Tuesday, December 17, 2013
Medical overtreatment: why doctors like to slay dragons
I’m sending a patient downtown to see a pancreatic expert. He’s a young man who didn’t fully appreciate the health risks of a former alcohol addiction. He’s been sober for well over a year, but alcohol toxicity can be unforgiving and permanent. We don’t fully understand why some alcoholics develop cirrhosis and other complications while others seem to skate by without a scratch. While I want folks who have the strength to conquer addictions to regain lost health and opportunities, many life choices lead to irreversible consequences. Life is often an unfair mystery. We witness this in medicine often. Some smokers live well into their 80s, while others become tethered to oxygen tanks or contract cancer. Trim athletes who eat seaweed salads seasoned with probiotics keel over while obese Whopper-swallowers wallow their way into old age.
My guy has chronic pancreatitis, a known consequence of alcohol abuse. Most of us don’t pay much attention to our pancreas, until it’s not performing well. His is sick and is causing him pain. He’s got a ball of fluid hanging off the tail of the pancreas, which shouldn’t be there and is not going way. In fact, it has enlarged some as seen on his most recent CAT scan.
There are three things that doctors love to do.
Enter any orifice possible. Why do you think that gastroenterologists, ear, nose and throat, urologists, proctologists, gynecologists and pulmonologists are always smiling?
Stretch any narrowed tube in body. If a cardiologist finds a narrowed coronary artery on a cardiac catheterization, the impulse to stretch it will be overpowering convinced that this has to be a good idea even if medical studies have refuted this.
Drain fluid. Doctors like to do this because it’s cool and it always sounds right to patients and their families. We welcome telling patients afterward that we’ve successfully shrunk their fluid collection by 50%. Patients then become 50% relieved. It sounds right that we should attack an abnormal fluid collection and that eliminating it is the ideal objective.
Here are the unasked questions.
1) Does the orifice need to be violated or do we do just because we can?
2) Is the narrowed artery, bile duct or artery actually a medical threat that needs to be stretched, or do we widen these narrowed structures because we can convincing ourselves and others that we have averted a medical crisis?
3) Is the fluid we drain actually bothering or threatening a patient or should it have been just left alone?
My patient is not getting better under my care and I want the advice of an expert. I cautioned the patient that the mere presence of abnormal fluid doesn’t mandate its removal. I am hopeful that he will receive a sober assessment.
Sure, we all like men of action, medical swashbucklers wielding tools and weapons to slice into our diseases and make us well. Would we rather watch a warrior slay a dragon or a farmer plant seeds?
Sometimes, a quiet contemplative man of inaction is the true healer.
This post by Michael Kirsch, MD, FACP, appeared at MD Whistleblower. Dr. Kirsch is a full time practicing physician and writer who addresses the joys and challenges of medical practice, including controversies in the doctor-patient relationship, medical ethics and measuring medical quality. When he's not writing, he's performing colonoscopies.
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