Sunday, April 19, 2009

Are we getting stupider?

Two recent cases have lead me to believe that the medical profession as a whole is getting stupider rather than smarter.

I got a phone call from an acquaintance a few months ago asking if I could intervene with X-ray. I explained to him that I had absolutely no clout with X-ray but asked him what the problem was to see if I could help in some other way.

His father-in-law as part of a check up had a PSA done which was elevated. He was referred to a urologist who sent him for an ultrasound guided biopsy. This unfortunately could not be done for 3 months and his father-in-law was very upset about being eaten away by cancer while he waited.

I told him, don't worry.... PSA is a very non-specific test, prostatic cancer is slow growing and I am sure your urologist did a rectal exam so if there is cancer it is very small if he couldn't feel it.

Turns out his urologist didn't do a rectal exam!!!!. This is not some elderly urologist eking out a living to pay off his first wife or his bad investments. This is the program director of our urology residency program.

One of the few things I remember from medical school is urologists imploring us to stick our fingers up people's bums. "The worlds greatest cancer detector" they would call their index finger. "You don't put your finger in it, you put your foot in it".

Anyway I advised my friend to ask X-ray to phone his father-in-law in the event of a cancellation which they did and the biopsy was negative.

The second case was related to me by two colleagues who were equally disgusted.

These lucky individuals work in a private dental suite. (Taking wisdom teeth out of healthy people pays a whole lot more than doing ?necessary surgery on sick people.) One day the dentist wasn't feeling well; he was nauseated and had pain in the right lower quadrant. One of my colleagues examined him and told him he might have appendicitis and told him to go to the ER.

After waiting in the ER he was seen by an ER doctor who may or may not have examined him before trying to do an ultrasound of the abdomen. Unfortunately the dentist was in two much pain to be able to press down on the ultrasound probe so they weren't able to do the exam. (I believe this is a sign of peritonitis but then again I am only an anaesthesiologist). So the unfortunate dentist was send back to the waiting room to get a CT. Only after the CT was positive was surgery consulted and he was relieved of his appendix. Surgery was not consulted until after the CT.

Now I am not much of a Luddite and I appreciate the use of diagnostic tests but the bottom line is that as physicians we talk to patients and examine them and then order the relevant tests. The means sticking your finger up peoples bums (and that is one major reason I went into anaesthesiology). It also means that when you have a diagnosis like appendicitis which was first described in the nineteenth century, has a classic presentation and has been diagnosed fairly reliably by surgeons using only history, physical exam and a white blood count for years, why would you subject a patient to two unnecessary exams and delay his treatment when the presentation is so obvious that an anaesthesiologist for god's sake was able to make the diagnosis?

We all complain about ER overcrowding, and waits for diagnostic testing but how much of this is now because we as a profession have become so stupid and helpless?

As an aside, I used to belong to a discussion group on pain and chemical dependency. Some of the doctors on the group were being hassled by the DEA or licencing bodies which I think is unfortunate. One doctor actually complained that he had been criminally charged after a DEA agent came to his office "wearing a wire". I had to jump in and I asked why he didn't ask the agent to take off his shirt and examine him. The doctor replied, "why would I examine someone with a perfectly good MRI?" and several other people jumped to his defence.

No comments: