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Madge’s Waltz: the delicate dance of medical decision-making

With specialist skulduggery again in the spotlight this week, and the release of new Choosing Wisely recommendations, Dr Steven Faux steps us through the delicate dance of medical decision-making.

He hits back at suggestions that doctors share part of the blame for Australia’s budget woes and argues that where expectations of care are high, costs tend to follow.

[divide style=”dots” width=”medium”]

 

head shot of me 2014

Steven Faux writes:

Last weekend I am pretty sure I over serviced and some among you will say I committed fraud and should repay all amounts that I received from Medicare and the health funds.

The problem is there was no other way to deliver the clinically relevant services that Madge required.

Madge, in her eighties (let’s call her Madge, the name of Dame Edna’s long suffering accompanist, and one who could never be accused of complicity) was referred to a private hospital for post stroke rehabilitation. She had suffered a bleed into the front part of the brain which had destroyed most of her left frontal lobe and a bit of the right (about 15-20% of her brain).

Now despite that being incredibly tragic, life changing and sudden – no one could work out why it happened.  So my instruction from the equally quizzical neurosurgeon, was to organise another brain MRI in 6 weeks, to check that whatever had bled so catastrophically was not still there, and could therefore potentially bleed again.

If it was still there, the next bleed would be curtains for Madge, and the neurosurgeon would have to get whatever that bleeding thing was out (now you know I know all the fancy words for these type of events but frankly they are confusing and shroud medicine in an unnecessary and impenetrable cloak of jargon – so don’t mistake plain language for ignorance or a dull mind, I have been battling that fight all my life).

Simple enough; a brain MRI is worth about $450 at the private radiologist up the road, and even if she needed transport to and from the private x-ray place it would only cost about another $800. Because ambulances are not covered by Medicare, only by health insurance, every time you use a central district ambulance (CDA) it costs — and you can’t expect it on time because they are all on alert for emergencies. You can get a patient transport van from say a large private provider and the costs are less, maybe $400 and covered by some health funds.

So Madge was looking at using CDA and paying the radiology fee, for which she would be out of pocket $450 because the radiologist doesn’t bulk bill for his MRI — he does not have a registered Medicare machine, not bought before a certain date, but it can do the job – no question. (That’s another story of skulduggery in the health system during the Howard era by ‘preferred providers’ but let’s leave that now for Madge’s sake)

The good news is that the cost to the public purse would be $0.00. A good result for an overburdened health budget.

A delicate waltz

But the thing about bleeding into the front part of the brain is that it affects your personality. It’s what we call an eloquent area, a poetic form of medical jargon – islands of lucidity, the caput medusa… the list goes on.

Madge the matriarch had become incredibly passive, she couldn’t start things off or create things, and could no longer plan how to do a thing. So I was presented with a mute, zombie-like elderly grandmother who sat and looked at her dinner, unable to start off the process of eating it. The nurses were alarmed as she was virtually catatonic, stuck in certain positions. They said she neither spoke nor walked nor assisted in her dressing, and her facial expression remained perplexed.

I had seen this before and knew that, while Madge could not initiate anything, if she was led she would follow. So long as we didn’t want her to think about what she was doing she would respond – she had to operate automatically like the way we ride a bike, once we know.

If you have ever ridden one you remember how complicated it was and what a leap of faith it was to commit your balance to the two wheel construction and believe that if you moved fast enough you would not fall. And for those of us who were nervous in nature, the process of learning to ride was excruciating.

That was how Madge felt about walking. She wouldn’t, for fear of falling, and was nervous about even getting into a position that might result in walking, but I knew she could waltz if I led.

With the patients in the room incredulous, and the nurses ready to pounce on me, I stood her and started to hum the Blue Danube, and we waltzed perfectly around the room. I led and she was like a feather in my arms, enjoying things with a coy smile and later a throaty laugh. We didn’t stop there — she sang happy birthday to me, despite the fact that she couldn’t initiate a word of language.

And so progressed her rehabilitation. She remained inappropriate in behaviour, she aped the exercises of other patients in the gym and she would wander out of the ward lost and perplexed whenever she wasn’t attended to personally.

In short, getting her to the MRI machine would be a complex task, followed by a neurological review of the scans and to decide whether she needed surgery, medicine, or whatever.

I had my own thoughts and I could have just decided that she didn’t need any other studies. Indeed, many of my geriatrician colleagues would have argued that she needed care only from now on, that we could have saved significant sums by deciding that:

  • if the thing in her brain bled again and finished her off it would be kind enough exit for an octogenarian (a patronising opinion, I know),
  • if she needed to have brain surgery and survived ( a big ask for an older person) she would still require rehabilitation and full time care in the future; so
  • an MRI would not change the way she would ultimately be managed.

The way forward was to consult the family, it was their decision after all.

First, do no harm

Clearly Madge could not make a decision for herself, so I turned to her 85 year old husband who had initially found her unconscious next to him, on a car trip when he thought she was snoozing. Obviously traumatised by the whole affair, he contacted his three children: the academic, the company director and the teacher.

They wanted, and pretty much demanded, the MRI. I didn’t paint a very rosy picture of her future, and told them that the outcome would be the same (care in a nursing home) with or without the MRI. But most people these days are information hungry and they wanted to know if they would have to consider surgery. Our technological world has taught us not to accept any mystery of the universe unless all avenues of intelligence-gathering have been exhausted.

When asked to undertake a new activity Madge would often lie still and firmly close her eyes, sometimes trembling in fear and twitching about, unable to get comfortable. I realised she would have to be sedated to get the MRI, and that meant it had to be done in a private hospital, so that if she had a reaction to the sedation she would be admitted and treated (public hospitals would be unlikely to give up a sought-after public bed just to execute what is normally an outpatient service).

Now the costs were really going to rise, but I rationalised that if she just had the MRI and all went well it would be an overnight admission and I could get the neurologist to see her while she was in (adding costs of about $200 for the consult and advice).

The best projection of the costs was now:

  • two days in hospital (about $2000)
  • transport to and from hospital (CDA no cost to tax payers)
  • an MRI with sedation (about $900)
  • a neurology consultation (about $200)
  • a visit by me to collect all the information and coordinate the discharge back to rehab (about $60).

A total cost of $3160 (conservative estimate)

But here’s what happened.

Madge went to hospital with letters from me, she had the MRI with sedation ($900) and then following the MRI, and as the sedative wore off, she became confused and lay still, eyes closed, trembling and twitching about trying to get comfortable.

In a large hospital, behaviour like that will trigger an emergency response because it mimics brain injury (it’s a nursing protocol thing). A junior doctor was called who was five years out of medical school, and had never seen anything like this. He made a call to intensive care, fearful that Madge had uncontrolled epilepsy or that she was rapidly losing consciousness.

The ICU consultant agreed (initial consult $115) and proceeded to order an urgent brain CT ($400) to exclude a bleed into the brain between the end of the MRI and the arrival to the ward bed. Then I was called ($60), but by then the wheels were well and truly set in motion. The ICU bed was being prepared and to be honest, I hadn’t been there during the behaviour so I couldn’t say whether it was just her unusual behaviour or something else.

She spent the night in intensive care ($3000/day for the bed plus intensive care consultant $271.60 for first 24 hours +/- $300 worth of additional tests). After hours x-rays are read by an outsourced radiology mob (say $200) who are pretty good but not always specialised in the area of concern.

Then I realised that one of the phases of the MRI had not been done, so I called the  neuro-radiologist who wasn’t on call but understood the complexity of the situation. He logged onto the server and read the MRI films to ensure that there wasn’t anything else there that might have triggered the behaviour, like a tumour or an unusual  intertwined collection of arteries and veins that we were looking to exclude ($0.00 – he did it gratis), and sensibly suggested that while the patient was there and still had the contrast injected from the MRI two hours earlier (to save costs) that the missing venous phase of the original MRI be done (an additional $300 which would have cost $900 if we had to repeat the whole series the next day and caused an extra bed day at a cost of $1000).

This helped us diagnose the condition, a disease of the blood vessels in the brain that make them leaky and likely to bleed.

I called the neurologist at home and told him of the case. He supported our decision to move her to ICU saying that she may have had a seizure, and to put her on some antiepileptics ($0.0 gratis again).

I visited Madge and her anxious husband the next day, spoke to the ICU people and shipped her out back to the ward. The neurologist saw her the following day ($200), confirmed the diagnosis and commenced her on low dose antiepileptics, and cautioned that certain medications should be avoided in perpetuity.

Her hospital stay was 4 days; 1 day in ICU ($3000) and 3 days on the ward at about $1000/day.

Counting the cost

In total, the cost of that MRI ended up being well in excess of $7,500 and everyone made bit of dough –  me, the radiologist, the hospital, the ICU consultant and the neurologist.

Now if that is over servicing it certainly wasn’t wilful.  It wasn’t part of a conspiracy to rip off Medicare and the health funds, and none of us apart from the afterhours radiology service was answerable to any shareholders.

Was it due to a constellation of errors (read air crash investigation)? It might have been, due to a private hospital infrastructure that puts patient safety above all else with strict nursing and medical protocols around the dropping in consciousness of patients.

Was it due to poor communication? (I could have told them about her behaviour but because the junior doctors rotate every eight hours I would have had to do it three times a day on both days of the weekend), or was it due to  inexperience (probably played a role but when inexperienced we teach junior doctors to follow protocols which are safe and hopefully fool proof, because we would rather cost the system money that lose a life).

Perhaps it was overzealous care (I guess that’s what you pay ICU specialists to do – make sure every eventuality is covered and every treatment is offered).

Then there was high patient complexity (sure, and that’s not going to go away — people are living with more complex illnesses because medicine is getting better at managing symptoms), and finally an oversight when one phase of the MRI was not done – but we remedied that at less than a 1/3 of the cost of a repeat scan (and yes you are right, we could have saved $300 of that admission by getting the scan sequence right).

Madge cost Medicare and the health funds a lot more than expected, but eventually there was no harm done, we reached a diagnosis and may have treated an underlying epilepsy.

When commentators like Ross Gittins imply that doctors’ greed is what is making healthcare more expensive, I think Madge’s case will illustrate that it is far more complex, and in fact requires a comprehensive and thoughtful approach, not simply one based on moving one of the levers of economic control. Sorry Ross, but people are infinitely variable and their health care will always reflect that — the economic drivers applicable to the management of mining or banking (now let’s talk about greed) or manufacturing, just don’t apply.

In Madge’s situation the only way to have avoided all these costs would have been if the family had accepted that nothing could be done and just trusted the doctor completely – but those days are gone since the advent of Dr Google.

Bean counters cannot really understand health, because of the role of uncertainty, infinite variation and public expectations of acceptable levels of suffering.  In the developing world there are different cultural norms about what amounts of suffering can be tolerated and what to do when that level is exceeded. Some go to doctors, others to healers, and some accept that it is part of ageing or nature or a spiritual journey.

Australians accept different levels of tolerable suffering – an ingrown toenail won’t have most going to the doctor put pain of an unknown origin will.

Maybe it will take a public education campaign to help Australians understand that if expectations of care are going to remain high then necessarily the costs of care will rise. We may have to look at the whole system, its efficiencies, its costs and its delivery processes and perhaps most importantly what we as individuals hope for and accept with respect to treatment, communication, access and safety.

Ross, it’s just not as simple as blaming the greed of doctors.

Steven Faux is Director of the Rehabilitation Unit at St Vincent’s Public Hospital in Sydney, specialising in pain management and rehabilitation medicine.

He is also a senior lecturer at the University of New South Wales.

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