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The Cost-Effectiveness of Family Physicians – The Harms of Aggressiveness

July 7, 2013
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Continuing my series discussing our findings in a recently published study on the ways family physicians deliver better care at a lower cost than a multi-ologist model.

John was a 53-year-old man who went to an ER for several weeks of abdominal pain. It was never severe. He was never doubled over in pain. He just wanted to know what was going on and had no relationship with a family physician prior to his ER visit.

Of course, the ER physician ordred a CAT scan, which showed a round smooth mass in his kidney about the size of a marble. There were no other abnormalities, and this abnormality did not explain his pain, which got much better after John started taking acid-blocking medicine daily. But the ER doctor told John that this kidney lesion could be cancer.

John went to see the urologist he was referred to, who recommended surgery. In the OR after making a large incision on John’s back, the urologist ran into difficulties and suddenly the surgical hole began rapidly filling with blood. The fear was that either the renal artery, which supplies  blood to the kidney, or the aorta itself, was cut. The surgeons rolled John over on his back and cut his abdomen from just below his ribs to just above his pubic area. They needed full exposure of the internal organs to better see what had happened.

A vascular surgeon came in to help with the case and together the two surgeons discovered that indeed the base of the renal artery was pumping blood. Ninety minutes later the hole was patched and the attention was turned to the kidney mass, which was successfully cut out and sent to the lab. Two weeks later John found out the tumor was benign.

Two months later, a gaping protrusion from John’s abdomen was still present and still very bothersome. It was caused by the underlying soft tissues not sticking together well as the surgical incision healed. Every time he put any strain on his abdominal muscles, the center part of his belly bulged out. Kind of like from the movie Alien, though no monster ever appeared.

For some, this would be annoying. For John, it meant he could no longer work lifting heavy objects. Between the grotesque protrusion and the soreness that grew after he even attempted to work at his old job, he just couldn’t work the way he had supported his family for over 30 years. Another surgery to fix the problem didn’t. Last I heard, John was still waiting for his disability status to kick in.

No non-invasive test is completely non-invasive. A predictable number of these tests will have abnormalities that probably aren’t bad, but could be. The only way to know for sure is for an invasive procedure to take place. These days, family physicians don’t initiate a lot of these diagnostic journeys, but they are forced to deal with these issues because of a test ordered by an emergency physician with little judgement and a poor understanding of healthcare systems and the downstream effects of his decisions.

Family physicians realize that over-aggressive testing often leads to physical harm; certainly psychological harm, and always financial harm to the patient and the overall healthcare system. Lots of CAT scans and MRIs should be ordered in routine clinical care. They are great tools. However the U.S. has completely gone wacky overboard on these tests. Other groups such as the Avoiding Avoidable Care movement have helped highlight this problem. Most family physicians have known about this issue and practiced with some restraint their whole careers.

 

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