The patient offered a diagnosis, and the doctor missed it

I recently got back from a brief trip to Florida. I went down there to celebrate my mother’s 85th birthday. As you might expect, her social circle has shrunk in recent years, but she did get a number of cards and calls from friends and family members. The cards were on display in her kitchen, and a few calls came in while I was there. One in particular pointed out some of the many things wrong with medicine these days.

The caller was a cousin of mine whose elderly father is one of the few remaining friends my mother sees on a regular basis. He and my father grew up together, and our families were always close. Since my father died, and his wife passed, he and my mother go out to dinner on a weekly basis.

My mother had told me that he was having back trouble, so when his daughter called my mother with birthday greetings, she and I spoke and I asked after her father. She sounded a bit frustrated with him, and said that she had told him to “just get an MRI already” to see what was wrong, since it was clear, she said, that “nobody was going to operate on someone his age.”

I did not challenge her suggestion, but I couldn’t for the life of me figure out what an MRI would add to his management, especiallys ince, as she pointed out, he was not a surgical candidate (and his symptoms, by her account, were neither disabling nor accompanied by neurological signs). I just chalked it up to another example of consumer-driven demand, the perfect companion to fee-for-service imaging in a well-insured population, and pretty typical of what we know to be one of the causes of overutilization of imaging studies. Sad, but hardly reportable.

The really sad part came when I called her father, since I wanted to see how he was coping with his back pain. He told me that he was actually feeling much better, and told me that his back had not ever been the problem, but rather nagging aches in his calves. His physician had prescribed hydrocodone — really, for an 88-year-old? — which lessened the pain, but made him feel woozy (big surprise there).

What really made the difference, he said, was something that seemed crazy, and he wanted my opinion. Turns out he loves grapefruit, and eats them daily, but he read someplace that it might be interacting with his lovastatin, so he cut out the grapefruit and his leg pain got better. I totally endorsed his theory and told him that he would probably be better off stopping the lovastatin and continuing his grapefruit, but he thought I was kidding (I was not!).

So here’s the sad part. An 88-year-old man who loves grapefruit is now deprived of it, so that he can continue taking a medication of dubious value in his age/risk profile, prescribed by a physician who prescribed a narcotic to someone with an adverse drug reaction. At least he stopped the narcotic before he had a complication from that.

What happened to talking to patients? The patient was offering the diagnosis, and his doctor still missed it.

What is wrong with this picture?

Ira Nash is a cardiologist who blogs at Auscultation.

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  • JPedersenB

    One wonders why, indeed, an 88 year old man was put on statins? Blindly following guidelines?

  • southerndoc1

    In addition to using his finely-tuned retrospectroscope, I wonder if the OP was doing data entry chores while getting the correct history from the patient.

  • Doug Arenberg

    Great story KevinMD, and a reminder of how important it is to (as my coach used to say) do the ordinary things extraordinarily well.

  • Hants Hippy

    Great article.

    Every one of my circle of friends seem to be suffering a multitude of medical problems between them and must be costing the UK NHS £millions if not £billions!!

    Most interesting is that every one of us, and myself included cannot, or could not move their shoulders at all without excruciating pain which no Dr can explain the cause of! I cured my shoulder pain when I realised I was having the same symptoms I had 20yrs ago – rhabdomyolysis secondary to dermatomyositis and I stopped myself exercising and cut out almost everything from my diet except fish and finally replaced coenzymeq10 tablets with ubiquinol 300mg/day.

    Took me 6yrs to recover as my Dr refused to help in any way because I refused to take any further statin tablets he insisted I would die without. He totally denied statins could possible be responsible for my multitude of chronic, but invisible (to him) symptoms!

  • NewMexicoRam

    Isn’t that the truth?

  • Steven Reznick

    Not having or taking the time to listen to the patient is a crime but none of us were there to actually witness the encounter and see what transpired. I agree that starting a statin in an eighty eight year old is questionable but what if it was started 15 years ago after an MI, stent placement or revascularization procedure? What if the 88 year old has taken the statin without problems for 15 years? As for pain control the choices are very limited with 88 year old kidneys ,gastric mucosas and impaired vision balance and proprioception.
    The idea and theme that high volume and technological equipment divert concentration and attention is a good one. The cheap shots at the treating doc is in poor taste especially from a specialist not caring for the complex multisystem chronic problems of the active elderly who sometimes have more treating physicians prescribing in more locations than we have fingers and toes

    • goonerdoc

      Well put, Dr. Reznick. Exactly my thoughts. Good to see you posting again.

  • Suzi Q 38

    Why would a physician be punished for not putting every male 65 year old on a statin?

  • JPedersenB

    How are doctors punished financially for not prescribing statins? (Lowered office visit fees from the insurance co? Then one has to ask, why is the insurance co. allowed access to patient records or prescribing records?)

    If what I am conjecturing is correct, this is more evidence of how dysfunctional our current system is! It seems that the insurance companies are actually dictating patient care, not the doctor. Outrageous, yes! What can we do and how do we change this?

  • rbthe4th2

    Welcome to life as one of us. This is typical from a few doctors I had. Then they blame me when things go wrong. For some odd reason, a patient who doesn’t watch TV and reads medical research is not someone some docs listen to. I can’t imagine why we asking questions and upsetting doctors with the information we have – could it actually be that patients are interested in their health, want to be an active partner in doing so?

  • leslie fay

    Amen. It’s the doctors primary job to listen to the patient and it’s the patient’s job to actually make sure the doctor is listening and to use his/her ‘inner voice’ to know when something is just not right. I think it was the daughter’s job to research the issue including medications he was taking, accompany her father to his appointments, make sure her father was accurately describing his symptoms and ask why you would give an 88 year old man a strong pain killer instead of actually diagnosing the issue. Granted you would want to start out with simple things-which in this case would have resolved the issue.

  • Sara Stein MD

    Great post. At 88, life should be grapefruit and walking around in FL. It should not be pain and doctor’s waiting rooms. At the very least, offer the patient the risk/benefit profile and let them make their own decision. I’m guessing most will choose the grapefruit!

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