A Country Doctor Writes:

Archive Page 186

The Call

Published October 8, 2010 Progress Notes 1 Comment

I got the call again tonight. It’s always the same:

“Hello, Doc, Officer Moran here. We have an unattended death…”

The patient’s age, gender and circumstances aren’t predictable, but it’s always the same story. Once again, someone died, who wasn’t supposed to die.

I never get used to getting these kinds of calls, even after all these years. They wake me up early on Saturday mornings, they come in the middle of a late supper, they come while I work and when I rest.

An unemployed sixty-two year-old woman on pain medications is found dead in her bed one morning; a successful businessman dies suddenly behind the wheel of his Mercedes near the golf course; a father, who lost his parental rights in a divorce, is found hanging from the rafters of his barn.

These calls last only a minute or two, but their effects linger and accumulate, one by one and over the years. They are different from losing patients to illnesses that span over time, however short. They offer glimpses into desperate recesses of people’s lives and they announce medical disasters I never saw coming.

Each call stops my day, suspends my own life, while my mind brings forth images of the patient and my last interactions with them. Was there any clue that this could happen? Did I do everything I could with what I knew at the time?

I gather my thoughts, register the emptiness, and try to return to where I was before the call came. If I am at work, I must quickly get back to a waiting patient, who expects my full attention. At home, my family understands and gives me latitude. It does take time to work through the emotions after these calls, even after thirty years in this business. That’s probably a good sign.

Fearing the Worst

Published October 6, 2010 Progress Notes 1 Comment

Seeing George Hess last Friday, I almost gasped as I registered his dramatic weight loss over the last four months. His complexion was pasty, his cheekbones protruding and his eyes sunken, yet intense with an expression of anguish, framed by dark circles.

He seemed tired and not himself. He barely spoke at first. Harriet, his wife, listed all the symptoms George had developed since I last saw him: severe, unrelenting back pain at first, followed by steady abdominal pain, loss of appetite and later intense nausea with vomiting with most attempts at eating.

George was always thin, but now he looked cachectic after losing more than twenty pounds. His eyes showed no jaundice and his urine and bowels had normal color. His back wasn’t tender, but his abdomen was tender just about everywhere, yet soft. I couldn’t feel his liver, spleen or any tumors.

“You’ve got to help me”, he said in a quiet voice. “I can’t go on like this”. Even when he was quite ill last year with diverticulitis, he had not looked or acted like this.

“We need some bloodwork right away and then some x-rays. We should know by Monday or Tuesday what this is”, I said. In my mind I wondered if this was yet another case of pancreas cancer. I have seen several in the past five or six years. My wife, in her entire career, has never seen one.

I prescribed some pain medication and something for nausea and sent George to the lab. I needed to know if his kidneys could tolerate the CT scan contrast and I wondered if he was anemic and what his liver and pancreas chemistries would show.

By the close of business his blood test results were back – all normal, except nearly borderline kidney function for using contrast. We couldn’t get a CT scheduled until late Monday. I worried over the weekend what was the matter with George. I even described the clinical scenario to my wife over dinner as I reviewed in my mind what I knew so far about George’s case. She thought for a moment, then asked if the patient still had his gallbladder and wondered if I had considered ordering a gallbladder ultrasound before thinking pancreas cancer and CT scan.

“He just looked too sick, and his eyes had that intense, terrified stare all my other pancreatic cancer patients have had”, I explained.

Yesterday the radiologist called me and said he wasn’t comfortable using contrast. By his calculation, George was just under the creatinine clearance limit.

“Do it without contrast then”, I said. “You’ve got him there, and maybe we’ll see something.”

The rest of the afternoon went by and I didn’t hear anything from the x-ray department.

Mid-morning today the report came in. The CT scan showed no evidence of any tumors or fluid in his abdomen. It did show that in comparison with last year’s scan, George’s gallbladder was significantly larger, but no gallstones were visible. The radiologist suggested an ultrasound to better assess for gallstones.

I guess my wife was right in reminding me of one of my own favorite expressions: Common things are common.

Playing the Odds

Published October 4, 2010 Health Topics 2 Comments

Much of what we do today in medicine isn’t treating diseases, but manipulating risk of disease.

Two people with the same elevated cholesterol value may be treated differently because their other risk factors for heart disease are different. A 65-year-old smoker with diabetes and high blood pressure is statistically more likely to benefit from cholesterol lowering medication than a younger, healthier person. Both these people can lower their heart attack risk by 50%, but, in the case of the younger, healthier person with an already low risk of heart disease, 50% of nothing is nothing. One of the findings of the recent JUPITER study was that lower risk patients could also reduce their heart attack risk by lowering their cholesterol. The question is whether they should be treated, since their risk is already low.

The way I explain this to patients is with lottery tickets and rebate coupons.

“If I buy a megabucks ticket and you buy two, you will have twice the chance of winning that I have, but you probably shouldn’t start spending your money yet” usually gets a nod or a smile.

That example illustrates relative risk. Just like in the example with one or two lottery tickets, relative risk isn’t enough to make a treatment decision. You need to know the absolute risk. For example, who would wear an insulated rubber suit just because it reduces your risk of getting hit by lightning while walking your dog by 60%? Most of us would probably say, “No thank you, I’ll take my chances”.

The Framingham Heart Study provides a simple risk calculator for heart disease. With it, I can show patients their relative and absolute risk of disease in the next ten years. I can then show them the impact of reducing that risk by lowering blood pressure, quitting smoking or treating cholesterol.

Our middle aged diabetic, hypertensive smoker may be facing more than 20% risk of getting a stroke, heart attack or a symptomatic blockage of a coronary artery, while the younger, healthier person may have only a 2% risk of disease in the next ten years.

Which one of these patients to treat for their high cholesterol might be illustrated with a question of when you would rather use a “50% off” coupon – buying a cup of coffee or buying a new car?

Let’s look at the wisdom of treating both the low risk and the high risk person for their high cholesterol in order to reduce their heart attack risk by 50%:

If we treat 100 patients with a 25% 10-year heart attack risk for ten years, only 12 would have a heart attack instead of 25. Treating 100 patients for ten years would prevent 12 heart attacks. You would therefore have to treat 8 patients to prevent one heart attack. We call this the Number Needed to Treat (NNT). An NNT of 8 is a pretty good deal.

For patients with a 2% heart attack risk, we would have to treat 100 of them for ten years in order to avoid one heart attack. An NNT of 100 is clearly very different from an NNT of 8, so “50% risk reduction” really doesn’t tell us much if we don’t know the absolute risk.

Here are some more or less surprising examples of the number needed to treat:

Shingles vaccine doses given in order to avoid one case of shingles: 59.
Ear infections treated with Amoxicillin to avoid one ruptured eardrum: 20.
65-69-year old women treated for osteoporosis to avoid one hip fracture: 88.
Cortisone shots to relieve one sore shoulder: 3.
Aspirin prescriptions to prevent one heart attack: 200.
Prostate cancers treated in order to prevent one death: 18-48 (most men with prostate cancer don’t die from their disease)
Adenomatous colon polyps removed to prevent one colon cancer: 50 (only 2% of “precancerous polyps” actually turn into cancer)

The Number Needed To Treat is not popular with the makers of many of today’s blockbuster drugs. In the case of symptomatic treatment, like heartburn, bladder spasms or pneumonia, patients can more easily judge whether a medication works or not. With risk reduction, we’ll never know ourselves whether we wasted our time and money or not.

As physicians we should not accept claims of relative risk reduction without knowing the absolute risk and the Number Needed To Treat.

I remember people in Sweden talking about a book in the sixties, titled “Hur man ljuger med statistik”. The author, it turns out, was American. Darrell Huff’s “How to lie with statistics”, first published in 1954, is still in print. No wonder; statistics are still being used to trick people, including doctors and patients.

Mechanical Voices

Published October 2, 2010 Progress Notes 4 Comments

Today at the nursing home in the next town, where I occasionally admit patients, there was an elderly gentleman sitting in a chair right across from the nurses’ station. As he leaned forward in his chair, a red light turned on at the top of a small box on the back of his chair and a slightly metallic woman’s voice said sternly “Albert, please sit down” four times in a row. The old man just sat there, frozen, and a bewildered frown spread across his brow.

“I am sitting down”, he said in a meek and exasperated voice as one of the nurse’s aides came over. She explained to the old gentleman that he needed to lean back more in his chair as she silenced the alarm.

A curious sadness filled my heart as I returned to my charting at the nurses’ station. The mechanical voice had started inappropriately just because the poor fellow leaned forward in his chair, and at the time of day this took place, in the middle of the afternoon and right across from the nurses’ station, the whole electronic getup seemed unnecessary and a bit dehumanizing.

It reminded me of a video presentation I had witnessed about heart failure patients in their homes, sitting down in front of a computer screen with a blood pressure cuff and an oximeter. After entering their information and strapping on the blood pressure cuff, a computerized voice said “Good job!” and the elderly person would get on with their morning routine while a Registered Nurse somewhere would start her day at her computer screen and see the uploaded information from her various clients. She would then call the ones who had gained weight or showed abnormal vital signs. I remember feeling a bit disturbed about the computerized voice giving positive feedback to an elderly woman, who seemed a bit forlorn as she navigated the digital communication. I wondered how much longer it would have taken if she and the nurse had been on the telephone together at that time and chatted in person about how she was doing.

Health care without the personal touch is not what it used to be when people answered telephones and gave comfort and advise in person.

Today I also had to call the cardiology office at Cityside Hospital. The computerized voice said what she always says:

“Thank you for calling Cityside Cardiology. Please listen to the entire menu as our options have changed. If this is an emergency, please hang up and dial 911 or your local emergency number. If you are a physician or a physician extender and need to speak to a cardiologist now, please press ‘one’.” The other options were many and confusing and I was relieved I wasn’t elderly, sick or scared and trying to maneuver that system. The automated switchboards also don’t work for those of my patients who have rotary phones.

Our clinic doesn’t have the latest technology, and I am proud that we have human beings answering the telephones for our patients.

This evening, I had to call American Express to pay my monthly bill. A cheerful, youngish woman asked me to punch in my credit card number, then said “just a moment while I look up your account – okay, found it! – and for security purposes, I see that the number you are calling from matches…” Her comforting voice walked me through the transaction I have made so many times before, and even remembered my checking account number from last time. At the end, she said in a reassuring tone “You’re all set…”, gave me my confirmation and told me “you can go ahead and hang up”. She sounded nicer than many of the live voices I had talked to today. Actually, she was a pleasure to deal with.

Mechanical voices and computers can be okay if they make a transaction convenient, quick and logical, like using the automated check-in at the airport if you are an experienced traveler. But if you are unfamiliar with the system, elderly, sick or scared, you deserve a human voice with some heart and caring behind it.

Fecal Occult Blood Tests Illustrate What’s Wrong With Health Care Today

Published September 28, 2010 Reflections 1 Comment

After a busy Monday at the clinic, I sat down to look at some journals while our supper was warming up in the oven. An article in Medical Economics caught my attention. It made me first a little bemused, but that soon changed into something between anger and sadness.

Under the heading “Coding Cues” a question was posed about how to bill insurances for fecal occult blood testing – those little cards we use to see if a stool sample has blood in it. The answer exceeded 400 words in length. I looked up what the reimbursement is – $4.54, less in some states.

The essence of the article is that, as the simplest of all screening tests for colon cancer, you cannot bill for only one test. You must hand out, and charge for, three of them (CPT code 82270). As a diagnostic test for blood in the stool, if the first one is positive, doing three is a waste of money (CPT code 82272). An unclear clinical scenario may require 3 samples to determine the presence of blood (CPT code 82272). Choosing the wrong CPT code for the wrong scenario means no payment, even though both codes represent stool testing for blood.

A few years ago, our clinic seemed to talk about these hemoccult cards a lot. At that time providers were simply forgetting to charge for them. I had no idea how complicated the subject was, since I am several steps removed from the billing process. It is not hard to imagine why our health care system is in shambles when a test that costs less than $5 is so complicated to charge and bill for that it becomes a full-page article in a Family Practice business magazine.

Someone is clearly watching over us with incredible suspicion and mistrust. And we are surely being micromanaged.

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