D. had brought me his mother for her health, and I guess he learned to trust me, because next he brought himself. I learned that D. was, like a lot of attorneys in my life, more than most somewhat fearful of medical matters and of his own health. He asked a lot of questions, and required a lot of reassurance. More than most.
One day, D got dizzy. We had always had one of our group on call after office hours and on weekends and holidays. Always. D. didn’t call, though. He went to the Emergency Department. There he had a physician evaluation and a scan of his head. The doc told him that he had discussed the results of the scan with a neuroradiologist, specialized in reading images of the brain. There was a “thing” in D’s cerebellum, the part of the brain most involved in automatic movement, like walking, and potentially with dizziness, although the vast majority of dizziness episodes involved the ear, inner ear, and connections, not the cerebellum. D was of course very very concerned. The doctor told him it looked like a scar from a hemorrhage from D’s birth, that had calcified over time, and likely would need nothing. “How can you know for sure?” D wanted to know. So the ED doc referred him to a neurosurgeon. The surgeon agreed it was an old scar that needed nothing, but got the same question. Did I mention D was an attorney? Doctors are particularly cautious about avoiding malpractice accusations when dealing with attorneys. Why? Really? You have to ask that?
“Well, we can do another scan in 6 months.” said the surgeon. I heard about this event after the first scan and consultation, and before the second one. Then I heard again how relieved D was after the second scan looked just like the first one. I thought that was the end of it. A year later, D had another scan, and again a year after that. Why a year? What’s so special about 365 calendar days? The billing cycle for insurance.
After four scans, D was in my office, and asked, “When should I get the next scan?” I was incredulous. “Why would you do that again? It hasn’t changed since you got the first one!” “So you think I don’t need another scan?” “No, D, I don’t think you needed the first one! If you had called us and come in later, I wouldn’t have ordered a brain scan for ordinary dizziness. Even if I had, the reading was of a healed hemorrhage from childhood. There never was a good reason to get another one other than to reassure you, and I think that instead it has just kept you worrying about it!”
D. stopped getting scans. We had a strong trusting relationship. I simply told him the truth, a truth that he already knew: he was anxious, and it wasn’t serving him well, and worrying about the wrong thing never does.
Patient care should be about caring for the patient, not liability, not about insurance, and not about money. It’s incredibly easy to transfer any concern I might have as a doctor to the patient. But that doesn’t make it the right thing to do. I once got concerned about a dark “mole,” that might have been an early melanoma, a dangerous skin cancer. I told the patient, and did the minor surgery to remove it. The pathology report said it was a normal nevus. To me that meant I should never have gotten worried about it nor removed it. I apologized to the patient, and he had to reassure ME that he was grateful I had performed his unnecessary minor operation! As I said, it’s easy to transfer my anxiety onto the patient, and sometimes lucrative to do a procedure and receive thanks, even when it’s unnecessary. Happens a lot! Here’s another real example. My friend, an older woman, saw her cardiologist. Why she had one at all I don’t recall. Anyway, she asked about getting a coronary calcium scan. Really, she wanted one, and he accommodated her. It showed significant coronary disease, and although she had NO symptoms, her anxiety, his ability, some data, or whatever, she scheduled and he did a cardiac catheter study. While probing one of her major arteries, the catheter disrupted the artery, and it dissected, meaning a flap of tissue moved into the open artery and closed it. That result required the cardiologist to insert a stent, commonly used AFTER a procedure like a balloon angioplasty, in which a narrowing is blown open with a very small but hard, tense balloon, then a stent inserted to keep that part of the artery open. Well, in this case, the first stent failed, the dissection proceeded “downstream” in the artery, and a second, then a third stent were required to stop the progressing damage. My friend went into shock, had an out of body near death experience, which she was telling me and others about, prompting this story to come out as I’ve told it. From my point of view, the coronary calcium screen was never indicated, nor was the cardiac cath procedure, which had triggered the dissection of the artery, three stents, and nearly killed her. The cardiologist was prominent, a well known figure. I had another patient who had chosen him also. But after learning about this episode, I would never consider referring anyone to him. Within some months, he retired, perhaps, after nearly killing someone with his poor judgment. My friend, or someone else. It would be very easy to find any number of cardiologists who would defend all of his decisions, and my friend had NO intention of suing or blaming. Instead, she was grateful that he had saved her life with his three stents, even though he had caused the need for them!
Go figure!