One source of inefficiency in American health care

The Buckeye Surgeon educates us with a case.

In brief, it’s the case of an elderly woman with a clinical picture, including right upper quadrant pain and an elevated white blood cell count consistent with rip-roaring cholecystitis who was admitted to the medical service for her right upper quadrant pain. She underwent an ultrasound, which was consistent with rip-roaring cholecystitis, after which she was admitted to the medical service, which duly consulted the gastroenterology service. Then a CT scan was ordered, which showed a rip-roaring case of cholecystitis. Then the patient was bowel-prepped and underwent upper and lower endoscopy and the patient treated for gastritis. Then she underwent a cardiology consult, which failed to find a cardiac cause. Finally she underwent a HIDA scan, which is very specific for cholecystitis.

And then the surgeon was called.

This was a case about which a couple of old attendings in my residency program would have a sarcastic saying about, one that they used in castigating residents who failed to make a mind-numbingly obvious diagnosis. When that happened, they’d say, “The janitor is calling you and asking you when you’re going to take this woman’s gallbladder out.” Either that, or they’d say it’s a diagnosis that the janitor can make from across the room.

Observes the Buckeye Surgeon:

The next morning she underwent a laparoscopic cholecystectomy, with severe inflammation of the gallbladder noted. She was in the hospital three days before a surgeon saw her. Multiple radiographic tests were obtained. Invasive procedures were performed. What is going on here? I’d love to see her hospital bill and tally up all the unnecessary work that was done. Multiply this case by the surprisingly numerous times similar patients are managed you’ll find a gigantic sinkhole into which much of our health care dollars are lost.

I have one additional observation about cases like this.

I’m sure there are other specialties for which this sort of thing happens, but in my anecdotal experience not as much as surgery, much to the patient’s detriment. One major aspect of the problem is that surgeons have ceded much of the evaluation of abdominal pain to internists and gastroenterologists, along with endoscopy, endoscopic retrograde cholangiopancreatography, and other diagnostic modalities. It’s a narrow-mindedness and, yes, downright laziness that we’ve developed, in which we don’t want to see abdominal pain unless it’s a surgical disease; i.e., unless the pain is such that it indicates that the patient “needs an operation.”

Some of this was to the patient’s benefit. After all, removing gallstones from the common bile duct by endoscopy is just as effective and less invasive than doing it the old-fashioned way, by an operation called a common bile duct exploration. However, along with the advantages, we as surgeons have allowed ourselves to become marginalized in the evaluation of what was previously considered our forté, our raison d’être, abdominal pain. As the Buckeye Surgeon puts it:

The troubling thing is, primary care and internal medicine increasingly look primarily to GI for ANY abdominal complaint. I can’t tell you how many times I’ve seen a patient with an incarcerated hernia or appendicitis AFTER the GI consultant.

And we have no one to blame for this but ourselves as a profession.

Another tendency is the trend towards increasingly “noninvasive” treatments. Unfortunately, this attitude and trend has taken hold even for diseases for which the best treatment is surgical, such as acute cholecystitis.