A high index of suspicion

I had been trying for several years to get Wes, a patient in his 40s, to go on cholesterol medication. His father had died of an MI at age 41 and his cholesterol was moderately high. Each time he blew me off, saying he'd try harder with diet and exercise. But the numbers didn't change, so finally he agreed to go on a statin. Not satisfied, I also insisted he have a stress echocardiogram. “Wes,” I said, “at your age your father was already dead. Let's get you checked out.” He begrudgingly acquiesced.

The stress echo came back normal, so we relaxed. Three months later, he had a prolonged episode of chest pain. At first, I was ready to write it off as reflux, but remembering how little in this business you can take to the bank, I had him come in. His office exam and EKG were unremarkable; however, his story was too suspicious for ischemia, so I drew blood for cardiac enzymes and a serum troponin. His CPK was normal, but his troponin-I was 5, twice the upper limit of normal. “Wes,” I said, “I think you just bought yourself a cardiac cath.”

George, the cardiologist I consulted, thought Wes might have ruptured a small plaque and didn't think he'd find much on angiography but agreed it was indicated. He suggested a beta-blocker and aspirin therapy in the meantime. Wes had an uneventful weekend at home and went for his catheter on Monday. Tuesday morning George phoned with bad news. “Your patient has triple vessel disease. I stented his right coronary artery, which was barely a trickle, but he has over 50 percent occlusion in his left main and LAD. I've doubled his statin dose. He should have an LDL of 60.”

“I don't get it,” I told George. “He had an unremarkable stress test just three months ago. Does everyone with a family history of heart disease need an angiogram?”

“These false negatives bother me too,” George confessed. “I guess medicine is still an imperfect art. Keep up your high index of suspicion. And by the way,” he added, “Good save.”

The ED

My patients continually complain to me about the cost of emergency care, yet I seem unable to train them to call me when they have what they feel are serious (but not life-threatening) illnesses or accidents. Instead, they go to the ED and are seen by doctors who don't know them and who, nine times out of 10, wind up treating them for non-emergent problems while ordering batteries of tests and procedures they don't really need.

One of my patients recently presented to the ED with back pain. The ED physician ordered a CT of the abdomen and X-rays of the right ribs, lumbosacral spine and chest, all of which were negative – as was cash flow to the patient. He was discharged with pain medication and a $1,500 bill and told to follow up with his primary care physician. A subsequent exam in my office disclosed a positive straight-leg-raising test and a history compatible with sciatica. I billed $55 for the visit.

The ED motif seems to be “chart more, do more, bill more.” Although this benefits the occasional patient, it runs up the cost of care for the rest of us. Plus, it just doesn't make sense. No one knows our patients as well as we do.

The annual exam

A great believer in preventive maintenance, I brought my dirt bike to Bruce, my motorcycle doctor, for its routine checkup. “I'll adjust the valves, change the fork oil and check out the kickstarter mechanism, which failed in your bike last year,” he said. “You're probably looking at $300, tops.”

“Great,” I said, “and by the way, it's making this sound – like when we were kids and used to put a playing card between our bicycle spokes – a rat-ta-ta-ta-ta.”

“I'll check it out,” he said.

Two hours later, Bruce had finished his diagnostics. “That sound you were hearing was your almost non-existent front sprocket slapping against the chain. Your kickstarter gear is showing signs of wear and should also be replaced, as well as its meshing gear. The really bad news is that your clutch basket is worn out too. And, since we're replacing the front sprocket, we should also replace the rear one and throw in a new chain. Now you're looking at a thousand bucks.”

“Do I really have to do all that?” I asked. “I mean, when will the bike fail if we just do the front sprocket and the $300 job?”

“Next week, next month, next year, maybe never,” he said. “What do your patients do when you tell them they need an overhaul? Wait until they break down?” Some of them do, I thought, but I saw Bruce's point – even though $1,000 was a lot of money for something that might never happen.

My son, Gabe, who accompanied me to the shop to view the bad parts, thought Bruce was being a bit obsessive and was giving me a worst-case scenario, but he also admitted that he didn't know much about what the parts should look like. I decided not to cheap out and to trust my mechanic. “So,” I said, after okaying the $1,000 repair, “is this going to be like the patient who gets a clean bill of health and dies of a heart attack the next day?”

“Naw, doc,” Bruce said, “I guarantee my work for 90 days. That's 90 days longer than you guys do, isn't it?”