All!
I know I haven’t been able to shut up about my medical problems lately, but I want to call your attention to this NYT article from a few days ago. First, though, let me express my deep thanks to everyone who offered me support before my surgery in August. I had the procedure on the 26th, was up and about the next afternoon, and am relieved to have the whole thing behind me. I created a blog about dacryocystorhinostomy, aka DCR, aka “blocked tear duct surgery,” in case anyone who needs to have it done wants to read an account of what it’s like. The blog’s purpose is mainly to reassure anyone who’s as freaked out as I was, so I didn’t get into any deep analysis or anything – not even of the very fucked-up power dynamics of hospitals, which I got a small taste of even as a white, het, cis, middle class patient. Anyway, if anyone you know calls you up and is like, “there are stones in my tear ducts and now they’re going to operate!?” you can send them here.
Anyway. The article discusses a doctor who’s trying to wean the medical profession off of its dependence on tests, and bring back the physical exam as a way of diagnosing ailments:
At Stanford, [Dr. Abraham Verghese] is on a mission to bring back something he considers a lost art: the physical exam. The old-fashioned touching, looking and listening — the once prized, almost magical skills of the doctor who missed nothing and could swiftly diagnose a peculiar walk, sluggish thyroid or leaky heart valve using just keen eyes, practiced hands and a stethoscope.
…
He is out to save the physical exam because it seems to be wasting away, he says, in an era of CT, ultrasound, M.R.I., countless lab tests and doctor visits that whip by like speed dates. Who has not felt slighted by a stethoscope applied through the shirt, or a millisecond peek into the throat?
Some doctors would gladly let the exam go, claiming that much of it has been rendered obsolete by technology and that there are better ways to spend their time with patients. Some admit they do the exam almost as a token gesture, only because patients expect it.
Medical schools in the United States have let the exam slide, Dr. Verghese says, noting that over time he has encountered more and more interns and residents who do not know how to test a patient’s reflexes or palpate a spleen. He likes to joke that a person could show up at the hospital with a finger missing, and doctors would insist on an M.R.I., a CT scan and an orthopedic consult to confirm it.
A few years ago, I flipped my car on an icy Iowa freeway. The car was totaled, but I got out unscathed; when an ambulance showed up, they found me sitting in the passenger seat of a good Samaritan’s car, picking windshield fragments out of my sweater. The EMTs asked if I wanted to go to the hospital and I said no, I was fine. Then I felt a rush of weakness in my neck and reconsidered. “Is this normal?” I asked. “Just come in,” they shrugged. You hear these horror stories about people dropping dead from sudden blood clots and whatnot, so I agreed. I even let them strap me onto a back board, ridiculous as it seemed, and arrived at the hospital with really no symptoms to speak of – just the weakness. I was 95% sure I was okay, but I’d just been in a car accident, after all, and wanted to be 100% sure.
Throughout my whole afternoon in that hospital in rural Iowa, no doctor examined me. Rather, someone somewhere ordered two X-rays and a CT scan of my neck. When the back board started digging into my scalp and I told the nurses it hurt, Dr. Whoever ordered a CT scan of my head, too (yes, I told the staff it was just the back board; no, they didn’t listen). It took a whopping 4 hours for the test results to come back, and left me with a bill of about $600 after insurance.
I’m pretty sure that if a doctor had just felt my neck and had me wiggle my fingers and toes, I would have been out of there in a lot less time, owing a lot less money.
And here’s the icing on the cake: as I lay there, having just peed into a bedpan because the nurses wouldn’t unstrap me, weeping over the death of the first car I’d ever bought myself, I received a phone call from my graduate program saying they needed someone to pick up Jonathan Lethem from the airport. Would I be interested? I’d get a free book for my trouble. True story.
So is the physical exam “obsolete?” Look, just because technology makes something different, that doesn’t mean technology makes it better. CT scans and X-rays allowed this Iowan doctor to treat me without ever laying eyes on me. Great – here’s a medal. But it was a rotten, cumbersome, time-consuming, and expensive experience that I wouldn’t wish on anyone. Is this what we consider progress?
I have a chronic condition (endometriosis) that can currently only be definitively diagnosed by surgery, and I’m glad of my doctors’ dependence on tests. It gives me the ammunition to deal with OTHER doctors who want to give me helpful advice like “period pain is normal”, and “just take some Advil”. The problem with subjective techniques like physicals is that they’re mostly as informative as tests if the doctor is very good and the patient is cooperative and helpful, but it’s *so* easy for biases to creep in and distort the results.
Many patients with poorly understood health conditions fervently wish that they could be tested and get some kind of objective evidence, especially those who are less-privileged. As a white, upper-middle-class, English-speaking, het/cis professional, it’s relatively easy for me to get doctors to take me seriously — and it’s still not foolproof. If I were a woman of color, or if I had a mental illness or were on public assistance, I’d be much likelier to be labeled a malingerer or an attention hound, or (worst of all) a drug-seeker.
Yes, you got an “unnecessary” CT scan, but the flip side of that is that someone else’s CT scan got them a diagnosis of kidney stones instead of a quick dismissal and a few ibuprofen.
But I don’t think that means that “CT scans for all, physicals for none” is good policy – just as the opposite wouldn’t be good policy, either.
Use of technology doesn’t prevent biases from creeping in and distorting things. It’s a tool, as good or as bad as the use that’s made of it. I’ve had a dentist look at an x-ray and tell me I had cavities it turned out I didn’t have. Routine use of continuous fetal monitoring in labor has led to an increase in the c-section rate without improving outcomes for babies. My brother underwent a bunch of tests for a sinus condition, all of them inconclusive. When the tests found nothing wrong, my brother (white, cis, het, male, etc.) was told his condition was all in his head and maybe he was depressed about his dead-end job. He got his relief when a different doctor bothered to actually examine him and found a deviated septum (which then required surgery).
You seem to imply that unnecessary tests are, in the worst case scenario, neutral. They aren’t neutral when they result in delayed treatment and unnecessary surgeries or medications, all of which have their own risks.
Julie, glad the surgery went well. I would have been freaked out, too.
There is no doubt that U.S. medical culture seems to be set up to hemorrhage as much money as possible, and I’m all for Dr. Verghese’s campaign. He’s not alone.
But what we doctors run into is a enormous bias by patients that if we “deprive” them of an MRI, then we are giving them inferior care or even trying to kill them. (Such perceptions were not helped by Sarah Palin screaming “DEATH PANELS” at the top of her lungs during the health care reform debates.) Americans are bedazzled by technology.
The ugly elephant in the room that no one will talk about is that the needless use of such expensive technology, with no sympathy for the paying customers on the other end of the bill, drives up the costs of care for all of us. And doctors rely on technology to cover their butts, because they do not wish to get sued.
There needs to be a happy middle ground, of course, but it will only be reached when patients are willing to believe that less technology might mean better care, not worse care. In an era where primary care docs like myself are going under financially because they can’t see enough patients per day to support their overhead and pay their staff, using technology is faster, and so is incentivized. What we need is more support for primaries to spend time with their patients. Doing a careful exam and the careful interview that will make 90% of the diagnoses takes TIME, and that’s the one thing we don’t have anymore.
using technology is faster, and so is incentivized.
This isn’t something I’ve seen; group insurance plans strongly discourage the use of technology. I had to argue with the last primary physician I saw in order to get a blood test for my failing thyroid. I had all the classic symptoms (along with all three of my father’s sisters with Hashimoto’s—and I’ve since found out two of my mother’s sisters have it as well). The doctor blithely said, “oh, those aren’t symptoms…that’s just your age!” (I was 41 at the time). Having taken half-a-day off from work (did you know most people don’t get paid for this?! well, this physician didn’t know that either), I wasn’t about to let the appointment go to waste—I insisted it wasn’t “my age” and argued strongly for the (inexpensive, fast, not-really-invasive) blood test that would confirm my condition. She spent more time trying to convince me I was just a depressed older woman* than she did listening to me describe my symptoms. Regarding my family history, she even said that “aunts are too distant a relative to have any connection for hypothyroid.”
I assume her reluctance stemmed partially from my insurance plan (which is a really damn good one, but like most of them gives incentives for fewer tests). When I finally wore her down with my insistence on a blood test, she kept muttering something about “but this isn’t enough to warrant a test….” (because…I’m an “older woman”, and supposedly we’re supposed to feel like we’ve been hit by a bus all the time).
So. Long story short—yes, my blood work indicated obvious hypothyroidism. Yes, this was a lousy doctor. Yes, I finally had to ask for a referral to an endocrinologist, who is an excellent doctor and had my blood work back on track. (the primary first overdosed me, then underdosed me and wouldn’t consider raising it.) I feel great now—literally the difference between night and day.
Dr. Loftus, what is the medical profession doing to eliminate the sexism, racism, and ageism towards patients? Because “time” wasn’t a problem in my case—the physician spent twenty minutes with me, total. (that doesn’t include the two hours I spent waiting for her, mostly in the exam room. I know the drill. I brought a book.) No, the problem was that because of my visible identifiers (age, sex, ethnicity) she assumed a condition I didn’t have (depression) and wouldn’t consider either my visible or nonvisible symptoms as pertaining to anything other than age. That “careful interview” you reference does no good if the doctor is listening to an internal script based on stereotypes, and not the verbal one given by the patient.
So….some of that push by patients is to provide “proof” of the underlying condition. I was really glad to have my bloodwork to prove that I wasn’t “imagining” how I felt. Many of us are written off by physicians—not considered, not listened to. That’s a universal experience of women where I come from, and especially if we are over 40 (any symptoms immediately written off as menopausal, even if we ourselves are not menopausal yet. My physician was surprised that I was still menstruating at 41. She’d probably fall over to know that my period is still going strong at 43.)
*can you say, “drug company perks?”
La Lubu, you’d get treated better if you were paying the bill instead of a third party. That’s the trouble with insurance and government programs and anything else that moves the economic power away from the patient – people who are working for money, and doctors, nurses, hospitals, radiologists, etc. work for money, respond to the people who pay their salary.
We could head in the right direction on many structural decision-making problems in health care, by moving the money back to the patient. I’m not necessarily saying let’s end insurance and government payouts and make everybody pay cash, but when we have insurance and government payouts, we need to move those to the patient and give the patient control over the $. Healthcare vouchers, for example, that go to the individual and which they decide where to spend, and what on.
Only then will the doctor be more interested in what the patient wants, than in what an insurance company or government regulator wants.