“I think this patient needs a CT scan of her chest,” the consulting
physician said to me over the phone. “Her lungs sound bad, and given her
history, we need to make sure she isn’t developing pneumonia.”
The patient, though only thirty-five, had been through a lot during her
hospitalization. She came in a week prior with some shortness of breath, an
abnormally high heart rate (tachycardia) and chest pain. But her heart
checked out just fine. An EKG was normal and her troponin, a protein
that spills into the blood with damage to heart, was undetectable. Because
of her tachycardia and chest pain we tested her for a
pulmonary embolus, or clot in the lungs, with a CT scan. It was positive. The potentially
deadly clot blocks off blood flow coming from the right side of the heart
into the lungs causing heart strain and disrupting oxygenation of blood and
the functioning of the heart.
We admitted the patient to the
intensive care unit
where she received IV medication to thin her blood. She recovered but
continued to experience residual chest pain that would clear in the months
ahead. As we prepared to discharge the patient, the consulting physician, a
cardiologist, told us he wanted her to get another CT scan of her chest.
She had not had a scan since the initial stages of her workup. What if she
developed pneumonia in the interim? Her white blood cell count, often a
crude marker of infection, was not elevated. She did not have fevers. When
asked, she felt well enough to go home and wanted to leave. Then again,
being in the hospital made her susceptible to infection. Moreover, on her
physical exam, we heard crackles in her lungs –
this sometimes indicates an intrapulmonary pathology. The cardiologist’s
concern gave us pause and we ordered the imaging study.
Doctors often feel uncomfortable with areas outside of our expertise. Consequently, we call other specialists to see the patient and give us advice. Moreover,
patients sometimes ask to see a specialist in the hospital: “Can you call
the neurologist to come see me?” or “We’d like you to call a cardiologist
to see our father while he’s here.” Because consultants share a different
knowledge base than the team primarily caring for the patient they may ask
for more tests to rule out other serious pathologies that the primary team
neglected to consider.
The patient’s repeat CT scan merely demonstrated small collapsed alveoli.
These terminal branches of the lungs often collapse when we draw shallow
breaths or lie flat for a long time, a typical finding in many hospitalized
patients. Given the benign nature of this finding, we discharged the
patient. Yet she had received an extraneous dose of radiation and her
hospital bill would be hundreds of dollars more. Did she absolutely need
this? This common story raises other questions, too. Do patients do better
with more specialists seeing them? Do patients do better with more testing?
In a 2012 post for the New York Times Well blog, Tara Parker-Pope
that “overtreatment – too many scans, too many blood tests, too many
procedures – is costing the nation’s healthcare system at least $210
billion a year, according to the Institute of Medicine.” And the stories
she tells about astronomical hospital bills due to overtesting are
a 2015 article in the Journal of the American Medical Association, a group of researchers found mortality for high-risk
heart failure and cardiac arrest among patients was lower in teaching hospitals
during national cardiology meetings compared to the rest of the year – meaning that the absence of a large number of cardiologists, who were attending meetings, was correlated with lower mortality for these heart conditions in the hospital. In an editorial in the same issue, Dr.
Rita Redberg makes a disquieting suggestion: “How should we interpret these findings? One possibility is that more interventions in high-risk patients with heart failure and cardiac arrest leads to higher mortality.” Is there too much being done, especially by experienced
Dr. Ezekiel Emanuel, an oncologist and bioethicist, elaborated on these questions in a New York Times op-ed in 2015:
We – both physicians and patients – usually think more treatment means
better treatment. We often forget that every test and treatment can go
wrong, produce side effects or lead to additional interventions that
themselves can go wrong. We have learned this lesson with treatments like
antibiotics for simple medical problems from sore throats to ear
infections. Despite often repeating the mantra “First, do no harm,” doctors
have difficulty with doing less – even nothing. We find it hard to refrain
from trying another drug, blood test, imaging study or surgery.
When specialists like neurologists or cardiologists see a patient, they
approach the bedside from a unique perspective. The pathologies they know
and think about are very different from what family medicine or internal medicine doctors thinks of when they see a patient. Specialists, who often act as consultants, consider the diseases they are most worried about within their field. They’ve been asked to see the patient to
recommend workup for a disease potentially related to
their area of expertise. Their view, in other words, is necessarily myopic – if you give a carpenter a hammer, surely the carpenter will find a nail.
This does not always happen, but by nature there is a bias when a consultant
approaches a patient – and that bias is toward ordering another test,
toward doing something. Part of the art of medicine, especially as a specialist or consultant, is figuring out when the patient needs
something and when the best approach is to do nothing at all. Our patient
at the beginning of the story did not really need a repeat CT scan. To be
sure, the cardiologist didn’t recommend it simply to radiate the patient or
increase the hospital bill. But none of us wanted to miss something.
A conservative method of practice can come with experience, but as evident
from the JAMA study referenced above, that’s not necessarily the
whole story. Some of this, I think, requires thinking regularly about how well the
patient in front of the doctor is doing and how a test will change the
course of the patient’s treatment. “Will this change our management?” is a
question our attending physicians always ask us before we order a test. And it is a
question all doctors must ask themselves.