Kate of Healthy Policy hosts Health Wonk Review #3 at her site; Health Wonk Review is a health policy weekly summary of the best of blogging about health care policy. Great work!

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I’ve written before about how I think culture affects patient expectations and medical care, and it’s time to make it a trilogy: I anecdotally put forward the hypothesis that inpatient impatience leads to increased health care payments. (Okay, fine, outpatients and physician impatience too, but I’m in an alliteration mood.)

And the anecdote: Awhile back, I saw a patient get an $80,000 workup for mono. This is that same mono that is viral, that resolves on its own. The teenager had a chain of enlarged lymph nodes in her neck, felt pretty tired, wasn’t eating well. The differential diagnosis? Mono versus lymphoma. A scary differential–viral process where you should avoid contact sports and take it easy… versus cancer. She was under the care of experienced physicians, who have seen both mono and lymphoma many, many times. She got: many, many lab draws (including a botched mono test that should have been repeated earlier in her course), a bone marrow biopsy, a lymph node aspirate, and finally, a lymph node biopsy. These are not totally benign tests; they have significant risks involved, and significant costs as well.

Yes, yes, hindsight is 20/20. But the fact that the patient started to improve clinically within about 4 days of her inpatient hospital course (and with that, essentially showed us that she had mono, not lymphoma) makes me wonder if it was all necessary. A cursory PubMed search didn’t turn up much on, say, delaying a possible cancer workup by a week or 5 days (by which time someone with a non-cancer might expect to start to improve). I can’t say whether the extra week does much for survival or quality of life. If a week really dose make a difference, then maybe the $80,000 is worth it–after all, cancer can be fatal if not caught early.

I also anecdotally recall how many times our team has tried to workup an anemia, or a wacky blood pressure, and we come up with nothing. Or how many times doctors are just stumped for a cause for a disease. Or how many times we do a CT and find something incidentally (often a non-specific, possibly-nothing possibly-something mass known as an “incidentaloma”) and spend thousands of dollars evaluating it, when it turns out to be nothing. With all this increased monitoring and increased lab draws and increased this and that, we’re picking up a ton of human variation that has no correlation with human disease. My friend E told me she went in to donate blood and was told she had a hematocrit of 30, well below the “normal” limit, even for women. Were she to get this result from a doctor, I wouldn’t be all that surprised if he or she wanted to work it up. But she’s walking around just fine with her low blood count, and couldn’t tell the difference either way.

We’re so pressured for now now now, to save time and be efficient, that we’re often wanting an immediate diagnosis when the body won’t give out the answer without the tincture of time. We do a much better job already managing patients as outpatients, which is much less costly than managing them as inpatients–but how much could be avoided if we just learned to wait? Patiently?

How much of all of this is real disease, and how much is just Mother Nature’s wild goose chase as a punishment for trying to peek inside our bodies and understand ourselves? I think the next big thing we need in medicine won’t be a new lab test or a new gene discovery: it’ll be a better way for us to tell who actually is sick, and who just looks like it; which one person out of 100 will require more serious care, when the other 99 do fine with nothing more than reassurance and rehydration.

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I really wasn’t expecting Michael to email me back. But he did. He had some pretty good answers, which I couldn’t find him plagiarizing anywhere from Google, so I sent back some replies to help him with his paper. Never assume!

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The first expression of religion I’ve seen from an attending happened more than 9 months into my first clinical year:

A very, very sick pre-teen that we made sicker with chemotherapy wasn’t initially improving when he should have been, and the oncologist told us that she hasn’t slept in days, worrying about the child’s health. After another sleepless night, she told us that she

“Sat down and just prayed. Just prayed that [the child] would be okay, and that his counts would come back. I figured it couldn’t hurt. And then my daughter came into the room, and asked me what I was doing. And I said, ‘I’m praying for a little sick child who needs to get better,’ and my daughter decided to pray with me. And then my other daughter walked in, not saying a word, and sat down, bowing her head as well. After about a minute, she whispered, ‘What are we doing?'”

The attending on staff said that he knows an Indian adult oncologist who can get 1,500 people praying for a patient back in her hometown at a phonecall’s notice.

Desperate times call for desperate measures, I guess. Kate and Matthew discuss a Forbes article noting that doctors are more religious than the general public, at least according to the survey. I think it’s easy in medicine to lose faith in God or religion day-to-day; you see terrible tragedies walk into your office or hospital on a regular basis. But I think there’s probably a part of many physicians that at least hopes there’s something more to all of this, something out of our control. It’s not something that we can rely on–but at least something that we can try to call upon when our medicines simply aren’t enough, or when we could really use the scale to tip in the right direction.

One of the many reasons medicine’s an art, not a science.

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is up , a great review!

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