This week I began my internal medicine rotation. Whereas the surgeons worked me to death a few months, I think that the internists are going to bore me to death. I mentioned earlier of surgeons who could evaluate a patient’s progress in less than 40 seconds. This week I ran into physicians who could spend 40 minutes going over every lab value in a patient’s workup. My team took 2 hours to see four patients. The attendings were wringing their hands over a particular woman’s sodium level. Never mind that she had no symptoms and that the concentration of sodium in her blood was two points below the limit, she got the full battery of tests—thyroid function, hepatitis screening, steroid levels… We probably could have solved the mystery if we had bothered to ask her if she began drinking more water than usual; but what do I know?
The story of the lady with a low sodium level is a perfect example of the over-treating of disease that occurs in hospitals. Her lab workup must have cost several hundred dollars for what is essentially a non-issue. The patient came in for a scheduled chemotherapy regiment. The discovery that her electrolytes were out of range was an incidental finding for which there really is no cure other than backing off the amount of fluids she’s receiving. Even if we do find a thyroid abnormality or a problem with the adrenal gland, she’ll still need to finish her current health battles before moving on to something else.
Over-treatment takes away from clinical skills and instead puts the pressure on the laboratory to come up with a diagnosis. We’re no longer training physicians, we’re training data interpreters—very expensive data interpreters. While one of those tests might come back positive, we could getting feel for the need of the thyroid study by rubbing the patient’s neck and asking her if she’s noticed any changes in the amount that she sweats everyday.
Over-treatment is not only unnecessarily expensive, it can also lead to further disease. I came across one patient this week her received a port—a valve implanted through the skin to push medications through. The port developed a blood clot that broke off and traveled to her lung, where she then developed a pulmonary embolism—the cause of death for international travelers that generated a media buzz a few years ago. To diagnose the pulmonary embolism, we rushed her off to radiology to get a CAT scan. She received intravenous contrast to better aid in visualize the clot in her lung. Unfortunately, since she’s diabetic, the dye injured her kidneys and sent her into renal failure. By the end of the week, my attending stated that the patient had too many co-morbid conditions to continue chemotherapy. He discharged her and recommended Hospice care.
Let’s summarize the sequence of events: come in for treatment of cancer, get a blood clot in the lung, have your kidneys damaged, and then get told you can’t have the treatment as initially planned and instead have six months to live. The moral of the story is that patients should be left to die alone at home instead of coming to the hospital to get killed off for $10,000.