Let Doctors Be Doctors
Dr. Robert Pearl, a former Kaiser hospital CEO, blames doctors for most of the problems with the U.S. healthcare system in his recent book Uncaring: How the Culture of Medicine Kills Doctors and Patients.
One of Dr. Pearl’s complaints is doctors order too many tests. He cites orders for CT scans for long-term headaches. What Dr. Pearl does not supply are the statistics citing how many people die for lack of these so-called unnecessary tests. The problem is those who didn’t have a CT scan for long-term headaches may well have a brain aneurysm which could lead to spending 10 or 20 years paralyzed in a nursing home, or worse, death. The money saved by not doing the CT scan may in the long run create far greater expenses in nursing home care, or even patient death.
Doctors don’t have the advantage of the retrospectiscope. In other words, when you already have the answer, it’s easy to know the best treatment. Planning the treatment without knowing the outcome beforehand involves a lot of work. What’s worse, the lack of something as simple as a CT scan can have dire consequences.
In medicine, the answer isn’t always apparent from the beginning, although most of us experienced doctors have developed judgment which sometimes involves thinking outside the box. Yes, we are supposed to rely on evidence-based medicine, but limiting our diagnoses to the evidence-based medicine checklists can result in dead patients.
For example, Bruce is a 30-year-old farmer, rancher, and trucker presented to my office a week after he had driven his truck several thousand miles, parked it, and while unloading the truck, fainted. In the ER, he had a head CT scan. His history of trauma is important here. Before driving his truck a thousand miles, he was chasing a calf on a four-wheeler. He hit a rut and the four-wheeler flipped over on top of him. He had gotten a head injury from the accident, but hadn’t sought medical treatment. Farmer are known for getting injured and just keeping on working. So Bruce didn’t go see a doctor after his four-wheeler accident.
About four weeks later Bruce presented again with a headache, but reported no more incidents of passing out. Again, the CT scan was normal. In another month, he presented still complaining of headaches. His physical exam remained normal. I later ordered an MRI to see if maybe we would get some more helpful information. The report indicated a congenital malformation in his right frontal lobe. He was sent home but continued having headaches. A month later I sent him to the ER in the next larger town and I called the ER doctor to explain the nuances of his care. He told Bruce to go home for the weekend and stay in bed. His headache was so bad that he returned to see me once again on the same day. I ordered the third CT scan because that was what we had available. This time he had two large subdural hematomas one on each side. One was 1.5 cm deep and the other one was 1.7 cm deep. I sent him back to the larger town where they had a neurosurgeon. The patient underwent a 13-hour surgery. He seemed to do better, but still wasn’t completely back to normal. Recovery took several months but he eventually recovered, and he remains in good health today, six years later. One of the problems with CT scans is that head injuries and strokes do not always show up immediately. Sometimes it’s three or more weeks later, but by that time the knee-jerk reaction is one CT scan is enough. The CT scan still needs to be done with head trauma at the time of the injury, but there are times a need to repeat the CT scan, even more than once.
In another instance, a man about 65 years old fell out of a tree. His head CT in the ER was read as normal. He was observed overnight. No abnormal physical findings were found and he was sent home. A month later, while driving his car he passed out and went into a ditch. Luckily it was winter time and the ditch was full of snow. He wasn’t injured. The next time his head CT showed a subdural hematoma on the right side.
In another instance, 37-year-old women went to the emergency room with a chronic headache. She had six children at home. Because her headache was long-term, no CT scan was done. Two days later the patient was found dead on her bathroom floor by her children. She had died from a ruptured cerebral aneurism.
The patient’s husband also had headaches. One was particularly bad. He went to the ER but because his headaches were chronic, no CT scan was done. Exam was normal. He died at home from a ruptured cerebral aneurysm in the same bathroom that his wife had died two years earlier.
Evidence-based medicine and attempts to cut costs by omitting testing can lead to higher costs later or death of the patient. Hospital CEOs need to stop blaming doctors for testing too much and let doctors be doctors.