A surgeon's busy Friday, an unexpected diagnosis

I recently had one of the more memorable experiences in the 16 years since I have been honored to place the initials M.D. after my name.

It was one of those moments where I was able to see both sides of the health care issue, and it is a sort of metaphor for my experiences over the last 10 years in private practice, as well as the 20 years that I have been in medicine.

It was late on a Friday afternoon. My clinic was full, as it often is on Fridays. I was running an hour behind. Each room that I entered potentially harbored a patient whose first greeting would be a reprimand or complaint for how delayed I was. Upon arriving in the room of each consecutive patient, the first few minutes would be spent defending why I was so behind. Each of these conversations further delayed my treatment of the next patient.

In my office we have "physician extenders," physician assistants (PAs) who run their own schedule, parallel to mine and enable our office to bring in patients with acute problems without an unreasonable wait.

I am an orthopedic surgeon. My schedule is booked out for several weeks. If a patient falls and breaks a wrist, making an appointment at my next available opening does not make sense. It is not fair to the person with the injured wrist, nor is it fair to the people who already had appointments to have to wait because I am overbooked. The PA can see the patients, initiate treatment, and since I am across the hall, they can seek me for advice on a complicated patient.

My office received a call on a 21-year-old woman who had no insurance. She had already been to a walk-in clinic and had an MRI of her knee that demonstrated a meniscal tear. This is a typical orthopedic problem, and having just seen the MRI report, but knowing nothing else about the patient, I agreed to accept her as a patient. She was placed on the schedule of the PA.

As I was scurrying around having trouble keeping up with my schedule, my PA came over and asked me if I could help him with this patient. My first thought was of course, how difficult could this be, she has a torn meniscus and she will likely need surgery, why do I need to see her now?

This was quickly tempered by the fact that I know I am responsible for every patient in my clinic. One of the pitfalls with the way our system works is that once a doctor-patient relationship is established, the doctor is responsible for anything that a reasonable doctor would be expected to do. The law does not care about backed-up patients, late Friday afternoons, or any other confounding factors that might change how much attention is given to a patient in the real world.

I have learned that the hard way. We doctors are human. I took a deep breath, put my other patients on hold a little longer and went over to the new patient across the hall.

It turns out my PA was correct. Her exam was a little off, not the normal exam for someone with a meniscal tear. She came limping in with a crutch. She told me that she had numbness on the left side of her body for three or four weeks. She had been to the ER and was referred to a charity-type clinic. The ER and the clinic actually did a reasonable job. She came with an MRI of her ankle, her knee, her hip and her lower back. In fact, she had more studies than most insured patients. Except for the knee MRI that showed the meniscal tear, the rest of her tests were normal.

On her notes, she had written the phrase "foot drop." I asked her where she had heard that term, she said she had read it on the Internet, and it seemed to fit her symptoms. She had no knee pain whatsoever. In my mind things were not adding up. I examined her and she did have a foot drop — she was unable to pick up her toes or bend her ankle up. This was not her knee. I continued my exam.

In medicine, 95 percent of the diagnosis is obtained from the history. The art of examination is slowly dying. I cannot tell you how many patients tell me their physician has never touched them. In her case, her history helped, but the exam is what cemented it for me.

She had several signs that her spinal cord was affected, most significantly something called clonus. This is basically when the foot beats back after a firm upward pressure is placed on the sole of the foot, bending it up abruptly. I immediately had my staff order a stat MRI of the rest of her central nervous system, her brain and spinal cord. I reassured her we would get to the bottom of this, and went back to my patients.

I took my 8-year-old son to dinner that night. We had not been out alone in a while. We went to a nice dinner then stopped and got a new CD, which my son had been wanting. I had not thought about this girl since our encounter a few hours earlier. As we pulled into the driveway that evening, I received a call from my PA that was on call.

He told me that the MRI of her brain showed a large, probably malignant, brain tumor similar to the one from which Sen. Edward Kennedy had recently died. I was pretty much dumbfounded. Part of me was excited that I had found the problem, knowing many orthopedic surgeons might have missed it. The other part of me felt an incredible amount of empathy for this young girl and her mother, knowing full well the path to which I had just led them. I turned to look at my son, jamming to his new CD.

This event is important to me on many levels. Emotionally, being the one to tell a young woman that her life is to be forever changed saddens me. This event also speaks to our health care system. The patient had been to the ER, yet a malignant brain tumor was missed.

She had also been to a primary care clinic. The best they could do was tell her it was her knee and that she should find an orthopedic surgeon. It is impossible for me to know the reason her diagnosis was missed at these two earlier visits. Was it because of her insurance status, or was it just simply missed? I have seen examples of both happen. In this case, I do not feel it was because of her insurance status.

Having been on the front lines of clinical medicine for a decade, I am not sure of all the answers to health care reform. Reform is necessary. People need insurance. Physicians need patients to have insurance. I did not charge that patient; the hospital wrote off the MRI tests. Is that fair? I have to pay my staff. We spent a lot of time and manpower on that patient. They want raises every year. How can we afford to treat patients for free, yet pay for a more complicated and expensive health care environment?

She is going to get brain surgery. Who will pay for that? If I were the neurosurgeon, I certainly would not want to have to do that surgery for free just because I was on call. These are tough questions and even tougher answers. As a society, we want to have access to the best health care, the most compassionate doctors, yet many patients are upset with having to pay their $25 co-pay.

I think the answer to health care reform lies somewhere in the middle, as do most answers. I do know this: The next time you are waiting a long time for your doctor to come, have a little empathy. You never know what he or she could be dealing with in the next room.

By the way, I hugged my little one a little tighter that night.

Craig R. Bennett is an orthopedic surgeon who practices in Hudson.

A surgeon's busy Friday, an unexpected diagnosis 10/24/09 [Last modified: Monday, November 7, 2011 10:12am]

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