A Tale of Two Sisters

Jane Barker and Judy Swift didn’t look like sisters, and from what I understand, they didn’t spend much time in each other’s company. They had both been my patients for years by the time I learned that they were sisters.

The one thing they had in common was their smoking history. Jane was discreet about it, but Judy’s struggles to quit were obvious. She had tried every available smoking cessation drug. She had COPD and saw a pulmonologist regularly to help manage her chronic cough and shortness of breath.

Jane’s most pressing medical problem was always her touchy digestive symptom, and Judy came in a couple of times last fall for fatigue. Then just before Christmas, Jane developed a severe cough. Her chest x-ray was negative and the cough was non-productive. I told her it was probably viral, and prescribed inhalers for her. She called back asking for antibiotics and cough suppressants. I tested her for influenza and prescribed empiric antibiotics for mycoplasma, but she continued to be plagued by her dry cough. A repeat x-ray suggested a lesion in her right lung, and it looked malignant on CT scanning. I referred her to a pulmonologist and a thoracic surgeon.

Jane’s cough made the thoracic surgeon nervous, and her surgery was delayed several times because of the severity of her cough. Finally, in mid-February, she had her surgery. I saw her for a couple of postoperative visits, and although she felt terrible and continued to cough, her surgery seemed to have been a success. We spoke of her stubborn cough and how it probably saved her life.

In late February I saw her sister Judy again. She looked terrible, and she had lost weight. I had done all kinds of tests on her just before Christmas when she came in for fatigue. She had seen her pulmonologist not that long ago, but I sent her for a CT scan of her chest, even though her x-ray didn’t show anything new. The scan showed a plum-sized irregularly shaped tumor deep inside her right lung. She also had several enlarged lymph nodes.

I called Barry Wolf, her pulmonologist. I could hear him sigh when I told him what I had found.

“I’ll get her right in,” Barry said.

I received a couple of courtesy copies of her test results in the mail that told the rest of the story. Her pulmonary function tests were very poor, and she wasn’t a surgical candidate. There was a consultation note from a radiation oncologist, then nothing more.

Her obituary was printed in Saturday’s paper.

My Most Expensive Instrument

Doctors in other specialties treat their patients with exotic and expensive instruments to peer inside their bodies or rearrange minute and delicate body parts. Not so Family Practitioners. When I think about it, I am convinced that my most expensive, or, shall we say costly, instrument is my pen. Not the Montblanc my wife gave me for Christmas one year, but the disposable rollerball pen I buy by the box and use when I order tests and prescribe medications.

How often does a doctor reach for the prescription pad as a quick solution to a problem that really should be dealt with in a meeting of the minds between healer and patient? How often does a doctor order a test to document what is already evident through the history and physical exam?

I often hear patients ask for an MRI “just to know what’s going on in there”, and unless they have managed care that requires “prior authorization” for expensive tests, how much faster isn’t it to order the test than it is to explain to the patient that the test serves little purpose in a case of low back pain, for example, since science still hasn’t sorted out what causes most cases of that particular ailment.

We are constantly bombarded with advertisements and promotions for expensive medications that offer theoretical advantages over older, less expensive, drugs. And all the studies backing up the effectiveness claims of these new wonder drugs are double blind comparisons with placebos. How polite, not to compare them with the well established treatments they are hoping to replace.

We as physicians have an obligation to our patients to watch over their health, but also to help them get reasonable value for their health care dollars (or Francs, kronor, Pounds or Marks). One of our duties is to test and prescribe responsibly, and to strive for achieving a fair balance between protecting the individual patient’s interest and the collective interest of all our patients.

I often find myself comparing physicians’ work with that of other professionals, particularly lawyers. I imagine a lawyer, hired by one client to protect that client’s interests, can devote just about any amount of time that the client is willing to pay for, and that ultimately someone else within the legal system, be that a jury or a judge, will balance, arbitrate or adjudicate the claims of the opposing parties. As physicians, we usually can’t give a disproportionate amount of attention to a single patient, at least if we expect the insurance companies to pay us for our work. We also cannot usually practice with complete disregard for the greater common good. We need to be the ones to say “If I did this for all of my patients, what would happen?”

If I prescribe broad spectrum, expensive antibiotics for one patient who doesn’t need them, I need to ask myself what would happen if I did that for most of my patients. This is why we have multidrug resistance today. If I order unnecessary tests “just to be sure” in a few cases, what would the impact be if I extended that behavior to most similar situations?

Doctors in the United States often think that ordering more tests is a way of avoiding criticism or even malpractice litigation. Time and time again, we see that the biggest danger of such events is practicing in a hurried fashion without really stopping to listen to our patients.

Sometimes I reflect on the irony that even one month’s worth of any one of the new maintenance drugs I am asked to prescribe for restless legs, overactive bladder, migraine prevention or prostate trouble costs more and is less regulated than my fee for the time, effort and expertise required in choosing, prescribing and monitoring the treatment.

Unfortunately, my simple rollerball pen is a more expensive instrument than the diagnostic and therapeutic acumen I have developed over the years, at least in this economy.