June 18, 2018
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A thoughtful discussion of a CT scan decision

By Dr. Erik Steele

I like to torment readers of my column, so two weeks ago I asked them what they would do as the doctor in a real patient care dilemma that came straight out of my family practice. Embedded in one difficult decision were “simple” issues of potentially fatal medical errors, health care costs, how fear drives patient care and much more.

The dilemma was this: What would you do if your patient George had an abdominal CT scan incidentally show a “spot” on his lung that had a tiny chance of being cancer? Would you do another costly CT scan now and a third in a year to rule out cancer because you and the patient are paranoid about the risk? Or would you take a tiny risk and just do one CT scan in a year to confirm the spot is not cancer, which is what the radiologist — an expert in CT scan interpretation — recommended? And should the issue of whether the patient or his health care insurance would pay for the second scan make a difference in the decision?

What I got in response was some of the most thoughtful discourse about health care that I have seen in a long time. Twenty-five people weighed in on the issue at the Bangor Daily News website; not one sounded like a blowhard with nothing but hot air to offer. That is in direct contrast to most national political commentators covering such issues. It reminded me how thoughtful Americans can be when we move past slogans, headlines and ranting to thoughtful debate.

Here’s what respondents said. They split pretty evenly over whether to get another CT scan now. One-third said do it now, one-third said do it in a year, and one-third suggested alternatives that focused on good discussions between doctor and patient (what a concept!). The split was not surprising; it was, after all, a difficult de-cision to make. By three to one, however, they opposed the idea that the ability of the patient to pay for the CT scan should have anything to do with the decision.

Here’s what I did. I chickened out and ordered the second CT scan of the lungs now. That scan showed no other evidence of cancer, and the patient will have another one in a year, just to make sure. The patient and I made that decision despite both of us thinking that scientifically it was the wrong thing to do because the risk of that spot being a cancer was so low.

Why we did that has a lot to do with why all of our health care costs so much and why that will be so difficult to change in America. Most of the factors one or both of us considered in the decision came down on the side of doing the test:

  • Risk of diagnosing cancer late and untreatable? Do the test.
  • Related, risk of his early death? It seems higher if we diagnose the cancer late, so do the test.
  • Cost of the test — borne by the insurance company, so we don’t really care. Do the test.
  • Risk of me getting sued? If I miss a cancer that might be treatable with early diagnosis, I will probably get sued and lose. Do the test.
  • Patient satisfaction, if he wants the test and I think it’s unnecessary? Do the test.
  • Peace of mind, for him and for me, for his family and my lawyer? Do the test.

By comparison, the fact his spot was very unlikely to be cancer, that an additional CT scan might increase his cancer risk down the road, that he and I have some social responsibility to help control all of our health care costs by controlling his health care costs, collectively seemed pretty weak.

What are we to conclude from this case, doctor? While I think skipping the second scan was the right thing to do, there will be no fixing the American health care system until doing the right things in patient care makes a lot more sense than it often does right now.

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

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