The doc is out; it’s your call

Posted Nov. 02, 2010, at 12:32 a.m.

This is the second in an occasional series of columns about taking care of patients in my office, and because it’s the 21st century, this column will be interactive.

Being my patient should be pretty simple. You come into my office with a nail of a problem and I hit it with the hammer of my therapy. You get cured, I get paid, everyone is happy. Why is it so many patients keep screwing up my life by being complicated?

Here’s an example: George comes to me with a little problem in his abdomen that I can’t figure out, so I order a CT scan looking for tumors, gallstones, alien infestations, whatever. If he followed the plan as above his scan would be negative, his pain would go away, and the Patriots would win the Super Bowl. But noooooo — the CT of his abdomen is normal, but the lower part of the darn lungs are covered, incidentally, in the scan and one of them has a “spot” in it.

Unfortunately, “spots” to most patients mean cancer, because they often turn out to be exactly that. This one is probably no more dangerous than the Spot that Dick and Jane had, and almost certainly is not cancer. I tell George but am certain all he hears after this spot news is “Blah — spot possibly cancer — blah.”

The radiologist who studied the scan said this spot was very unlikely to be cancer if the patient was not at high risk for cancer, which George isn’t. That’s why this expert in CT scans just recommended doing another CT scan in a year to make sure the spot is stable and therefore not cancerous. If there was any real concern about cancer, a full CT scan of the lungs now would basically rule out cancer if that was the only spot, with a follow-up CT scan in a year just to be sure. But a full lung scan now, in addition to the one in a year, would probably just be a waste of money, increase the patient’s cancer risk down the road from CT radiation exposure, and it’s probably not cancer, so why not wait a year?

So you tell the patient all of this and recommend that repeat CT scan next year. But you and he agree there is this teeny, tiny problem — what if it really is a cancer? Then waiting a year might allow a treatable cancer to spread to the point of being untreatable. Then maybe he dies prematurely, his kids grow up without a father, and you feel like a lobster scalding forever in a pot of guilt and lawsuits.

As you discuss all of this, it dawns on you that he and most patients, you and most docs, and the practice of medicine, are all a little complicated. In fact, that’s why chimpanzees cannot practice medicine and decide whether to order CT scans now or just wait a year.

So what would you do if you were the doc — not the patient — faced with this decision? Choice A — order a CT scan now and then again in a year, probably find out it’s not cancer, but spend a lot of someone’s money and increase the patient’s risk of cancer from radiation by doing two CT scans instead of one? Choice B — just wait a year for another CT scan — less money, less CT radiation risk, but more peace of mind for doc and patient?

Here’s the interactive part: In the comments section at the end of my column give me two answers — one assuming the patient had insurance that will pay for most of the CT scan, and another assuming the patient was going to pay $800 out of his own pocket for each scan. Then in two weeks I will tell you what I did and why.

While you ponder, remember you’ll never have all the information you and the patient want to make the decision. Don’t waste any money because health care is too expensive. Every CT scan adds a little risk of causing cancer. Don’t make any mistakes, and you are already late to see the next patient, so hurry up, Doc.

Erik Steele, D.O., a physician in Bangor, is chief medical officer of Eastern Maine Healthcare Systems.

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