| Who Needs Reform? “How am I doing, Doc?” Ray asked. I had watched him walk down the hall ten minutes earlier. His relaxed arm swing and effortless stride, the absence of any tremor, and his quick ready smile made it impossible to guess that he had Parkinson’s disease. “The medication is really working well,” I said. “You’re doing great.” I finished my note in the computer. “I’ll send a new prescription to the pharmacy and see you in four months,” I said. “Good,” he responded. He paused and then added, “What do you think of health care reform?” I thought about the 19 year old college student with severe migraine headaches I had seen earlier that morning. Two of her headaches had disappeared after taking samples of a new medication. They were too expensive for her and her parents to buy. I gave her more samples but knew that was not a solution. And there was the woman, disabled by multiple sclerosis, who couldn’t afford the co-pay for the expensive medicine to slow the progression of her disease. “It’s $320 every month. That’s like another car payment,” she had said. I closed down the computer and turned back to my patient. “I think we need reform pretty badly,” I said. “People get the health care they deserve,” he said. “If they don’t want to work, they shouldn’t expect insurance. The government needs to stay out of the health care business. It’s socialized medicine.” I sighed. I’d heard all before. “Easy enough for you to say,” I replied. “You’re on Medicare.” _______________________________________ The Patient’s Story Matters The current health care reimbursement to doctors and hospitals places a premium on procedures and pays less for delving into the patient's life story. This is a potent problem in terms of society getting the best value for its medical care dollar. There is an old adage in medicine—that the patient’s history is everything. Although the word, everything, may be a bit of an overstatement in today’s health care environment, the details of the patient’s history are often sacrificed in favor of expensive laboratory tests and scans. In part, this reflects the limited reimbursement for spending time with the patient. My book, “The Immobile Man’, emphasizes the importance of the patient’s story. Knowing the details of his or her life leads to better patient care and minimizes the need for testing, thereby decreasing the cost of medical care. Patients with severe headaches, for example, often have multiple CT and MRI scans because the headaches recur. Recognizing that the headache symptoms are typical of migraine requires taking the time to probe the details of the symptoms and the patient’s life. Scans are of little value in this circumstance. The stories demonstrate the importance of observation. Tests and scans should serve as important tools to corroborate and further define the physician’s initial diagnosis based on talking with the patient. _________________________________________ Expensive Health Care, to what purpose? The frail old man hobbled into the exam room. I waited for him to lean his cane against the desk before we shook hands. “Hello, Ray,” I said. “You don’t look any too comfortable.” The 90 year old retired pathologist settled down heavily in the chair. “My right leg is weak, it’s numb, and my back hurts.” “Worse than three weeks ago?” I asked. “Yes,” he answered, “the weakness and numbness are worse; the back pain is tolerable.” The weakness and numbness were, indeed, worse when I examined him. “What did the MRI we took show?” he asked. I smiled, remembering our previous meeting. He was determined on getting an MRI. “What’s the point, Ray?” I’d asked. “I’m pretty sure this is all due to spinal stenosis. If the MRI documents that to be the case, you are hardly a candidate for surgery to fix it. You’re like a fragile piece of Meissen china—what with your age and congestive heart failure. Surgery is not an option. So why bother? It’s an expensive test.” “Nonetheless, I want it,” he had said and that ended the discussion. Now I pointed to the computer. “It shows that the spinal stenosis is fairly severe just as I thought,” I said, answering his question, as we looked at the images together. “It does look bad,” he said, “but I don’t think I want to go through an operation for it—too risky.” “I think that’s right,” I responded. “So what do we do about it?” Ray asked. “We’ll do physical therapy and take ibuprofen,” I said, “and, of course, keep using your cane.” Just what I told you we would do before you pushed me into ordering the MRI, I thought. _________________________________________ Dizzy Sonya, a 54 year old woman came to see for her dizziness. “It all started right after I slipped and hit the back of my head. That was six months ago. Ever since, I get dizzy—everything spins—sometimes when I roll over in bed or turn my head fast. It’s very upsetting especially when I’m driving my car.” “How long do the spells last?” I asked. “Only a few seconds,” she answered. “It feels like I’m coming of the merry-go-round.” “Does anything make the spells better?” “Nothing,” she said. “I’ve tried meclizine, , valium—none of them help.” My examination was normal except when she turned her head fast. She became dizzy and had abnormal eye movements—nystagmus— for a few seconds. “Your story and the findings are characteristic of benign positional vertigo. It’s often caused by minor head trauma. Some cells in the inner ear—semi-circular canals—break lose and when you turn your head fast, those cells swimming around, causes the vertigo. It’s certainly annoying but not serious. There are some special exercises that can be helpful.” “I like to try those,” she said. “The doctors I’ve seen have gotten some scans trying to figure this thing out. Do you want to see them?” “Sure,” I answered. I looked at all the scans loaded on the CD she handed me. The CT scan done when she first injured herself was normal. So were the MRI scans of the cervical and thoracic spine and two of the head. Except for the initial CT scan, I wasn’t sure why the others were done. Thousands of dollars spent needlessly when the story was so typical. “A cervical collar might help too—especially when you’re driving,” I said. “It’ll keep you from moving your head. There are no medicines that are really helpful—just the exercises. It always finally goes away but it can take a while.” __________________________________________________________ White Spots Wanda, a 32 year old single mother, is the office manager of a small internal medicine group practice. For the past ten years she has had occasional severe throbbing headaches associated with intense sensitivity to light and noise as well as nausea and vomiting. Over-the- counter migraine medicines have been without benefit. Recently, the headaches have been occurring once weekly. “I’m really worried about them,” she told one of her employer- doctors. “I know I’m under more pressure at home and that’s interfered with my sleep but this is not right. There’s something wrong.” “We’ll check it out with an MRI scan of your brain,” said the doctor. The report came back saying the scan showed no abnormalities except some areas of increased intensity in the deep white matter of both hemispheres. “Although these white spots may be non-specific,” the report concluded, “they raise the question of multiple sclerosis.” That prompted my seeing her in consultation. Her story was typical for migraine headaches. She noted her mother had similar ones. There was no history of other neurological events that might suggest multiple sclerosis. “Patients with multiple sclerosis have a series of neurological symptoms which you don’t have,” I told her. “The changes on the MRI are also seen in patients with migraine. There is no evidence from listening to you and your normal exam to consider your having multiple sclerosis. “How do you know the MRI abnormalities aren’t a signal that I will get MS?” she asked. “How do you know you won’t get maimed driving back to work?” I asked in return. “I think the changes are compatible with migraine headaches. Let’s use one of the newer migraine drugs to treat the headaches and let’s try to get to bed earlier. “Too bad someone ordered the MRI,” I thought. ____________________________________________________________ Status Epilepticus “He’s having one convulsion after another,” the woman screeched into the telephone. “He’s gonna’ die.” The emergency department listened to the 911 operator. “We’ll send a helicopter for him,” they said. “He was still seizing when we got there but we stopped them with IV lorazepam,” the flight nurse told me. I called his mother who told me that he had grand mal seizures for the past 20 years. “He hasn’t had any in the past year,” she said, “ever since he’s been taking phenytoin, four capsules every day. He never misses it.” He never misses it, I thought, smiling. The phenytoin level had just come back from the laboratory. It was zero. I gave him an IV load of phenytoin and admitted him to the hospital. He was awake the next morning when I saw him. A CT scan showed no abnormality. “So what happened?” I asked. “Forget to take your medicines?” “I decided to quit one week ago,” he said. “I don’t like taking medications. Besides, I thought I didn’t need it anymore.” “I guess you do,” I said. “You could have died. You need to start taking the phenytoin again.” He nodded his head slowly. “I suppose you’re going to tell me I can’t drive my truck,” it was a statement. “The law says for one year,” I said. I wanted to add, this is an expensive ride—the helicopter, a couple of days in the hospital, scans, and laboratory tests—all because you don’t like taking medicines. ___________________________________________________________ An article to read: There are many factors that contribute to the high cost of health care in the United States. In his latest article, “The Cost Conundrum,” published in The New Yorker magazine (June 1, 2009), author Atul Gawande examines a community in this country where the high cost of medicine does not equal quality care and another that is the opposite. He concludes that health care provided in an environment where physicians are motivated by their personal financial rewards rather than what is best for their patients, results in lower quality and more expensive care. His research is thoughtful and in-depth and his conclusions are important and insightful. The article may be read in its entirety on the magazine’s website, www. newyorker.com. Go to the Archive and search by title or author. ____________________________________________________________ The Seizure My mother was in her 90s and in the late stages of Alzheimer’s disease, spending most of her time in bed and unable to recognize her family. One evening, the floor nurse called to tell me that Mom had a grand mal seizure a few minutes earlier. “Give her phenobarbital,” I said. I was her personal physician. “Do you want us to send her to the emergency department at the hospital?” the nurse asked. “No, just call me if she has another seizure.” There was no call until the next day. It was the nursing home director. “I heard your mother had a seizure. Aren’t you going to order some tests—some blood work, an EEG, and a CT scan?” “I don’t think so,” I answered. “But, Doctor, that’s what neurologists always do. What if she has a brain tumor?” he asked. “Will it make a difference?” I asked in return. As it turned out, it was the only epileptic seizure she ever had. I put her on phenobarbital, an effective anticonvulsant medication, to prevent further seizures. Mom was in the terminal stage of a fatal disease. The tests would have made no difference except to increase the cost of her medical care. She was comfortable and that’s all that mattered. -- Lud Gutmann MD, © copyright 2009 |
| Dr. Lud speaks out... |
| Will the new program of health-care insurance survive? It has barely gotten started. There are many views of the needs of patients to consider. Many factors have an important impact on these issues -- from care, to expense, to cost, to understanding, to delivery. This series of vignettes will address, through anecdotes and examples from my experience, and from other writings, some of the problems and concerns and advantages of providing universal health care. My biography and scientific and story writing are shown on other pages. Information is also included about my book, The Immobile Man, A Neurologist's casebook. The stories in the book are about the ordinary and extraordinary people who are my patients. |
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| Lud Gutmann's Blog A discussion of medicine and health care Listed in reverse order. Most recent update, January, 2011. |
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