To CT scan or not: What is the ultimate goal of patients?

To CT scan or not: What is the ultimate goal of patients?

The patient – blue-eyed, red-haired, and healthy but worried looking – guided the doctor’s hand to just below the angle of her jaw, where a small lump was barely palpable.  She had first noticed the swollen lymph node after a cold and thought nothing of it at the time.  But five months later, it was still there.  She knew it was nothing, but she couldn’t shake the thought that it might be related to the skin cancer she had had cut off of her shoulder one year earlier.  After all, melanoma can spread through the lymphatic system, and her dermatologist checked carefully for swollen lymph nodes at every appointment to make sure the cancer had not escaped the scalpel and metastasized.

Melanoma is a terrifying disease.  When caught early, it is easily treated by surgical excision.  When caught late, however, it is universally fatal.  The doctor smiled at the anxious 20-something-year-old woman in front of him, told her it was most likely nothing, and then wrote her orders for a CT scan to look for more inflamed lymph nodes.  You’re young, he told her, and if I were you, I would want this test to make absolutely sure that the cancer has not spread.   For the doctor, that was end of it – another satisfied patient, reassured by the advanced technology of modern medicine.

As a medical student, I have witnessed many discussions between health care providers about this type of hyper-vigilant patient.  These conversations usually go something like this:  “Mr. Smith’s cough is probably just a cold, but he wants an x-ray to make sure it’s not pneumonia.”  Or “Susie’s headache is probably just a migraine, but her mom wants her to get a lumbar puncture [spinal tap] to make sure it’s not a serious infection.”  Doctors and residents may express reservations, but if the test or treatment is reasonably justifiable, they frequently bow to the patient’s wishes.  After all, medicine is no longer the paternalistic discipline it once was; doctors today are supposed to enable patients to make their own decisions, not simply tell them what to do.  And why not order a test if there is a possibility, even a small one, that it will reveal useful information – especially if the patient’s insurance will cover the costs?

For the patient in this case – me – that visit was not the end of things.  I walked out of the doctor’s office feeling temporarily reassured; after all, he told me it was probably nothing, and I could always get the CT scan if I wanted to.  But as the days went by, I found myself worrying more and more.  Weren’t the CT orders sitting on my desk at home proof that there was something to worry about?

On the other hand, I did not want a CT scan.  Though I was lucky enough to have insurance that would have covered the costs of the scan 100%, I knew that CT scans were expensive, and I did not want to undergo a test that would take time out of my busy schedule, expose me to radiation, and add to the social burden of health care costs.

So I made an appointment with a dermatologist.  She listened to my story, felt the lymph node, and then looked me dead in the eye and told me that there was absolutely nothing to be worried about.  The lymph node was soft, it moved around – unlike cancerous nodes – and it was on the wrong side and the wrong place to be related to the cancer that I had had on my shoulder.  In five minutes, she was in and out the door and I was on my way, without a single test having been done.  This time, armed not with test orders but with more information about why I should not worry, I felt infinitely more reassured.

Doctors often talk about patients coming into clinic “with an agenda.”   They feel at odds with these patients, many of whom push for extensive testing.  Yet in the end, the ultimate goal of most patients is not the testing itself – it is the answers that testing will provide.  A provider who takes the time to fully explain the benefits and drawbacks of testing is likely to find that patients are much less desirous of exhaustive testing than they originally seem.  In doing so, they are doing a favor for both the patient and the health care system that bears the cost of unnecessary testing.

Erin Plute is a medical student and a winner of the 2012 Costs of Care Essay Contest.

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  • ninguem

    Boston Globe

    January 27, 2013

    Dermatologist treats three precancerous skin lesions, using liquid nitrogen.

    Doctor’s bill $354.
    If I had treated that same patient, fee would probably have been $200-300.

    But if it were done in my office, or in the office of an independent dermatologist, that’s ALL that would have been charged.

    But because it was done at the Lahey Clinic, $1,525 bill for “operating room’’ and hospital “facility’’ charges…..and that’s ON TOP OF the doctor’s bill of $354.

    Time and time again, all over the country, people are starting to realize that the large organizations that take over physician practices, do not have any economy of scale, none at all.

    What they do…….ALL they do……is extract higher payment for the same service. In my area, it’s usually double. In Boston, just the Lahey example, a $354 bill becomes $1879, about a five-fold increase.

    • buzzkillerjsmith

      When I lived in a sunnier clime, I dreamed of giving up diabetes, HTN, CAD, COPD, depression, anxiety, drug-seeking behavior patients, acute alcoholic hepatitis patients, gi bleeders and hepatitis C cases to become a liquid nitrogen doc, once I found out how much liquid nitrogen docs got paid.

      Sadly, the volume was insufficient so, so I was stuck with having to provide actual medical care.

  • Jonathan Isbit

    Erin, I had a tumor in my jaw a few years ago. It was large, painful and growing fast. But without health insurance and without any faith in doctors, I decided to cure myself. I started fasting (nothing but water.) Within a few days the pain subsided. After 7 days, the tumor disappeared! The whole “treatment” cost nothing (I even saved money on food.) And it spared me from surgery and who knows what else post op. I used fasting to cure another condition, which I also believe was malignant, in a different part of my body. I’m so grateful that I was unable to afford conventional care. I feel sorry for wealthy people who feel obliged to consult doctors and then fall victim to their tender mercies.

    • Docbart

      Fasting to cure cancer? Really? Don’t you think someone would have found that before, and maybe gotten a Nobel prize, or do you subscribe to conspiracy theories, like this is a secret that doctors and drug companies have kept hidden so they can make more money?

      Perhaps your “tumor” was really something else, like an abscess that drained spontaneously. Others with real tumors may have tried your strategy and others like it before, but they don’t write in BECAUSE THEY ARE DEAD.

      • buzzkillerjsmith

        I remember a guy from back in the day who was using acupuncture for his squamous cell carcinoma of the external auditory canal. To be fair, the acupuncturist did ask him to see the doc since he wasn’t getting better. Things didn’t work out so well for that particular guy.

      • Suzi Q 38

        Don’t be so mean.
        He really believes this.
        My educated friends both died of lung cancer. The first friend died at the age of 37. She died with some unproven treatment in Mexico. Her mother had to pay big bucks to get her body back home to the U.S. for a funeral.
        Next, her mother got lung cancer 3 years later. She was dying and tried to cure it with acupuncture and herbs.
        Thank goodness she tried conventional treatment at a local hospital first.
        I lost both friends, (mother and daughter) within 3 years of each other.

        People get desperate and try unconventional methods.

        • Docbart

          If conventional Rx fails, then do whatever, but don’t waste time on ineffective Rx first, when it may make the difference between being cured or not. Think of Steve Jobs- might have been alive today if he hadn’t tried “alternative” Rx first.

          The only reason I replied sharply was to dissuade any other reader from following the silly idea that fasting cures cancer and not get effective and timely treatment. That would be a tragedy.

          • Suzi Q 38

            Thanks for your clarification.
            Yes, in both my friend’s cases, they at least did go the conventional route first.
            Steve job’s??? I could not profess to know him or to know what he was thinking.

            Suffice to say that based on his biography and business success, he was a genius that knew he was the “smartest man in any room.” He probably was.
            Maybe he sized up his doctors mentally and looked at the prognosis for pancreatic cancer and thought….”I am going to try something different.” He was an intense person. He also might have thought that they didn’t know everything. Who knows….I didn’t read his book.
            Once a decision in his mind was made, I doubt that any mere mortal could change it.
            I am sure that he realized at some point that he made the wrong choice and may have lost precious time.

            Part of the reason he went the herbal route was that he lived in the Bay Area of Northern California.
            This area embraces herbs, acupuncture, massage, and the like for most of what ails the human body, including cancer. Many people that live there welcome alternative treatments for all sorts of serious conditions.

            I just had two friends call me about an herbal treatment to cure my spinal stenosis and straighten the cord and spine. Fascinating. I was also given the number of an acupuncturist in Los Angeles.

            When I told my students that I would not be in class for 6 weeks due to my upcoming surgery, they were understandably concerned. One student from China waited after class to hook me up to a nerve and pain machine. This was supposed to improve my stenosis, pain, paralysis, and delay my need for surgery.

            This was not for me. I could see on the screen, read the medical reports from the neuro radiologist clearly.
            I talked to 2 neurosurgeons, 2 neurologists, 1 M.S. neurologist, 1 neuro fellow, and 1 gastroenterologist that
            all said I needed surgery.

            No herbs or acupuncture for me.

      • Jonathan Isbit

        When people use conventional treatments and wind up dead, it’s never blamed on the treatment. How come?

        • Docbart

          Who says conventional treatments are never blamed? Try reading medical literature or even current medical stories in the news. Few treatments are 100% effective, even assuming that the diagnosis is correct and the adherence to treatment is complete. All active treatments have side effects, At least conventional treatments are studied compared to placebo. Very few unconventional treatments are studied that way and even fewer prove out when tested scientifically. Obviously, you can believe what you like, but if you subject your belief to rigorous study, it may not stand up. Conventional medicine does that all the time and changes its practices based on the outcomes.

  • buzzkillerjsmith

    If I were worried about a node like this, I’d probably do a biopsy, not a CT scan.

  • Suzi Q 38

    I have learned my lesson.
    If it is an MRI. I compare the prices of the local teaching hospitals and fairly large private ones. I prefer the teaching hospitals though, especially since my diagnosis was spinal stenosis (C-spine).
    I just preferred the neuro radiologist reading my scan and writing the report.
    If I went to a smaller hospital or clinic, I don’t know the credentials of the radiologist.
    If it is for regular routine blood work, I have my PCP order it locally and photocopy the results for the doctors at the teaching hospital.
    It annoys them sometimes.
    When I ask why, they don’t have a good answer for me.
    I just tell them that going all the way to their hospital is too far.
    The real reason is that they teaching hospital sometimes charges double or triple.
    I am looking forward to getting healthy so that I can take a rest from the big hospitals for awhile. They refer you to more doctors than you really need to be referred to.
    The surgeon wouldn’t do my surgery until I saw the MS doctor. The MS doctor sends his patients to that surgeon.
    I already told the surgeon that not one, but TWO neurologists already cleared me for my surgery.
    He felt that I had to see this certain MS doctor.
    I respect that, but I didn’t have the time to wait 2 1/2 months for the appointment.
    That MS doctor was very good, but wanted to take a comparable MRI.
    I understand, but I was losing function in both legs day by day.

    I finally told everyone that I needed to have my surgery soon, or lose function entirely for good.

    I am hoping that I made the right decision.

  • meyati

    I’m finishing up radiation treatment for a stage 2 aggressive cancer. It moved around- didn’t seem rooted to anything. The surgeons wanted to cut off my face-well half of it- bone- right eye. i don’t what my chances are, but I know that I’m happier than I would be with my face gone.

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