A couple of years ago, my mother experienced sudden weakness in her left extremities and slurred speech. In the emergency room, she underwent a CT scan of the brain that did not reveal the obvious stroke she had suffered, nor did the MRI done the next day. These negative results did not mean she did not have a stroke — they simply were insufficiently detailed to reveal a small but important abnormality in her brain's circulation.
A few days later, a consulting neurologist ordered up another MRI, out to prove, I guess, that a stroke was there somewhere. I objected, as I did not see how this was going to make any difference in the therapy my mother would receive — even if the stroke finally showed up on a fancy X-ray.
I am a physician (an internist) who subscribes to the idea that medical tests should not be done unless the results are going to be acted upon (and this includes testing to obtain prognostic information that will help patients make important plans regarding, for instance, end-of-life decisions).
One scan of my mother's brain would have been enough — it would have had the capability of demonstrating a tumor that could have been the cause of the stroke or it could have shown a cerebral bleed, as opposed to simple blockage of a major artery. If a tumor were present, a search for a cancer from which the brain tumor originated (lung, breast, colon, etc.) could have been undertaken. In the absence of a bleed, blood thinners could have been considered.
Even before the stroke, however, my mother was already fairly feeble and was significantly demented. She was therefore not a candidate for blood thinners, nor would finding the "originating cancer" have accomplished anything but put her through a lot of uncomfortable tests, not to mention difficult, probably futile, interventions such as chemotherapy and/or radiation. When I questioned the neurologist's decision to get another MRI, he mumbled something to the effect that everyone seems to want these tests, shrugged, and relented.
I related the above to poker buddies — all of them intelligent and sophisticated, but not doctors. To a man, they agreed that I was the only one in the group who could have headed off that second MRI. They simply felt that they did not have the wherewithal to question the test, saying that challenging the neurologist would not even have occurred to them.
Republican vice-presidential candidate Paul Ryan's Medicare reform proposal incentivizes patients to keep their health care costs down by making smart consumer decisions. In his world, Medicare beneficiaries are expected to shop for the best medical deals and then pay out-of-pocket for plans that provide more than the basics. The reasoning is that, if people can weigh the advantages and disadvantages of, say, buying a Toyota rather than a Ford, they can apply the same thought processes to making medical decisions. And in the process, they will tend to keep our national health care bill lower, as companies will be forced to recruit patients through competitive pricing of health insurance plans.
Ryan's plan would also place expectations on patients to make judgments that even doctors find difficult. Some preventive procedures are quite controversial. For instance, the prostate specific antigen ("PSA") is a heretofore widely used screening blood test for prostate cancer. The test creates so many misleading results, however, that most recognized preventive medicine bodies (and the urologist who created the test) no longer recommend that the test be done on a routine basis. Screening mammography is also controversial. It has an important place in women 50 years of age or more, but the experts are divided regarding the usefulness of this test in 40- to 50-year-olds.
Are our elderly supposed to be making health care purchases in the face of such controversy and complexity? It is not a stretch to be concerned that decisions may not be in their best medical interests. For instance, senior citizens may try to keep costs down by buying health insurance plans that do not pay for certain preventive procedures, but since some of these interventions are universally accepted to be useful (e.g. blood pressure checks), they are at risk for making decisions that appear to be cost-effective, but medically unwise.
Consumers can easily decide whether they want to pay more for conveniences like seat warmers in the cars they buy, and the market place is quite effective in parceling out who gets to enjoy extras like these items. Congressman Ryan is right in trying to devise ways to restrain health care costs. He is wrong, however, to expect consumers, especially elderly consumers, to make prudent judgments regarding their health care purchases.
Dr. James Whalen is a resident of Oak Park.
Answer Book 2019
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