Wednesday, November 2, 2011

Parsimony

I got trained in the old school of thought as far as patient care is considered. There were several dos and don’ts that were dinned into our heads. Some of these were, don’t prescribe an expensive drug when an alternative cheaper one is available. The other is don’t investigate unless absolutely necessary. Always listen to the patient then proceed to examine and always try and come to a clinical conclusion. If you have to confirm do the minimum lab and other tests. When you are in doubt get another opinion.

These principles have stood me and my patients in good stead over the years and saved us lots of head ache and money. But occasionally it has backfired, to give an example or two.

I am against routine annual medical examinations and investigations to all and sundry and with valid reasons. I consider these a waste of money. But when there is a definite indication to screen a high risk patient I do order the required tests. In this case the Youngman’s company does many tests as a part of the employee benefit and an electrocardiogram is one of them. He knows that I am against routine screening for heart disease in low risk groups and the youngster was one such. He reluctantly came and apologetically asked me to have a look at the reports. The company and done many tests which included an ECG.

The ECG was abnormal. Though the rhythm was alight the rate was very high. Even if one gives margin to the fear of doctors and machines many have with the resulting increase in the heart rate, this kind of increase was a cause for concern. The report just said sinus tachycardia and the physician who signed it had not bothered to see the patient. There was also a marginal increase in the levels of thyroid hormone.On talking to him I realized he had lost weight, had been having some diarrhea and when I examined him he had a heart rate of 130 beats per minute. A repeat test for thyroid function revealed he had increased activity of thyroid gland and this was duly treated. Had he not done the annual tests would he have come to see me? Probably not immediately but would have because he was concerned with his loss of weight. He would have come much later when treating him may have become tougher than it did.

Another patient this time a friend of mine, who by nature a thrifty sort of a fellow [there is a very thin line between thrifty and miser].He tries his best avoid consulting me [read paying me]. He also treats himself with some success. He had symptoms of hyperacidity a year ago and as his usual antacid failed to help he sought my attention and I advised him to take a course of different class of anti acid drugs and get back after six weeks. He got better and did not get back to see me. When I met with him on the golf course he said he was well but once in a way he has to take the medicine. This worried me as at his age one should not have recurring symptoms like this. As the golf course is not the ideal place for a professional consultation, I asked him to see me in my chambers. This he did when his wife came to see me, he sort of hitched a ride.

I found he has been taking the medication prescribed and managing. Though there was nothing much detected on physical examination I told him to get an endoscopy done to have look at what his stomach looks like [this meant going to the hospital and getting a flexible tube thrust down the throat right up to the stomach, a not very pleasant procedure but was needed]. He said alright and went away. He did not go to the hospital. He came three months later with worsening of symptoms. I had no doubt about the diagnosis. He had cancer of the stomach and further tests including the endoscopy showed the cancer had spread all over. He does soon after.

Looking back I feel guilty for not having insisted that he get the tests done. I could have told his wife and she would certainly have succeeded in getting the tests done. Would he have survived had the tests been done six months earlier? Yes he would have.

There is a saying that you can take the horse to the water but you cannot make it drink it. Sometimes it is difficult to force the issue. But difficult or not I should have done it and he would have probably few more years of life. Now I am carrying this burden and it will be with me and his face will keep coming to haunt me, may be, till I die.

Another patient and another time. This person was a medical shopper. He saw many doctors and I was one of them. He had painful sensations on the skin of his thighs extending down to the calves. Only sensory involvement of pain sensation carrying nerve fibers may be due to many causes and cancer is one of them. He was a smoker and on testing he was found to be a diabetic. I was happy because diabetic neuropathy is very common and good control of diabetes will help. He was told the diagnosis. He appeared happy that a cause was found and went with the diet sheet and prescription. For three months I did not see him. When he did come he had with him records of three other doctors, one of them a homeopath. His diabetes was under control but his neuropathy [pain] had worsened. A neurologist who had seen him had done a scan of his spine and brain with no abnormality. Now he also had weakness and loss of weight which was attributed to diabetes. What is this patient’s illness?
I expressed my worry about cancer to the patient and told him to get a PET scan [an expensive test but will reveal cancer activity] of his whole body. After much deliberation and visit to another doctor [fortunately he too advised the same] this test was done. A tumor was found in the patient’s intestine [ceacum]!
Though nearly six months had elapsed from the onset of pain in region far removed from the place where the cancer was, it was found to be operable. The patient lived few more years but died due to recurrence. Here again if we had forced him to do this test and the diagnosis had been done early, may be, he would have lived his normal span of life. All of us [many doctors whom he went to] thought that diabetes is the cause when all the time it was cancer. This episode too has remained in my memory but does not haunt me as the other one does.

Despite this experience I stick to the principle of investigating only when necessary. But as you can guess, I have started forcing and even threatening them with dire consequences if they don’t follow my advice. Once bitten twice shy, that is what I have become.

Medicine is, in many ways, a cruel profession. You may be right 99 times out of 100 but you remember the 100th because willy nilly, you were responsible. And to the patient who suffered it is 100 percent.

1 comment:

roggman63 said...

You are right, patients have become spoiled and do not take into consideration how difficult it is to diagnose a problem tests and back ground questions to get answerers. Then there is always the risk of prescribing a product that works but has side effects and the patient i still unhappy. Bottom line, patients need to be more patient.