Saturday, January 27, 2007

Politics and Medicine

This blog entry starts with the story of my recent experience of what I'm guessing was probably what is often called "defensive medicine" in practice, and I leave it open for your comments.
To begin with, you should know something about me. Over the last few years, I've become a bit of a hypochondriac, imagining the worst when I get any little twinge. A headache? It must be a brain tumor! A shoulder pain? Probably my heart gasping for blood!
I know it's silly, but when I started having "skipped heart beats" while exercising a few years ago, I became obsessed with the idea that I was going to die mid-work out from a mystery defect that no one had caught. Although I exercise regularly, this functioned to make me pretty tense. I finally wound up going to a cardiologist to check it out, and it turned out that the skipped beats were premature atrial contractions,"" which are common and harmless. So, I went about my business and stopped worrying about them. The doctor had suggested back then that I follow up, but I never did.
However, this year, when the "PACs" started coming back, and because I was also having a lot of pain in my left arm, I decided to see the cardiologist again. The guy I had seen before wasn't there anymore and there was a new, youunger doctor. He told me he thought the left arm pain probably originated in a back problem, but "just to be sure" signed me up for a large number of tests, including a "plain stress test" - the kind where a person runs on a treadmill and the heart is monitored for changes in rhythm under stress.
My experience of the test was fine, although before the test began, the technician made a comment about athletes "keeling over" after races that freaked me out and probably led me to start hyperventilating before I got on the treadmill. Despite this, I walked and then ran for something over ten minutes, never felt short of breath or had any chest pain or "PACs" and I could talk during the whole thing with no problem. I was surprised when the doctor told me after the test that the result had been "positive" for ischemia. He was, he said "90% sure" that it was a false positive, because I didn't have any symptoms and spent enough time on the treadmill. However, he ordered a nuclear stress-test to follow up and "clarify" the result. Thankfully, I managed to schedule this test pretty soon after the initial plain test so that I didn't spend much time being a nervous wreck. I continued to work out in the interim, and because this doctor had also prescribed a "loop monitor" as part of my many tests, I was able to record my heart and phone in reports periodically, which I did during all my work-outs. So, yesterday, I spent almost the entire day in the hospital cardiac clinic doing my nuclear test, which was, as the doctor expected, normal. Now, I've taken off the loop monitor because the sticky tapes were ripping up my skin.
So, I guess the doctor HAD to do the nuclear test because I had the positive stress test, but my question to you is: why did he order the plain stress test in the first place? It seemed unnnecessary given my general profile, did it just add to my general anxiety level for no good reason? A 30-day loop monitor also seems excessive, even if it's pretty cool technology.

* * *
My experience seems to validate on the superficial level, the right wing's characterization of the entire American medical apparatus suffering from doctors' fear of malpractice suits, recently brought up again in Bush's State of the Union address. The administration's medical plan includes this point:

The glut of frivolous lawsuits are driving good doctors out of practice and driving up costs by forcing many doctors to practice defensive medicine – ordering unnecessary tests and writing unnecessary prescriptions. The total cost of defensive medicine to our society is an estimated $60 billion to $100 billion per year, including $28 billion billed directly to taxpayers through increased costs of Medicare, Medicaid, VA, and other Federal health programs. Junk lawsuits are a national issue requiring a national response. The House has passed a good medical liability reform bill, and it is time for the Senate to act.

The Bushies would argue that the nuclear test my doctor ordered was expensive, as were the others and that he could have easily ruled out heart disease based on my exercise history (I do about 1 hour of aerobic exercise 3-4 times per week), without sending me for all those tests, which just led my insurance company to spend money and caused needless worry on my part.
Or...maybe he just being exceptionally careful and thorough
There are a surprising number of failed diagnoses, and silent heart-disease is a major killer. According to Kate Steadman at "", 100,000 patients die every year due to medical errors. According to "" heart-attacks are the number one misdiagnosed or undiagnosed major medical problem. A friend pointed out to me while all this was going on, that there was an article in The New Yorker that showed the danger of failing to do tests such as the plain stress test because of the patient's appearance and history.
These realities favor my doctor's choice to do the first, low-cost and non-invasive stress test. If you weigh the outcomes of the risks, the answer seems simple. The worst-case scenario risk of not doing the stress test for a patient with a regular heavy exercise regimen and left arm pain is not catching a potentially fatal condition. The worst-case scenario risk of doing the stress test on a healthy patient is getting a false positive result whose main consequence is patient anxiety until further testing can be done, and additional costs from the other unneccessary tests. What role do the costs of such tests play in raising the cost of American medicine? Even the free-marketeers at Forbes Magazine suggests that people should get "stress tests" which are not expensive. Most studies of this process have concluded that the cost of "unnecessary testing" accounts for less of the increasing health-care costs than do the marketing efforts of the pharmaceutical industry. Some even suggest that improved management of tests would avoid much more costly medical errors.
My other question about these tests was whether this is unique in American medicine, and makes an argument for our system of health care. The common right-wing talking point is that people in countries with "socialized medicine" receive substandard health care. This article from the Washington Post suggests similar problems by comparing US health care with that in other countries. On the testing issue, the article reports that more Americans don't get recommended tests because of not being able to afford them. The complicated bureaucracy in the US leads to doctors ordering duplicating tests and/or not having test results available. There were substantially more medical errors in the US than in other countries, which would suggest that the problem is not unneccesary tests, but some kind of profound inefficiency in the system as a whole.
I don't know the answer to the actual availability of every test in other countries, but I'm currently listening to an interview on "This is Hell" with Marilyn Clement of Health Care Now, who mentioned that some patients in Canada might have to wait two-three weeks for an MRI. That doesn't seem like that much time. I've had enough trouble getting in to see doctors and make appointments in the US that two-three weeks of waiting for a non-urgent test doesn't seem like that long to me.
* * * and that's all for now.


The Pagan Science Monitor said...

Thanks for sharing such a personal story, which also serves to put a human face on the health policy issues that need to be debated EVEN MORE now, in light of what Bush said in SOTU. The need for a simple single-payor system is as great as it's ever been. I just read the new, authoritative biography of Earl Warren (Jim Newton, 2006) and re-visited a little-remembered aspect of Warren's time as the Republican governor of California. He proposed a very modest insurance reform plan with employer-employee contributions, and the AMA in California openly called him Communist. *Sigh.* It's pure, unadulterated ideology that keeps us from having a rational health policy in the U.S.

reb said...

That story explains why some of my students, whose access to health care might be limited, but whose health problems are legion, have such a rosy view of communism.

bartelby said...

It's good to hear that you are well.
I underwent some of the very same tests after my younger brother died.
He had a congenital heart condition which combined with male body dysmorphia resulted in his death in a bodybuilding gym. The "loop" monitor sounds similar to the halter monitor test which was administered to me. I wore the monitor for 24 hours and found I was O.K. Blood pressure results before the stress test were another story, probably a result of being pretty nervous.
At the time I was on Social Security for an unrelated condition.
I spent years going to evaluations and arguing that I was inept, incompetent and unable to function.
Meanwhile I had to work to supplement the SSD checks. Finally, because I worked and took some classes they gave me the boot and I had to go on job interviews and argue that I was adept and competent. The decision to end my benefits included no input from any doctor on the part of the Social Security Administration.