“You need to see a neurologist, specifically a headache specialist.”
“Fine, Doc, but I want to see someone around here. I don’t want to drive downtown.”
“I understand. I hate driving up there, too, so I would not push it if I did not feel strongly about it. There really isn’t anyone around here that I would recommend.”
“What about this guy?” He showed me the name of a neurologist from the nearby hospital that he had just pulled up on his smart phone.
“I would rather not send you there.”
“Why not?” He looked at me suspiciously.
“I really think you are going to get better care with this other physician.” What I wanted to say was that the one he had pulled up was bordering on quack, that he would order crazy amounts of completely unnecessary tests including a sleep study in the fellow’s sleep lab, multiple EEGs, a lumbar puncture, an MRI and an MRA, ungodly amounts of irrelevant lab tests and if the patient was lucky, would be told thousands of dollars later that there was nothing wrong except for migraines. If the patient was unlucky, he would be told that he had some rare, complicated disease and would need IVIG or some sort of other crazy, obscure treatment that would later be refuted by another neurologist. “You have migraines. I have tried everything I know to try. You need to move up to a specialist as maybe Botox or something else is in order.”
“I really want to see this guy.”
“He isn’t a headache specialist.”
“I still want to see him.” He narrowed his eyes.
“I can’t do that.” We had a stare down.
“I am not driving up there.”
“What about having a family member drive you? Taking a taxi?”
“Please trust me.”
“Send me to this other guy.”
You know what? Screw it.
“Fine. I’ll send you.” I wrote the referral, feeling guilty. This is how patient satisfaction increases cost and morbidity/mortality….
I watched the consult notes coming back noting the negative EEG, the MRI, the MRA, the sleep study, the lumbar puncture, the ungodly amounts of irrelevant labs…
Final diagnosis? Migraines.
A few months later the patient was back in my office.
“Say, Doc, thanks for sending me to that neurologist after all! He was so thorough.”
“Has he helped your migraines?”
“Well, no. Not yet…”
Here is a fascinating article from the New Yorker entitled Overkill. As physicians we like to point fingers at hospitals, drug companies, CEO salaries, equipment manufacturers and suppliers, etc. for the exploding costs of healthcare and while that is certainly true, there is a nice chunk of blame that should rest squarely on our own shoulders. This is the reason I have to battle the insurance companies like I did in my last post, Imaging. They know the secret we are not willing to admit to ourselves.
The reasons for over testing and over treating are numerous: patient pressure and expectation, protection from litigation, not being familiar with current guidelines, interest in personal financial gain, etc.
I would love to hear your thoughts! Do you think that your physician has ordered unnecessary tests? If so, why? What do you think their motivation was? Did you ask them of it was necessary?