Too many of the same test
Two month ago, my daughter had just completed her 2nd year of college and was on a quick road trip to Canada before heading home. On the ride up, she twisted her body to get something from the back seat and she felt a pain in her knee. Not thinking much of it, my daughter stayed on her journey into our neighboring country. By the time she arrived, when she stepped out of the car, she could not bare weight on her right leg. Maybe at age 50, I can expect such odd pains but at 20, and being a fit spin instructor, why should she be experiencing this. She did not recall any fall, accident or other injury causing event. It was a mystery. Painful enough, she visited a Canadian doctor who was conscientious to not to rack up a bill that would not be covered by her insurance and suggested it could be her meniscus but encouraged her to seek medical attention in the U.S. She went on her merry way and enjoyed the rest of her trip but was careful not to bare too much weight on her leg.
5 days later, she comes home for Mother’s Day. I do not see significant swelling but we keep ice on it and ace bandage it up until we can go to urgent care in the morning. At urgent care, they take x-rays but say it is inconclusive and refer her to an Orthopedic doctor. Along with a knee brace, we get the specialist appointment the next day. Upon entry, I hand them the disk with the X-ray images from the day prior.
Without even pretending to review the images, the nurse announces they are going to take their own images. Whoa, whoa, whoa. I do not have a limitless checkbook. The costs are quickly racking up and while we pay for pretty good health insurance, my deductible is high and, as it is only the month of May, has not yet been reached. I explain to her that all expenses are out of pocket and since no one is thinking this is a bone issue (which is what X-Rays are supposed to reveal), I’d rather not pay for another round and I encourage them to look at the images I have brought to them. Clearly, I was not making her day easy but she said she would relay my concerns to the doctor.
Obviously, the nurse had shared my concerns and given him an interesting picture of me because I could overhear him in the hallway telling her “I’m going in!” as he came through the door. He promptly explained why their imaging is better than anyone else’s but clearly had not looked at the disk. At some point, he decided to stop debating an issue that had no relevance because he agreed, in this case, an MRI would be a more appropriate next step. His theory at that time was something being pinched in her knee, but the MRI would show more facts, so we held off on any official diagnosis.
We were able to get into the MRI center the same afternoon and promptly returned to the Orthopedic center with the disk and report. They loaded the information and gave us a follow up appointment for 2 days later.
Note: these appointments may seem close together but that is only because we begged to fast track them to accommodate my daughter’s departure at the end of the week for her 5-week study abroad trip. We needed to know what we were dealing with before sending her off to Europe. I am appreciative they accommodated us with urgency.
At the follow up appointment, the MRI showed a knee that was unremarkable (medical talk for nothing visibly wrong with it). The mystery continued until the doctor asked more questions about the days leading up to the painful twist in the car. Fearing she may not find a studio to spin with close to campus, she started to run. This sudden movement appeared to have caused a stress fracture below the knee despite the pain presenting itself in the knee. Pictures say 1000 words and one could not deny the fracture. As I write this article, I am now curious if the X-ray showed the same thing but because no one looked at it, we wasted more time and money.
Not much can be done for a stress fracture so she is off to Europe with instructions to reduce weight baring activities and healing should be complete in 6-8 weeks.
The Full Picture
Probably best to take this approach all the time but especially when a patient has a chronic condition, looking at the whole picture rather than one test result or one seemingly unrelated symptom would lead to better care.
My husband was diagnosed 10 years ago with Hashimoto’s disease – a form of hypothyroidism. It is in the family of auto-immune disorders and, once you have one it is not uncommon to develop more so, we are vigilant when it comes to monitoring and noticing changes. It also requires routine blood work which results in a history of changes that can be tracked to see if there are anomalies or concerning changes occurring in the body over time.
Results from the last several tests have shown slight but consistent elevations in blood sugars so reducing sugars and carbs are important lifestyle adjustments to make. Cholesterol counts as well as markers for kidney function are rising so those too need to be kept in check.
About 8 months ago, he started complaining about lower back pain. Having never experienced chronic pain before, he did not understand what could be happening, so he went to his new General Practitioner (GP). She suggested it was his mattress and referred him to physical therapy (PT) to learn how to sleep. Seriously?! Not, strengthen your core, not watch your lifting and bending, not O-L-D syndrome… but learn how to sleep? Has he not mastered that in 55 years? This was crazy talk, so he ignored it.
He did research hundreds of mattresses and we invested in one of the new hybrid beds only to discover that our old mattress was defective but that is another article for the future. With the new mattress came some relief but the pains persisted with little explanation.
6 weeks ago, he started complaining about radiating pain from the back through the side and into the front of his abdomen. Along with the pain came bouts of nausea. Back to the GP he goes. She data enters the information into her system and proposes an ultrasound test of his lower abdomen along with a referral to a nephrologist to inspect the kidney.
The nephrologist office is also part of John’s Hopkins so he is pleased to get the referral until he finds out that he will not be seen for 4 months. Again, a reminder that U.S healthcare has the same challenges that Canadian healthcare does. People can die of their diseases long before they are diagnosed if they all wait 4 plus months for specialists to be available. So, he keeps that appointment but schedules with another one sooner figuring if something is discovered, he can use the 2nd opinion. There is still a wait, but the middle of June is better than the end of August for sure.
In the meantime, the pain worsens. I hear Alex Trebek’s interview on the evening news where he describes his first symptoms of pancreatic cancer were pains radiating from the back, through the side and into the front. As I research further, some of my husband’s rising blood counts can be symptoms of the same disease. For over 8 months, he has been reporting back pain and rising blood counts and now he is experiencing increased pains. He decides to go back to the doctor to plead for a more complete scan than the upcoming ultrasound. The doctor admits that her entry of data is not enough to override the suggested tests, so she must force additional information into the system in order to submit for the expanded scan. Success, it has been approved but now one day prior to the Ultrasound, he cannot get both tests on the same day and will have to return the following week.
Nervous and impatient, I decide to search for alternative explanations. Perhaps the symptoms are not related. Perhaps there are multiple things going on simultaneously. While the tests are the smartest way to quickly rule in or out potentially catastrophic illnesses, as I learned from my daughters MRI, you also have to look for things that may not be as obvious. With my research, I hit pay dirt. I discover that the SI Joint could cause his recent and long-term back pains. That would mean his blood tests are unrelated and will still need monitoring and lifestyle changes to keep in check but all of that is better than pancreatic cancer, kidney disease or some other internal illness. I feel a moment to breathe easier and hope the scans prove out my theory.
Bingo! Both the ultrasound and the CT scan show “unremarkable” results for all the organs. There is inflammation of the joints in and around the hip and further tests may be required to determine if Arthritis is the cause, but we can live with that.
Now we have a baseline image for the future and were able to rule out significant organ ailments at one time. Isn’t this far more efficient and effective than the death by 10,000 pin pricks approach? Can’t help but think it is cheaper for the consumer too.
As I noted in my previous article about the ACA, the system needed to change to protect patients from predatory insurance practices. The birth of the medical administration industry is a direct result of the melted down version of the ACA implementation and has brought on new challenges. When will leadership develop a plan that balances the needs of patients (all patients of all incomes, education levels, and races) and those of a capitalistic insurance industry? Great minds from business, science, medicine and government can solve this problem when politics are removed. U.S. citizens need to demand more from our healthcare and our leaders to ensure our children have better choices and have the needed programs to care for us, as we age, and their families, as they grow.