude this diagnosis. I spent more time with her to explain why this test was unnecessary, and told her that she might be able to be discharged late in the afternoon. I promised to check on her progress later.

It is more typical for gastroenterologists to coax folks into colonoscopies and other intestinal delights, than to dissuade them from sampling our diagnostic bag of tricks. This patient was an exception.

I called her nurse that afternoon to inquire on her condition. She advised me that the patient’s family had visited and they all insisted that an EGD be performed prior to discharge.

Here were my options:

* Return to the hospital for a family meeting

* Refuse to do the procedure and see the patient on rounds the following morning

* Resign from the case and request another consulting gastroenterologist to see her

* Perform the procedure

Medicine is not a perfect world and its practitioners are imperfect members of the human species. It was clear to me that if the scope were not performed, that this patient and her family would believe that an essential medical service was being denied. They would be angry. In similar instances in the past, when I had counseled patients against having tests performed that they desired, I had been falsely accused of trying to save insurance company money. I did not return to the hospital to meet with the family as I believed that discussing the futile scope test with them would be futile. As the EGD has nearly no risk, I decided that performing it would serve the greater good. I recognize that other physicians may have chosen differently.

The results were normal. I’d like to think that no one got hurt in this vignette, but this isn’t true. Health care reform took a direct hit from me and my personal integrity was grazed. I’m blowing the whistle on myself.

Michael Kirsch is a gastroenterologist who blogs at MD Whistleblower.

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