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Healthcare Costs: Under-Thinking Leads To Over-Testing

My mother-in-law just had a CT scan of her head in the Emergency Department of her local hospital. My husband called me to ask if I could “talk to her about her headache.”

Severe headaches in the elderly are indeed worrisome, and I wondered if she had fallen recently – if she might have a bleed in her brain requiring immediate surgery. Of course, she’d need a CT scan to rule that out… I was prepared for the worst. But what I learned by simply talking to Mrs. Zlotkus was unexpectedly revealing – not only about her diagnosis but about our healthcare system in general.

As it turns out, Mrs. Zlotkus had been having severe headaches for about 3 months. She was taking Vicodin daily to “take the edge off.” When I asked her about the location of the pain, she said that it was “just on one side of my head, from the top of my neck to the top of my head.” I asked her if the pain sometimes traveled to the other side, or if it involved her eye. “Never,” was her quick response. She also told me that she’d been seeing a physical therapist for 2.5 months for neck stretching exercises.

Mrs. Zlotkus told me her CT scan was negative, and that her blood tests didn’t show any “temporary arthritis.” (That’s temporal arteritis, I presume.)

“Well,” I said, “There’s only one thing left that I can think of that will give you a headache in the exact area you’re describing – and that’s shingles. Did you notice any scabs or painful bumps on your scalp when the headaches first started?”

“Why, yes!” Said Mrs. Zlotkus. “About 3 months ago I noticed some very painful, crusty scabs on my scalp. I thought for sure it was because my hairdresser used extra strong chemicals on my hair. I scolded her for it. She told me to put tea tree oil on it.”

Oh, boy. There it was – a diagnosis as plain as the nose on her face.

“Um… Well did you tell the ER docs about the scabs?”

“No. They never asked me about it and I didn’t see what my hairdresser’s chemical burn had to do with my severe headaches.”

My mother-in-law’s work up (ER visit, CT scan, several doctor visits, pain medicines), misdiagnosis (neck muscle stiffness), and mistreatment (physical therapy) for shingles probably cost upwards of $10,000. Worse than that, she did not get anti-viral treatment early enough in her outbreak to prevent a long-lasting pain syndrome (called post-herpetic neuralgia). Now that she has this shingles-related headache, it’s very hard to treat. And taking lots of acetaminophen-rich medications (Vicodin) is the last thing her liver needs right now.

So how did the healthcare system fail Mrs. Zlotkus? In my opinion, this is a great example of the “failure of synthesis” that Evan Falchuk discusses on his See First blog. Somehow, the physicians involved in Mrs. Zlotkus’ care didn’t take the time to think about her symptoms, to ask the right questions, and to put all the puzzle pieces together. Instead, they just ruled out the potential emergency issues (a stroke/hemorrhage, or temporal arteritis) and gave her a follow up appointment with a neurologist (who couldn’t fit her in their schedule for 2 months). They didn’t take a full history – they just dumped her in the most likely diagnostic category (neck stiffness) and let some other specialist follow up. Shameful.

I’ve described more egregious examples of hasty medical care on this blog – consider the case of an elderly woman (the mother of a friend of mine) who was misdiagnosed with “end stage dementia” when she really had acute delirium from an overdose of diuretics… Or the case of my girlfriend who was mistaken in the ER for a drug seeker when she was suffering from a kidney stone.

Sometimes I feel as if I have to keep an eye on all my friends and family before they set foot in a hospital, ER, or doctor’s office. I’m afraid that those providing their care will be so rushed and thoughtless that my loved ones will wind up with a huge bill, the wrong diagnosis, and perhaps even a near-death experience. I am seriously afraid for them.

The bottom line is that we have to stop rewarding providers for volume over quality. We have to value the history and physical exam beyond the CT scan and lab tests. We have to give doctors the chance to think about their patients – rather than turn up the speed dial on the clinical treadmills as a means to reduce costs.

My mother-in-law just spent $10,000 of our tax dollars on a diagnosis that could be made in 5 minutes of thoughtful questioning over the telephone. Multiply that cost by the number of other Medicare beneficiaries who are suffering similar misdiagnoses in this country and we’re talking serious money.

Under-thinking leads to over-testing. Has the CBO taken that into consideration in its scoring of various reform plans? I don’t think so. To me, this is yet another reason why we need physicians at the table in healthcare reform – we see the real cost drivers that others might not think of – even if some of us are too busy to diagnose shingles correctly!


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4 Responses to “Healthcare Costs: Under-Thinking Leads To Over-Testing”

  1. roguemedic says:

    Excellent points. It is frustrating for me to be several states away from my mother. She has had both hips replaced, but not had adequate pain relief with either replacement. She does not want to bother anyone with her pain, since the doctor and nurses tell her the pain is not bad. How would they know?

  2. roguemedic says:

    Excellent points. It is frustrating for me to be several states away from my mother. She has had both hips replaced, but not had adequate pain relief with either replacement. She does not want to bother anyone with her pain, since the doctor and nurses tell her the pain is not bad. How would they know?

  3. Dar Lostrom says:

    THANK YOU DR. VAL…for revealing what genuine, thoughtful, and intelligent medical integrity 'could' look like. At this moment I am in a similar process of watching out for my 90 yr old Aunt who lives 2 time zones away. This past May, she had six teeth [including molars] extracted by an oral surgeon and while there are still problems with the ill-fitting denture, she has been doubly-challenged with new head pain that sits [only] behind her left eye [Ophthalmologist found nothing overt], plus, there's a cough, difficulty in swallowing, weight loss, and overall she says “I just don't feel well.” Thus, a/o last night, the on-call Dr put her on a second round [since extractions] of 10 day Amoxicillin for suspected 'sinus' infection [we said no to CT scan] and while there is no fever, what I am concerned about [after symptoms continue to evolve after 2+ months]…is the adverse potential of her immune system suddenly caving to really ill effects of either bacterial-related septicemia or pneumonia. Her 96-1/2 yr. old brother [my dad-in-law] and I did not learn of this [dubious] plan for such multiple tooth extraction until she was 5 wks into the denture fittings and cost [$4000], and worse, this is an elderly woman who is obviously compromised due to dowager hump frailty of Osteoporosis. I mean, I'd say this lack of bone integrity…alone…should have deterred those professionals from thinking she would be a suitable candidate for any degree of oral surgery. Sadly, the upper denture installed three years ago has never fit well, either…and by now, I'm sure you deduce how my dear Aunt [less than 5 ft/under 100 lbs] IS having difficulty in making 'appropriate' decisions for herself…and herein, is why I believe the professional integrity should have been firmly in-place to protect her, not incite further duress. Therefore, especially when family members do not live close enough for the day-to-day interface, I assert that every 'potential' patient sorely NEEDS the advantage of “ombudsmen advocacy” before they are similarly led astray or, denied a safest reality for their own [personalized] good. Thanks again Dr. Val; I've been duly impressed by both your compassionate honesty and downright blatant INTEGRITY.

  4. Dar Lostrom says:

    THANK YOU DR. VAL…for revealing what genuine, thoughtful, and intelligent medical integrity 'could' look like. At this moment I am in a similar process of watching out for my 90 yr old Aunt who lives 2 time zones away. This past May, she had six teeth [including molars] extracted by an oral surgeon and while there are still problems with the ill-fitting denture, she has been doubly-challenged with new head pain that sits [only] behind her left eye [Ophthalmologist found nothing overt], plus, there's a cough, difficulty in swallowing, weight loss, and overall she says “I just don't feel well.” Thus, a/o last night, the on-call Dr put her on a second round [since extractions] of 10 day Amoxicillin for suspected 'sinus' infection [we said no to CT scan] and while there is no fever, what I am concerned about [after symptoms continue to evolve after 2+ months]…is the adverse potential of her immune system suddenly caving to really ill effects of either bacterial-related septicemia or pneumonia. Her 96-1/2 yr. old brother [my dad-in-law] and I did not learn of this [dubious] plan for such multiple tooth extraction until she was 5 wks into the denture fittings and cost [$4000], and worse, this is an elderly woman who is obviously compromised due to dowager hump frailty of Osteoporosis. I mean, I'd say this lack of bone integrity…alone…should have deterred those professionals from thinking she would be a suitable candidate for any degree of oral surgery. Sadly, the upper denture installed three years ago has never fit well, either…and by now, I'm sure you deduce how my dear Aunt [less than 5 ft/under 100 lbs] IS having difficulty in making 'appropriate' decisions for herself…and herein, is why I believe the professional integrity should have been firmly in-place to protect her, not incite further duress. Therefore, especially when family members do not live close enough for the day-to-day interface, I assert that every 'potential' patient sorely NEEDS the advantage of “ombudsmen advocacy” before they are similarly led astray or, denied a safest reality for their own [personalized] good. Thanks again Dr. Val; I've been duly impressed by both your compassionate honesty and downright blatant INTEGRITY.

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