Cost of health care in the U.S.

What's driving up the cost of healthcare in the U.S.? We are. There is a tremendous amount of excess being performed in hospitals due to lack of thinking and diagnostic skills with heavy reliance upon objective testing and fear of litigation. Example: a 57 year old gentlemen with treated diabetes and HTN presented to our emergency department with the complaint of chestpain that had been persistent for > 12 hours. The pain was positional, worsened with a deep breath and he was very tender to palpation over the left anterior ribs. He was monitored in the chestpain unit overnight, serial biomarkers were drawn and normal, ECG was normal, Chest xray and a chest CT were performed and unremarkable. NTG was given without a response. Even with a diagnosis of "musculoskeltal" chest wall pain, I was called to come in and do a formal cardiovascular assessment on the patient before he was discharged. There was some surprise when I decided against any objective evaluation for coronary artery disease. In my day, the history and physical along with simple testing like ECG was enough to triage people in the acute setting. Every patient with chest discomfort does not need a CT scan, and myocardial perfusion study. You have to wonder if the excess radiation exposure from some of these studies might not have something to do with the incidence of soft tissue malignancies like breast CA in the population.

You need a heart cath!

Often a patient with a suspicion for coronary heart disease will have a non-invasive evaluation like a stress echocardiogram as an initial objective evaluation. If significant abnormalities are present a cardiac catheterization for possible revascularization therapy will be pursued. Obviously it is financially advantageous to have an abnormal non invasive study that will justify a follow up catheterization. The problem is that these stress tests, especially stress echocardiograms are very subjective. There is a cardiologist in my community who will acutally choose images for the final report on a stress echo that are either off axis or poor quality so that he can interpret the study as abnormal and subject the person to further testing even if it actually is a normal study! When the cath comes out normal, he tells the person that it was a good thing that he did the invasive procedure to find out for sure that the coronaries look okay and they are usually very happy to learn that they don't need bypass surgery. (Had he been honest in his interpretation of the stress test, the wouldn't need bypass surgery or the cath that he just did for the money.)

An MRI? I ordered a sleep study

I referred a patient for a sleep study on the suspicion that his daytime somnolence and history of snoring might indicate sleep apnea, a treatable condition. What I received was a report of a consultation performed by the physician at the sleep clinic and his ordering of the same exam I had asked for. This upset me a bit but I accepted it as a sign of the times and the economy. In the medical field as in every other area of business, everyone is trying to make a buck and requiring a consultation prior to testing is that medical group's policy. I would require that I meet and examine a patient before preforming an outpatient catheterization procedure. (That's because it is an invasive technique with true risks, not just watching someone sleep!)
What really pissed me off, however, was the part of the consultation report where the physician examined the patient for signs of spinal stenosis due to his history of lower extremity pain and recommended an MRI scan! How convenient that his group happens to own and operate an MR scanner. Obviously this is a case of attempt for self referral and taking advantage of the patient. All I wanted was a simple sleep study but I got a sleep physician's consultation and recommendation that he return for an MRI to evaluate possible neurogenic claudication!
What the F---?

Your patient is ready

Another small rant before I continue my story. "Dr. Miller, your pt. is on the table and ready!" This is the page I got this morning while making rounds on the inpatients in one of our hospitals. I apparently was supposed to to a cardiac catheterization procedure on one of my partners patients who had never spoken to me about this gentleman and the indications for the procedure let alone let me know it was being placed on my schedule. Now granted, a diagnostic coronary angiogram is not a major procedure, but knowing that it was ordered on an 84 yr.old man with exertional chest pain and syncope and an echo showing moderate/severe aortic stenosis would have been useful information when I walked into the lab. Do you think the patient and his family knew that I was walking in "blind"? Of course not. To save face I absolutely lied to them telling them I had discussed his case with my partner in detail and understood exactly why the procedure was to be done and that I had agreed with his recommendation. My partner is a non-invasive cardiologist and therefore does not perform catheterization procedures yet he is the person who obtained informed consent on this elderly man. Is that right? How can he get permission to do an invasive procedure on a person that he doesn't perform and that will be done by another individual they haven't met while he's in another state at a conference?
I understand that the path of least resistance for my partner after seeing a patient like this in the office is to simply check the box that says diagnostic left heart catheterization/coronary angiography on our discharge router and move on to the next room. But what about the patient involved? Shouldn't they get just a little more personal attention and know that if another provider is going to be involved in their care that they were well informed? Wouldn't my partner want to meet the person doing this same procedure on his wife or mother? This guy didn't put up any fuss so he never had a chance. I felt like such a fake and almost as if I were victimizing someone who due to his age and perhaps limited sophistication was being taken advantage of.

Why Me?

Okay, so why did I get started in the medical field? I'm not really sure but I do know that it was not my lifelong dream to become a doctor. I remember being terrified of going to the doctor when I was young, especially afraid on needles and such. I also recall feeling extremely queasy on the couple of occaisions I had to go to the hospital to visit a relative. My father was a veterinarian but I had no interest in watching him at work and even watching him do procedures or surgeries on small animals would often leave me feeling kinda faint.
I think my parents, especially my mother, wanted a doctor in the family and they choose me as opposed to my brother or sister. If I ever had to pick a favorite subject in school, I like alot of kids, would pick science. But I think I was thinkin more about rocket ships and outer space, not taking care of chronically ill elderly people. None the less, when I got to college (which was expected of all of us), I basically started in a "premed" program and never looked back or ahead. Before I knew it, I had an old lady as a counselor who had me registering for the MCAT and applying to medical school. I didn't have any other plans, and didn't like factory work, so I simply just followed her advice and went with the flow!!

Is There a Doctor in the House?

Okay, one more little rant before I begin the story of my "journey" into the medical field.
I got a page one evening while I was on call to see a patient in the hospital the next morning as a consultant. I notice that the patient was in the intensive care unit so I called the nurse to make sure they felt it was a routine consult and that they didn't feel I should see her that night. The nurse described the patient as being poorly responsive, hypotensive and in heart failure but not yet on the ventilator and she thought they did want a cardiologist to evaluate the patient rather urgently. (Seemed reasonable to me.) I asked to speak to the doctor in charge of the patient but they weren't sure who that was. There must be a physician responsible for this woman who was admitted from the emergency room to the ICU in unstable condition! After about 15 minutes of being on hold, the nurse again apologized and finally found a PA (physician assistant) to speak to me who basically said she was 84 years old so don't bother coming in to see her now. The lady was described by the RN and PA as being close to death, yet they didn't think they needed a doctor to come in and evaluate her even though they could not easily contact the Dr. in house! (Oh, yeah. This is the largest hospital in the second largest city in the state.)

He's having chest pain and his blood pressure is low

I know I said that my next entry would begin telling the story of how I got started in medicine but a couple small "happenings" recently occurred which themselves are "blog-worthy".

I began taking call for my group New Year's Eve which means I'm responsible for patients of my partner's currently in the hospital. I get a call by one of the hospital nurses regarding a patient seen by my partner earlier that day with chest pain and hypotension (low blood pressure). She also tells me that he is a Jehovah's Witness and refuses any blood products to treat his anemia, that she was told not to do ECG's on him and that he and his family want to address his code status. At this point in the evening, my partner has yet to call me to give me a "sign out" and tell me about the patients I am assuming care for. He is also not available by home phone, cell phone or pager. He has "checked out" and I'm left trying to make decisions on a potentially very sick individual whom I know nothing about!

When nurses in the hospital end and start their shifts, they go thru a very detailed "report" so that the nurse coming on duty knows everything of importance about the patient they will be caring for. This is standard practice. Well folks, I'm sorry to report that your doctors do not routinely share information with each other in this manner, even if they are responsible for critically ill people!