Friday, November 25, 2005

Dear Bluedude Please Consider This

Recently, I wrote a post about being names in a lawsuit which was brought forth by a patient I had cared for in the past. The patient had a bad outcome and felt that this was due to the medical care he/she recieved or did not recieve. I've written similar posts about others before and usually what happens is that a med-mal discussion begins to brew in the comment section. It did this time as well and I put an end to it early, honestly, because I'm tired of hearing about it and arguing about it.

So why am I writing this post? Well, I've observed that the readers who are drawn to medical blogs are either people in the field or patients who have chronic disease and do a lot of research on the web about their own disease. These readers like to pick physician's brains or are interested in hearing something that validates their pre-concieved notion about their prognosis or other concerns. Of course, there are the occasional readers who are just interested in medicine as a field. But I digress.

Whenever one of these posts gets written, and this discussion begins, there is always one or two comments from readers who are truly convinced that their physician made a mistake, or missed something or just plain didn't know. This time the reader goes by the name "Bluedude". As they say "if you live in a glass house don't throw stones" so I will be happy to address him as "Bluedude".

Bludude writes:

"My father died very suddenly, and it was revealed that his doctor, also personal friend, missed the spot on his lung on the xray. We are not a litigious family and people do make mistakes. But what infuriates me is the way each doctor consistently stood up for each other, and my dad's friend kept reassuring my mom that there was no way he could've been diagnosed by the xray. Everytime he said that, it made me angrier and angrier. If doctors make a mistake, which they will, since they're only human, please don't lie to my face. Also, we asked the oncologist, and he just kept stating he didn't have a chance to review it. Be honest, be remorseful; show that you care about this patient, at this time. There would be less law suits if doctors didn't circle the wagons so readily."
This is not the first time I recieved this kind of response. I believe that Bluedude really is upset by what he believes are "physicians covering up for each other". I do understand how the situation can appear to be as such but please allow me to offer some counter-arguments you may have not given any consideration to. The reason I am going to do this here is because if I were the one being confronted by this family memberI would probably not point this out, in fear of being misunderstood, further worsening the situation and infuriating the complaint or because it would simply take wayyyyyy too much time and the person with whom I am having the discussion does not have the approprate background knowledge to begin to understand the full ramificaions of what I am saying. Especially when they are angry and more closed minded. I believe this phenomenon occurs because on television decisions seem much more straightforward. X-rays always tell the truth. CAT scans are perfect, an MRI, undeniable! If only things were that simple in REAL LIFE medicine. Please don't forget that television shows are aimed at the general public and have to be extremely simplified. A shame, since the general public gets most of their impressions about medicine from a very simplistic version.

Here is my response:

Dear Bluedude, My deepest condolences on the passing of your father. I do understand how you came to believe that your father's physician made a mistake and, inferring from your response, he ultimately was diagnosed with lung cancer (I am not sure of this, however, you do mention an Oncologist being involved).

First, please allow me to discuss a personal story:

My father, then 49, continued to complain about chest pain radiating to both arms for about two months. He continued to return to his PMD with the same complaints however all the EKG showed nothing. I was still a student in college and did not understand medicine and certainly not interested. His doctor repeated an EKG on each occasion which (according to him) did not show anything.

When my father, finally, was reffered to see a cardiologist he went straight to cardiac catheterization (after the Cardiologist saw his EKG) which showed severe obstructive disease of the arteries to his heart. He needed an immediate triple bypass surgery.

For a long time we were very angry at our PMD for what we believed was ineptitude at reading an EKG. We never sued him although we didn't return and changed PMDs soon afterwards.

Now, after having studied medicine I do understand that what he was looking for was a CHANGE in the EKG. Which is medically legitimate. Although, I certainly feel a stress test was in order earlier I do understand that what he was doing was appropriate, if for example, he did not think the pain was truly cradiac.

Now, let's discuss your father. You believe that his doctor "missed" a spot on your father's CXR. OK. But have you thought about this:

1. Are you sure that the spot was truly lung cancer? (in your case it may have been but I am just making a point)

2. Was that same spot there before and therefore there really was NO CHANGE on this Chest-X-Rays from previous ones, something that would go against this "spot" representing a cancer?

3. If this WAS cancer, was it what really caused his death? Cancer usually causes a slow deterioration, therefore, dying suddenly is more uncommon (not to say it doesn't happen). Could your father have died with lung cancer, instead of, from lung cancer?

4. Where was this "spot" on the x-ray. Could other things have explained it in the medical history of your father, maybe it was an Aspergilloma (I know you probably never heard of this diagnosis but it goes to further point out that people not trained in medicine lack the knowledge needed). Maybe things he didn't ever tell you but did tell his physician. This may have caused your father's physician to choose observing this "spot" for growth as opposed to subjecting your father to a dangerous biopsy that would have caused his lung to blow and then really cause him to die.

Just understand that medicine is not as straight forward as it looks on TV. Chest X rays are imperfect, so are CAT scans (they sometimes show results which only cause further unnecessary workups- One, put the patients at further risk for procedure complications and are expensive). So are MRI's for that matter. Medicine takes EXPERIENCE and association of SYMPTOMS WITH results.

You can always second guess your physician. That doesn't mean you have any clue about what was really going on OR what were his considerations at the time. He may have only been trying to protect your father from a painful and unnecessary workup. You've never seen a complication from a procedure cause a patient's death, I've seen many. So has your father's physician.

5. Finally, By the time a mass appears on a CXR (if it is lung cancer). The disease has usually allready metastisized and the cure rate is EXTREMELY low!!!Meaning, chances are that even if he did pick this up and did subject your father to a painful workup and chemotherapy it would not have changes the ultimate outcome.

Furthermore, most likely your father's physician never even saw the x-ray, the radiologist who read the Chest X-ray may have missed it. Your PMD usually only recieves a report of the reading.

I've tried having this type of conversation with others who have similar beliefs but it's really too emotional for the other side and their view is too narrow and set on blaming someone. Again, I am truly saddened for your loss. I don't know if anyone is to blame after all but I'd like for you to consider that maybe nobody is to blame and everyone lost someone they loved (including your father's physician and good friend) because everyone dies sometimes and life is unfortunate and cruel in that way.