Health Care in Crisis: Patients Are Pushovers
Editor's Note: This is Part Four of a five-part series on the health-care crisis.
For 32 years, Don Grantham was considered one of the top engineers at General Dynamics in Fort Worth. He didn't know his genes were preparing to play one of the cruelest tricks imaginable on his body. Grantham would discover that he suffers from a rare condition that slowly affects the nervous system in the lower body, progressively eroding the nerves' ability to communicate with or control anything below the waist. His mind was as sharp as ever, but each year his legs' ability to respond to his brain's commands to walk deteriorated.
After he retired, Grantham would be confined to a wheelchair. Because nerve impulses no longer alerted him to problems in his lower extremities, his wife Pat would always have to look out for sores caused by her husband's immobility.
She missed one. Eradicating the sepsis that ensued required an extensive stay in Fort Worth's Kindred Hospital, which specializes in slow-to-heal wounds and infections. At Kindred, doctors recommended that Grantham undergo a colostomy, which would eliminate the danger of another potential infection in an area especially vulnerable to bedsores. Grantham was transferred to Fort Worth's Plaza Medical Center, and the operation was performed. But the doctor performed the wrong surgery.
The colostomy the doctor performed was not the prescribed Hartmann's colostomy. In a Hartmann's, the colon is permanently severed; the section leaving the stomach is brought through the abdomen and skin and the rectum is sealed so that waste can't get into an open bedsore and again cause sepsis. But this doctor performed a "partial colostomy," after which reinfection remains possible.
Did the surgeon check the chart?
Pat said that she was never consulted about which operation was planned, and she admits that her faith in doctors was so great that it never occurred to her that the surgeon might perform the wrong colostomy. But what disappoints her today is that she suspects the doctor did not even look at her husband's medical chart.
"If he had, he would have noticed that Don was confined to a wheelchair and had been hospitalized for sepsis—and that situation demanded only one type of colostomy." At 81, Grantham has become bedridden, and the original medical problem, for which he endured the wrong surgery, is unresolved.
Another case concerns Debbie (not her real name), who spent years following her husband around Asia. President of two oil-drilling companies that worked rigs onshore and offshore, he took the family to Indonesia, China, Malaysia, and Singapore. In his last oil-related job, he helped survey the potential of the giant Baku oil fields in Azerbaijan after the Soviet Union disintegrated. Debbie split her time between their homes in Texas and California, intensely focused on maintaining her health. An active swimmer, she had never smoked and only occasionally took a glass of wine. But six years ago, in her late 40s, Debbie suddenly found breathing so difficult that she could barely manage to climb the stairs of their two-story Dallas home.
Her physician immediately hospitalized her and called for tests. One that apparently was not conducted would have determined that blood clots were forming in her veins.
A key medical test: not given
When the hospital released her, Debbie boarded a jet for the West Coast. It is likely that another, larger blood clot formed in her left leg during the flight. When it broke loose the next morning, it nearly took her life. Her husband credits the timely work and dedication of their California doctors for having saved her. One surgeon told him that it was the worst damage from a blood clot he'd ever seen in a living person.
Today Debbie lives on the drug Coumadin, which reduces her risk of future heart attacks, strokes, and blood clots. A Greenfield filter placed in her aorta prevents any clots that might form from traveling through her bloodstream.
It cannot be medically proven, but there's a strong theory that the female hormone-replacement therapy she had been put on six months earlier likely caused the blood clots—a known side effect of the medicine she'd been taking. Debbie's family also believes that the most serious clot formed on that long flight as she sat, dehydrated and immobile .
The cost of the medical care that saved her life in California exceeded $250,000. Debbie has been recovering ever since.
Much is made today of the high costs of medical testing in the U.S. But this probably overlooks the fact that our relatively newfound ability to see into the human body with PET, MRI, and CAT scans has effectively replaced exploratory surgery. There are also concerns voiced about the level of radiation a patient receives in a full-body CAT scan. An article on New Scientist.com says it's the equivalent of what you'd get in 500 conventional X-ray sessions—"equivalent to the radiation received by some survivors of the Hiroshima and Nagasaki atomic bombs."
In his book, The Great American Heart Hoax, cardiologist Michael Ozner, medical director of Wellness and Prevention at Baptist Health South Florida, also compares CAT scan radiation to that seen in Japanese nuclear attack survivors, but he rates CAT scans as dosing patients with radiation equivalent to 750 normal X-rays.
"money machines:" for doctors
On the other hand, being able to explore the human body unobtrusively allows doctors to see how the human heart works (or doesn't), spot tumors early in their development, notice areas of demyelination in our nervous system, or determine why one's spine hurts so much, usually without making an incision. It has become a national pastime to second-guess doctors after things go wrong. But in Debbie's case it was a test not given that could have diagnosed blood clots forming in her veins. A simple, fairly inexpensive, nonsurgical treatment to break up those blood clots—such as Heparin—would have resolved her breathing problems and she never would have come so close to dying.
But the seemingly constant use of an extraordinary variety of scanning equipment and tests now available has triggered criticism. Some claim that many doctors order such tests far too frequently. They call such scanning devices "money machines." Often the doctors are partial owners of the equipment and can pad their income by ordering tests for patients whether they're crucial or not.
In some cases, this may be true. In June 2008, The New York Times carried a story involving Dr. Andrew Rosenblatt, a San Francisco cardiologist who had been approached by colleagues who suggested he join them in purchasing a CT Scanner. Not only was Rosenblatt concerned about his patients' potential radiation exposure, he worried about the doctors', too. He was quoted as saying: "If you have ownership of the machine, you're going to want to utilize it." He declined their proposal.
And yet, judging from the case histories I have related in this series, the scanners seem to be of crucial importance in helping doctors make the best possible diagnoses. The real question is whether or not Americans pay too much to use these diagnostic tools. And that resembles the debate about the prices we pay for prescription drugs in the U.S.—exorbitant compared with what citizens of other industrialized nations pay.
Is Most heart surgery unnecessary?
Judging by the medical events related to me by the families of my closest associates and friends, the health care costs that cause the biggest problems in America are those relating to hospitalization and surgery. Many physicians have medical and ethical issues here.
The Texas Back Institute's Dr. Ralph Rashbaum, for example, views surgery as the last resort, the least-desirable option for most of his patients—but readily admits that in his profession, the big money is in surgery. Then there's Dr. Ozner, who says that 70% to 90% of all heart operations performed in the U.S. are unnecessary. Ozner points out that in numerous studies, stent implantation (the Courage Trials, New England Journal of Medicine, March 2007), angioplasty, (AVERT Trial, Journal of the American College of Cardiology, 2003) and bypass operations, (National Institutes of Health Study, 1983) have never been proved to extend the lives of heart disease sufferers.
And while there's no excuse for performing the wrong colostomy, that case does uncover a basic and costly systemic flaw that came up numerous times as I researched this series: the lack of proper communication between physicians located in different facilities when they are jointly involved in a patient's course of treatment. This problem doesn't exist in such places as the Mayo Clinic, where exceptional communication among physicians was highlighted in Atul Gawande's "The Cost Conundrum" in Vanity Fair. Gawande also points out that the Mayo Clinic's cost to treat Medicare patients averages $6,688 per enrollee—or $8,000 less per person than in McAllen, Tex., the highest-cost Medicare region in the U.S. This issue needs to be investigated.
Now is a good time to remind readers that in spite of the high cost of health care in America, our physicians and health-care professionals save millions of lives each year. But the case studies in this series suggest that patients need to be activists. Was it Pat Grantham's responsibility to ensure that her husband was given the correct colostomy? Was that the job of the referring doctor at Kindred Hospital? Or was this simply a case of the surgeon not having taken the time to read Grantham's chart? In Debbie's case, tests were indeed run, but no conclusion was reached as to the cause of her labored breathing whenever she exerted herself. The ongoing health of both individuals will continue to be compromised. For the money spent, these were not results their families were looking for.
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