Page 28 - Delaware Medical Journal - September 2017
P. 28
A Case of Indifferent Medical Care
James F. Lally, MD
It was well known before Atul Gawande described it in an article in The
New Yorker, “The Bell Curve,” that
there’s a vast range of medical care in this country, the good, the bad, and the less often recognized, indifferent. Not the psychologically disturbing “la belle indifference,” but the more banal — not caring anymore.
Eventually, as my wife and I found out, when you seek medical care beyond
the catchment areas of large teaching hospitals, you may encounter physicians who in their clinical competence fall near the bottom of Gawande’s “Bell Curve.” Unfortunately, you may not recognize them initially as they have the appropriate credentials and the obligatory board from your primary care physician may weed out the less clinically skilled and
to practice medicine and that nebulous likeability factor may sway your decision, but the process of selecting a physician to manage one’s medical care is really trial and error, ultimately it’s potluck. You may naively believe that the Lake Wobegon effect, where everyone is above average, applies to physicians, but as Gawande makes clear: “Doctors like to think they’re doing their job as well as it can be done, but when you measure their results the spread is wide.”
Since we live in Southwest Florida, it is a drive of several hours to the major teaching hospitals in Tampa and Miami. That’s not meant to condemn our community as a medical backwater; what happened to my
wife could undoubtedly have occurred anywhere, although perhaps less likely in a medical environment where there are more checks and balances and more stringent standards of physician competency.
My wife’s steroid-induced diabetes mellitus (she’s treated for a vasculitis) prompted a referral to an endocrinologist. The blood-sugar levels were easily managed with diet and low doses
of insulin, however, several routine laboratory tests led to unexpected consequences. While thyroid dysfunction is common in older patients (particularly women), the routine ordering of thyroid screening tests is a debatable topic. I agree with H. Gilbert Welch’s (the author of Overdiagnosed) opinion that: “excessive testing of low-risk people produces real harm leading to treatments that have no
overutilization and overdiagnosis are also worrisome: turning people into patients.”
During a year of observation my wife’s thyroid-stimulating hormone (TSH) levels drifted into that gray zone between 5 and 10 mU/liter while the serum free thyroxine (FT4) levels remained normal.
With the increasing emphasis on teaching medical students communication skills, the following exchange between the endocrinologist (physician) and my wife (patient) could serve as a model of how not to interact with a patient.
Physician: “Your thyroid test was higher, you need to be on thyroid medication.” Patient: “I’d like to have the test done again.”
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Del Med J | September 2017 | Vol. 89 | No. 9
