Monday, November 12, 2007

Patient in my own hospital

Two stories about being a patient in my own hospital.

(1) I am really lucky to have a primary care doctor who knows how to protect me, as president of our hospital, from our well meaning doctors. Why do I need protection? Well, because the specialists are really proud of their work and want to use any malady that I have to show me their stuff. My doctor knows how dangerous this can be!

A few years ago, I signed up for an ocean kayaking trip in Patagonia. This was to entail pretty strenuous outdoor living and paddling all day long for two weeks. The program therefore required a physical exam and recommended a stress test for those over a "certain age." So I asked my PCP to order one.

She says, "No. I refuse to order a stress test for you."

"Huh?", I reply intelligently.

"Here's the deal," she says. "If I order the stress test, our especially attentive (knowing who you are) cardiologist will note some odd peculiarity about your heartbeat. He will then feel the need, because you are president of the hospital, to do a diagnostic catheterization. Then, there will be some kind of complication during the catheterization, and you will end up being harmed by the experience."

"But the reality is that whatever peculiarity he might find in your heartbeat has probably existed for decades, or your whole life. There is no history of heart disease in your family. You ride 100 miles per week on your bike and play and referee soccer for hours every week, and you have never had a symptom that would indicate a circulatory problem. Therefore, I will not authorize a stress test."

"Yes'm," I dutifully reply.

(2) A few years ago, I had a routine colonoscopy, and the GI doctor clipped off a couple of polyps and sent them to the lab for analysis. Standard practice to see if they are pre-cancerous.

Three days later, I am walking to work next to one of our pathologists down a very busy Longwood Avenue. I say, "Good morning. How are you?"

He quietly replies, "Fine, and so are you. I did your histology yesterday. No problems. Have a pleasant day."

8 comments:

Anonymous said...

I really identify with this post! As a pathologist myself, I frequently reviewed specimens from or heard about workups on my medical colleagues or hospital staff members. Invariably, the medical care was "different" because we were all trying so hard. I have also had my own colon polyps called "atypical" because my colleagues were worrying too much.
My most poignant memory, however, was calling a 42 year old cardiologist to tell him that his liver biopsy for a mass was negative. I thought he would be happy, but then he told me he had a 30 lb unexplained weight loss - an ominous sign. Turns out the radiologist had just missed the lesion (trying too hard?), a rare sarcoma from which the patient died 2 years later even after a liver transplant.
ps you have a VERY SMART doctor.

Lyette said...

re #1: She's so awesome. Probably the only doctor I've ever looked forward to going to see.

re #2: only slightly related, but my mother is the only registered mammographer at our local hospital, and my poor dad has had to endure years of local ladies coming up to him and saying, "Oh, your wife did my mammogram last week!" I think he wishes there was some way to extend HIPAA to the patients themselves.

eeka said...

Lyette, I'm definitely in favor of #2!

I've had so many clients mention a current or former client to me. I have a practice of not acknowledging at all that I recognize a name of a client. (I will make exceptions when someone comes in initially and says I was recommended by someone, then I'll acknowledge the name but won't discuss the person further). It's pretty easy to set this limit when a client (or other professional) directly states that they know a current or former client of mine, in which case I'll just say that I don't violate privacy, just as you can expect I won't violate your privacy. It's harder though when someone says something like "oh, I ran into X last week..." without stating that they know (or suspect!) the person is a client, because I'm not going to lie and say that I don't recognize the name, but I also don't want to acknowledge that they're a client in the course of my limit-setting. I work with a lot of people who have poor boundaries and engage in gossiping, harassment, intimidation, etc. as part of their disability, so many of the people who are trying to get me to acknowledge that I know so-and-so really DIDN'T hear it firsthand that s/he has been in treatment. I usually just deflect it: "Oh? Is that a friend of yours?" then if it comes back to asking if I know the person, I'll say that I prefer not to take up session time talking about whether I know people.

Anonymous said...

This is the exact reason why we should not offer “VIP” services to all trustees, overseers, board members, brothers of board members, friends of board members, etc. It is detrimental to their care (contrary to what they may think) and therefore the service should not be offered. It is the rare clinician that can remove external political influences from otherwise exceptional decision-making. Kudos to your personal physician!

DDx:dx said...

So this exec "valued" his primary care doc's honesty and appropriate care. Did his pay her half what he would have for a catherization, should it have come to that? By saving this procedure with her clincal acumen did she garner wealth for herself or anyone, or was the health care economic machine deprived of the fuel it needs. Imagine a whole hospital/ health care system with this sort of parsimony....What's the incentive? To treat patients appropriately....Does it pay? It should.
http://poemd.blogspot.com/2007/02/soldier-for-empire.html

Paul Levy said...

ddx:dx,

The whole payment system is convoluted, as you know. Doctors who make this kind of judgment call are not paid nearly as much as those who do procedures on payments. I wish primary care doctors were paid more by private insurers and Medicare, but I see litle progress in that direction.

Anonymous said...

Paul, As a specialist at BIMDC, I hope you don't actually feel that you need "protection" from your own docs, I know you know that the vast majority of procedures performed at academic institutions are not only indicated, but safe. If specialists are performing too many procedures (which I agree is possible even at high level academic institutions), I would argue that the current medico-legal atmosphere and reduced medical reimbursements, not the doctors, are to blame. Although I am not a cardiologist or cardiac surgeon, your PMD should know and show some trust in that the vast majority of cardiac caths are perfectly safe and many will save the lives of "healthy" middle aged men with abnormal stress tests.

Paul Levy said...

My doctor was especially concerned that our specialists, with their concern about their CEO's well-being, might try a little too hard to make sure I was OK!