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Healthcare Costs: Under-Thinking Leads To Over-Testing

Jul 08, 2009 - 14 comments
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healthcare costs





My mother-in-law just had a CT scan of her head in the Emergency Department of her local hospital. My husband called me to ask if I could “talk to her about her headache.”

Severe headaches in the elderly are indeed worrisome, and I wondered if she had fallen recently - if she might have a bleed in her brain requiring immediate surgery. Of course, she’d need a CT scan to rule that out… I was prepared for the worst. But what I learned by simply talking to Mrs. Zlotkus was unexpectedly revealing - not only about her diagnosis but about our healthcare system in general.

As it turns out, Mrs. Zlotkus had been having severe headaches for about 3 months. She was taking Vicodin daily to “take the edge off.” When I asked her about the location of the pain, she said that it was “just on one side of my head, from the top of my neck to the top of my head.” I asked her if the pain sometimes traveled to the other side, or if it involved her eye. “Never,” was her quick response. She also told me that she’d been seeing a physical therapist for 2.5 months for neck stretching exercises.

Mrs. Zlotkus told me her CT scan was negative, and that her blood tests didn’t show any “temporary arthritis.” (That’s temporal arteritis, I presume.)

“Well,” I said, “There’s only one thing left that I can think of that will give you a headache in the exact area you’re describing - and that’s shingles. Did you notice any scabs or painful bumps on your scalp when the headaches first started?”

“Why, yes!” Said Mrs. Zlotkus. “About 3 months ago I noticed some very painful, crusty scabs on my scalp. I thought for sure it was because my hairdresser used extra strong chemicals on my hair. I scolded her for it. She told me to put tea tree oil on it.”

Oh, boy. There it was - a diagnosis as plain as the nose on her face.

“Um… Well did you tell the ER docs about the scabs?”

“No. They never asked me about it and I didn’t see what my hairdresser’s chemical burn had to do with my severe headaches.”

My mother-in-law’s work up (ER visit, CT scan, several doctor visits, pain medicines), misdiagnosis (neck muscle stiffness), and mistreatment (physical therapy) for shingles probably cost upwards of $10,000. Worse than that, she did not get anti-viral treatment early enough in her outbreak to prevent a long-lasting pain syndrome (called post-herpetic neuralgia). Now that she has this shingles-related headache, it’s very hard to treat. And taking lots of acetaminophen-rich medications (Vicodin) is the last thing her liver needs right now.

So how did the healthcare system fail Mrs. Zlotkus? In my opinion, this is a great example of the “failure of synthesis” that Evan Falchuk discusses on his See First blog (http://www.seefirstblog.com/2009/06/03/is-this-really-how-we-should-measure-quality/). Somehow, the physicians involved in Mrs. Zlotkus’ care didn’t take the time to think about her symptoms, to ask the right questions, and to put all the puzzle pieces together. Instead, they just ruled out the potential emergency issues (a stroke/hemorrhage, or temporal arteritis) and gave her a follow up appointment with a neurologist (who couldn’t fit her in their schedule for 2 months). They didn’t take a full history - they just dumped her in the most likely diagnostic category (neck stiffness) and let some other specialist follow up. Shameful.

I’ve described more egregious examples of hasty medical care on this blog - consider the case of an elderly woman (the mother of a friend of mine) who was misdiagnosed with “end stage dementia” (http://www.getbetterhealth.com/lack-of-quot-continuity-of-care-quot-can-kill/2008.02.01) when she really had acute delirium from an overdose of diuretics… Or the case of my girlfriend who was mistaken in the ER for a drug seeker when she was suffering from a kidney stone (http://www.getbetterhealth.com/the-benefit-of-the-doubt-have-healthcare-professionals-lost-it/2007.11.08).

Sometimes I feel as if I have to keep an eye on all my friends and family before they set foot in a hospital, ER, or doctor’s office. I’m afraid that those providing their care will be so rushed and thoughtless that my loved ones will wind up with a huge bill, the wrong diagnosis, and perhaps even a near-death experience. I am seriously afraid for them.

The bottom line is that we have to stop rewarding providers for volume over quality. We have to value the history and physical exam beyond the CT scan and lab tests. We have to give doctors the chance to think about their patients - rather than turn up the speed dial on the clinical treadmills as a means to reduce costs.

My mother-in-law just spent $10,000 of our tax dollars on a diagnosis that could be made in 5 minutes of thoughtful questioning over the telephone. Multiply that cost by the number of other Medicare beneficiaries who are suffering similar misdiagnoses in this country and we’re talking serious money.

Under-thinking leads to over-testing. Has the CBO taken that into consideration in its scoring of various reform plans? I don’t think so. To me, this is yet another reason why we need physicians at the table in healthcare reform - we see the real cost drivers that others might not think of - even if some of us are too busy to diagnose shingles correctly!

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by margypops, Jul 08, 2009
Thank you Dr Val for this, I am going throught the same kind of thing ,I am being foisted off by a Doctor sending me off for the wrong tests and more than I need, he is not interested in what I have to say, scoffs at the idea I use the internet for Help, truly coming here I have had more information from knowledgeable members than from The Med Profession. I am trying to get tested for Lyme, but he is giving me all the other tests he thinks I should get ....he is a new Doctor to me as I moved into this area a year ago, I have found a LLMD but he doesnt take insurance .... He charges $495 for one hour of his time,then I need tests... several,    Bartinella and others that are hugly expensive , I may have to go this route but it is so unsatisfactory as all I need is a treatment with anti biotics...I wish we could obtain them OTC ...

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by peekawho, Jul 08, 2009
Unfortunately, as Dr. Val certainly knows, ER's are being overrun with non emergencies.  Simply overrun and overwhelmed.  It would certainly be a wonderful goal to shoot for, to be able to spend time talking to the patient for a while, musing over where the patient has been, what he/she has done, and to cast about in your mind for scenarios that might fit the bill.

Emergency rooms should be used for emergencies.  They are so swamped there is simply little time and personnel available to give everyone an extended visit and work through a long list of possible diagnoses.  ERs have had to become a place of "rule outs".  Rule out the bad things...the things that could kill you imminently if left unattended.  
Mrs Zlotkus had to have important conditions that could threaten her life ruled out quickly.  It would have been wonderful if the ER doctor could have spent some time sitting down with her and taking a close history.  But I'll bet my last dime that the ER doc had 40 other charts stacked up, corresponding to patients who had been sitting out in the waiting room for hours.  Many were likely there for minor illnesses.  But there might be one or two who are seriously ill, and might just be sitting in the waiting room bleeding internally or suffering some other dire consequence  that was not picked up by the triage nurse.  
They simply have to "treat 'em and street 'em".  Rule out the bad things, refer to a specialist if indicated, and move on to the next patient.

Why do people go to the ER?  We need to look into this, and find a way to encourage people who are ill with non emergent conditions to visit their personal health care practitioner.   Some people have no insurance, and without insurance have no primary care provider.  So they go to the ER, knowing that the ER can't turn them away.   Some people become mildly ill at inconvenient times, and feel the ER is the fastest way to feel better.    Some mistakenly believe that the ER has the "best" care available.    This is true for trauma and serious, life threatening injuries and illness, but rarely for anything else.  

I wouldn't pretend to know how to solve this problem.  But I do know how it happens.   And I know why Mrs. Zlotkus' ER doctor likely couldn't sit down and gather details and brainstorm.   Hindsight is always 20-20.  But in the thick of a busy ER, with patients pouring in, no beds to admit critical patients in, backed up CT and MRI scanners, and 40 or 50 people waiting in the waiting room, I can see how a harried doctor treats and streets.  It isn't the best care.  But its what we have right now.

Thank you for this blog.  Very interesting!

Peekawho

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by peekawho, Jul 08, 2009
And Mrs Zlotkus's ER doctor would not have been overjoyed if he/she took a careful history, and ascribed the headaches to shingles without a CT to rule out an intracranial bleed, or tests to rule out serious conditions.

For if Mrs Zlotkus were to go home and suddenly pass away from an undiagnosed bleed, the ER doctor would be sued, face a malpractice claim, and be censured by the hospital.  

As I said, hindsight is 20-20.  In retrospect, all those tests weren't necessary at all.  But in real life, they had to be done.  

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by jdwithhcv, Jul 08, 2009
Speaking as an attorney who practiced for many years in medical malpractice defense, I have to agree with peekawho 200%.  Those tests had to be done, its too risky to omit them.  Its nice to speculate about doctors would do in a perfect world, but the ER is hardly a perfect world.

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by alikat1205, Jul 08, 2009
All of this is true as to the ER doctor, but if you would read carefully, it wasn't the ER who made the error.  Ms. Z. had been treating with her own private physician for several months for headaches, and it is that doctor who failed her.  She finally turned to the ER after several months of pain.  

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by jdwithhcv, Jul 08, 2009
Correction, I fatfingered that number.  I meant to say I agree 100%.

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by peekawho, Jul 08, 2009
Well, she say the headache was present for 3 months, and she'd been seeing a physical therapist for 2 months or so.   For neck stretching exercises.  

I might be misreading in my fatigue from working all night, but it doesn't really say she went to her personal physician for 3 months, does it?  I could be wrong.  

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by alikat1205, Jul 08, 2009
I guess that isn't explicit, but I inferred that from her script for vicodin and a previous referral to pt for neck pain incident to headache.   Once she got to the ER, I agree with you that the ER doctor acted appropriately in running the tests, the hope is that she would have never gotten there if she had been treated appropriately prior to that point.

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by Barb135, Jul 08, 2009
I don't think the problem is only the ER doctor.  I have been seeing the same doctor for about 7 years and I think the longest appt I've ever had with him was when he removed a spot from my leg for biopsy and that appt was approx 20 - with him in the room!!  Usually when I see him, he is in the room for < 10 minutes, he refuses to look at records that I bring with me, doesn't want to hear about symptoms, etc AND he absolutely hates it when *I* make a suggestion regarding possible problems or solutions.  And normally, if I'm not progressing as expected, it's because *I* am doing something wrong, not following instructions, etc.  

In one instance, I requested blood work that could have given insight into a problem and he refused to order it.  As it went, I eventually had to go to another doctor for what was supposedly an unrelated problem.  The 2nd doctor ordered the tests that the first doctor refused to order and we had a good look at what my problem was.  

We have too many doctors who are bent on pushing that brand name script into your hand and sending you on your way, so s/he can get on to the patient in the next room..... I say that because my doctor had insisted that I MUST take a brand name product rather than a generic, but when a 2nd doctor said the generic was fine and I switched, I am actually doing better on the generic than I did on the brand.  

I think the problems with our health care system need to be solved from within - quality over quantity.  I'd like just once to have a doctor sit down and listen/talk to me long enough to get a good clear picture of what I'm all about.  

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by margypops, Jul 08, 2009
I also didnt read it as being only the ER doctor or the ER ,I particularly liked what you said Dr Val  regarding underthinking leads to over testing and misdiagnosis, I do think that what you said about giving Doctors the chance to think about their patients rather than turnup thespeed dial relevant to what is happening in my case and others I am sure.Thank you

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by wonko, Jul 08, 2009
Dr. Val,

Thank you for sharing a physician's perspective on this.  I personally experienced over-testing for what was not wrong, and under-testing for what was wrong.  My mis/non-diagnosis cost me valuable time in treating my illness, and unfortunately, some harmful treatments were administered during that time as well.

I consistently experienced that doctors relied heavily on the labs and disregarded my history.  It irreversible shattered my trust in medical doctors to be belittled in this way.  It is shameful that doctors would rather dismiss their patient instead of properly carrying out the role of diagnostician and taking a good, thorough history and following the clues.

I am bitter and angry that my condition, which is highly treatable in early stages, was allowed to smolder, fester and wreak havoc on my body while my doctors smugly assured me that because my tests were fine, that I too, was fine.  I'm a young, (30 counts as young, right?) highly educated woman with medical insurance and no pre-existing health problems.  Yet I was treated like a hysterical idiot who couldn't decipher if my own body was sick or not.  

I finally did find a doctor (after plenty of searching) who would listen to me, and was diagnosed and put on treatment immediately.  My diagnosis was made clinically based on my history and symptoms, and later confirmed by the proper blood tests.  Unfortunately, in order to get this quality of treatment, I had to seek out a doctor who does not accept insurance.  

To date I'm certain that my 7 MRIs, lumbar puncture, other miscellaneous tests, specialist consults, and PCP office visits, cost far more to my insurance than my out-of-pocket care has cost me.  My greatest financial burden has been the 40% pay-cut for all of 2009 (and ongoing) caused by my medical need to reduce to part-time hours.


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by Val Jones, MDBlank, Jul 08, 2009
Thanks for the comments everyone. Yes, Mrs. Zlotkus' PCP and ER docs both failed her. Everyone was rushing around, not thinking about her history and physical exam. Based on her headache's description, there is almost no way that she had a brain bleed - and I would feel comfortable (if I were her ER doc and asked her the right questions) NOT ordering the test, even in the face of a potential lawsuit.

Our medical system is geared towards rushing everyone out the door as fast as possible. This causes physician "burn out" and all kinds of job dissatisfaction. Some doctors have the will to spend time with patients despite the pay cuts and lack of incentives to opt out of unnecessary tests/procedures. Others put on their blinders and just do the work. Still others are on the verge of collapse/quitting. (A recent study found that 30% of primary care physicians were considering quitting clinical practice in the next 2 years!)

As for me, I volunteer only. That gives me the freedom to take time with patients and get to the bottom of things - without fear of legal repercussions. However, I don't see very many patients this way (I have another full time non-clinical job) and I've been considering quitting clinical medicine altogether. It breaks my heart... but I'd rather not practice medicine at all if I can't do it right. And besides - I have my hands full just trying to get the right care for my friends and family... How sad is that?

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by Barb135, Jul 09, 2009
I want you for MY doctor!!!!  

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by jlc924, Jul 27, 2009
yes i have a question about er too i have went three times for swollen and pain in leg and the have done really good they did venous leg dopplar rhey were all negative are tose really good test to rule out blood clots

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