from: Trust in a Medical Setting.
Like most internists, part of my practice is seeing healthy patients who request physical examinations which generally prove to be genteel encounters with interesting people. Many have become friends. They return periodically for re-examination, and I noticed that patients that I know well and see socially sit by my desk, heart racing, palms sweating, and throat parched before a visit that usually is pleasant for me, if at times a little tedious and routine. I have come to realize that the patient knows all too well that a check-up means facing the fearful unknown directly, and it has become apparent that there is no such thing as a "routine check-up." There is some reason this patient chose this particular time to face the possibility that something might be amiss. It may take extreme patience and the resources of Hercule Poriot, Sherlock Holmes, and Inspector Clouseau to find the reason, which may be apparent only in retrospect on discovering that a distant uncle or his wife's friend's neighbor has developed a dread malady.
Physicians have tried many ways to ease the tedium of the check-up, such as changing the name to interval examination, multiphasic examination, periodic examination, or some such euphemism, but a check-up is a check-up. Nor has the computer helped. The economists in their criticisms of medicine suggest the check-up is not "cost effective." The cost of finding a case of tuberculosis with routine chest X-rays or a rectal cancer with a routine proctoscopic examination runs upward of $15,000 and, come to think of it, neither patient thanked me. We take pride in a meticulous examination and finding a subclinical disease—"picked up a heart murmer," and the patient says, "Now, can I get life insurance?"; "picked up a thyroid nodule," and the patient says, "Now, I suppose I will have to have surgery."
The cost accountants and the econo-physicians say we shouldn't do "routine" examinations. Personally, I welcome the news. No more dull recitations of the litany of normal test results; no more explaining why a new hypertensive patient must take medication for life; no more exasperating diet instructions to the newly discovered, over-weight diabetic; and no more explosions from the bland, controlled executive whose serology turned positive this year.
As I become more experienced, I find that I, too, face the unknown when a patient appears for a routine examination, and I have lost some of my ease and assurance of the past. Now, I'm a bit guarded and chary; there is a slight tremor in my handwriting, by throat a little dry, and my chair uncomfortable. For example:
A man entered my office wearing a golf shirt, plaid slacks, and white leather tennis shoes. He shook my hand vigorously.
"How are ya, doc?"
He placed his billfold on the desk, on top of an insurance form, then neatly placed his sunglasses and car keys along side. He folded his hands across his lap and answered my inquiring the reason he interrupted his normal life cycle on the most beautiful day of the year to come to my office.
"Nothing. Feel great! Just want to make sure everything is okay. Actually, my wife made this appointment."
Now the flag is up, the chips are down. I tugged my collar as a few beads of sweat formed on my brow. I have learned from experience that this is my last chance, in a moment it will be too late.
"Usually, everything is as fine as it seems, but life is full of surprises. I never know where a check-up may lead."
He sat up abruptly, fumbled his keys in a moment of solemn concentration, then eased back in his chair, deciding in continue with it. Nothing good can come of this encounter for me except the lonely satisfaction that I have done a proper job. If he is well, we have appeased his spouse; if something abnormal turns up, all hell breaks loose. Small wonder that no patient has thanked me for finding something important that he or she didn't expect.
For several years running, such an insouciant gentleman appeared regularly for his annual check-ups, certain that it was all unnecessary as he felt well, sang regularly in the church choir, and played tennis daily. Since his son was a chiropractor, he took considerable pleasure and patience in bringing me up to date on the latest wonders of the actual "healing profession," and thoroughly eroded any confidence in this particular physician-patient relationship, since he was even more certain that neither the check-up nor I were necessary. The check-up, to him, was a talisman, like the atheist in church—just in case.
He offered a vague sensation, occurring only in certain infrequent circumstances, glowing with confidence that it was trivial and medically inexplicable. Further investigation demonstrated an abnormal exercise electrocardiogram, abnormal coronary angiograms, leading to coronary by-pass surgery at a prestigious university hospital of his own choosing. I never saw him again, although some time later, I received a note inclosed with his statement that he went along with it only to please his spouse, but that he was sure that it all, including the surgery, was unnecessary.
Another faithful and long-time patient kept his appointments regularly, although suspicious rumblings reached me that his wife questioned my professional competence, and she had departed my practice some years ago. No new symptoms appeared and no bowel complaints could be elicited. On rectal examination, there was a tiny fold of mucosa that was slightly prominent, but not clearly abnormal. My patient, my friend, dressed while I struggled with the conflict of the cost effectiveness of a possibly needless proctoscopic examination, versus letting it pass, as it was probably unimportant. We discussed it, and I decided it was so small I would have a surgeon handle it. The surgeon initially thought I was imagining things, a judgement I would gladly accept, then found a tiny area to biopsy—rectal cancer in the tip of a tiny polyp, likely cured by this minor procedure alone. I naively expected that the patient and his wife would congratulate me and gratefully acknowledge my skill and pertinacity. What followed was a bitter complaint about my nominal fee, and an abrupt change of physicians.
The residual carry-over of the check-up is even more treacherous as we hear of patients who drop dead outside their doctor's office after a satisfactory annual examination and negative test results. For example, a woman I had known for years, six months after examination, attended a lecture on self-examination of the breast. That night, she discovered a small nodule in her breast that proved to be malignant. There followed accusations and calumny that it should have been discovered six months previously at her check-up, even though these tumors may double in size every two weeks, and she did not return. A young woman that I had known since her adolescence, developed abdominal pain, went to an emergency room at a nearby city, and at surgery, a large ovarian cyst was found, which can develop rapidly. The last I saw of her was in a department store, where she loudly informed me that I had "missed it." I was surprised at my presence of mind when I reminded her that her exam was eight months earlier and the pelvic exam was performed a few weeks before that at the Student Health Center of her beloved university alma mater. No matter, someone, probably an intern, planted the words "missed it" to trump-up his or her own image, and the subject was no longer open to reason.
So, you see, dear economist, cost-accountant, I, too, have grave concerns about the wisdom of the check-up, but for entirely different reasons. Your dark and sinister motivations frighten me; mine are those of the jungle—survival!
After residency, like many physicians, I practiced my newly acquired skills, my trade, my profession as an officer and a gentleman in the United States Air Force. My trench, duty station, battle post, or excubitorium was designated "Sick Call." A staff sergeant of no outstanding features presented himself for a check-up. His symptoms were vague and nondescript, a review of his many wondrous bodily functions proved that they were performing harmoniously in their respective internal and external milieus, psycho-social environment, and efficiently extracting from the input and dejecting a proper output, leaving a slightly corpulent, nondescript staff sergeant with no outstanding features.
I then turned my attention to the corpus and found the bodily orchestra equally harmonious, if a bit dull in the treble, slightly flat in the bass, and a broad middle range, with a rhythm that was monotonously in step. He dressed, and I clasped his shoulder, and dispatched him on the laboratory rounds of sophisticated technical equipment that clicked and whirred, jiggled and teased his vital juices, and recorded his galvanic aura.
He returned to her "the news" a few days later. The news was that his results were nondescript, negative, no abnormality noted, within normal limits, and didn't vary from the textbook description of the perfect airman by so much as a tenth of a standard deviation. I was at my best. With calm and confidence, I committed my precious and hard-earned, if tenuous, reputation by saying that he was, in my opinion, as of that moment, in no uncertain terms, healthy.
I placed by black USAF ballpoint pen on his chart, sat back, and folded my arms across my white USAF coat. He sat starring out the window, there was snow on the Chugach Mountains. He slowly, absently, shifted his gaze to me, leaned forward, hands on knees, and said, "Is that it?"
I again affirmed my opinion as to his state of health, expressed relief upon receiving favorable test results, and suggested that he might even live a long and healthy life. He stood. And as he left, said, "Well, doc, thanks anyway."
His sky-blue, cerulean, ungainly military presence retrogressed down the long hallway. I watched with a mixture of confusion an anger. "Some gratitude," I said to myself, but wait, wait! I'll take it! I'll take it! A draw is the best I can expect!
Causes Richard Smith Supports