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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  • family doc

    This is fairly common in my experience as well. Family or patient want tests done despite very low pretest probabilities. Sometimes I’m able to convince them that the radiation or procedure risk is greater than the likely benefit but the moral hazard of Medicare and “good” insurance is quite real. HSA and cash patients don’t do this.

  • jsmith

    In my small eastern Washington farm town gastroenteritis is treated by me, the family doc. EGD simply does not come up. Dr. Kirsch has unwittingly identified the problem–he is in the wrong specialty for this case.

  • Kick the science and see if it stands

    Assume the patient is paying, if that helps.. Because except to the extent that your own services are going to be recompensed, it’s not your place to “protect” health care dollars or systems, and any such concern is perversion of your peculiar (meaning unique) duties.

    If the patient assumes the risk and the payment, and in your professional judgment a defensible, rational justification for the investigation is present, then only serious concern for harm should prevent the desired investigation. The patient should be made to appreciate the harm possible to her body as the basis of your decision.

  • Sarahw

    Where did physicians pick up the notion that they are gatekeepers of financial benefits, instead of professionals charged exclusively with the health and well-being of individual patients? (Not meant to exclude physicians natural self interests – their own concerns of personal compensation, professional reputation)

  • Doc99

    Medicine may be based on science, but it is still an art. Well done.

  • http://rebeldoctor.blogspot.com/ Michael Rack, MD

    “Where did physicians pick up the notion that they are gatekeepers of financial benefits”

    Politicians, especially Democrats. Congressman Stark. Obama. Obama says we order too many tests and cost the system too much.

    This all started in the ’70′s

  • Anonymous

    This was a perfect case in which having the patient pay out-of-pocket for the test in the event of no abnormal findings would have been completely appropriate.

  • joe

    “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”

    This is the crux of the economics and medicine in the US. What the naysayers here don’t get is that the doc did not think the EGD was necessary…period. Per the doc, rationale justification for the procedure DID NOT EXIST. This happens every day in every hospital in america. For example, ICU patients without meaningful hope of recovery are subjected to procedure after test at family insistance and with doc acceptance. Folks, for significant $$ savings in this country to occur using the Obama proposed model, some very honest and realistic conversations need to be held at political level about rationing of care. But since we are dealing with politicians and an American electorate that wants everything now, costs and benefits be damned. This conversation will never happen. I suggest those interested take a very good look at the VA and the European model (whether you are for or against it). They save money based on rationing. The problem is that Obama (like every politican before him dem and rep) doesn’t have the political balls to call the American people on it.

  • Medical Student

    “Assume the patient is paying, if that helps.. Because except to the extent that your own services are going to be recompensed, it’s not your place to ‘protect’ health care dollars or systems, and any such concern is perversion of your peculiar (meaning unique) duties.”

    Hang on, that’s not right. Tests like this should be avoided because they cause more harm than good. This is exactly what the phrase “First do no harm” means.

    Dr. Kirsch phrased this in terms of wasted money, which is also true, because unnecessary tests waste money. That only means that doing the test harms more than just your patient, but it harms other patients as well.

    Turning down a necessary test while considering the savings to healthcare dollars is wrong, but turning down an unnecessary test while considering the savings is not only right, it’s doubly right.

  • pat

    I think a lot of things contribute to this problem. First I think that conventional medicine has convinced us all that it’s better than it really is: diagnoses are precise, tests show us exactly what the problem is, etc. Secondly is the insurance company between the patient and the doctor. It would be the same with government run insurance. It would be the government between the patient and the doctor. With third party payors, it’s hard to keep the trust. I’m not sure what the answer is, but we need to do some serious thinking about it.

  • BobBapaso

    The answer is Health Care Savings Accounts for everyone. If you’re paying with your own money you will be more likely to listen to you doctor’s advice that the test may not be necessary and to wait a couple of day to see if it is. And not be mad about waiting. With this system everyone will ration their own care at a level they are comfortable with. Nobody wants rationing imposed on them, but we all know not everyone can have everything.

  • Kick the science and see if it stands

    Med student, the second paragraph of that post discusses that.