Fixing Health Care: When Patients Don't Know Best

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Few spontaneous injuries are as obvious as a rupture of the Achilles tendon. That ropelike cord in the back of our ankles carries enormous loads. It resists, literally, a thousand pounds of tension when a person, even of normal weight, runs or jumps. When the tendon pops, it's not subtle; many patients report actually hearing a bang. It hurts a lot. And most characteristically, they suddenly lose all "down power" in the ankle, making it impossible to get up on tiptoe.

The X-ray of an ankle with a torn Achilles tendon will generally be normal, but simply examining the patient makes the diagnosis quite easy. Instead of the stout tendon, you feel mush with a hole or divot at the spot where it's torn. It's easy to compare with the other ankle. And there's a great test we do by squeezing the calf and watching the ankle move; on the good side, it wiggles up and down when we squeeze. On the torn side, there's no motion at all. Yes, there is an occasional partial tear that might be harder to diagnose, but in the vast majority of cases, an orthopedist who simply looks, listens and feels will make the diagnosis of Achilles-tendon rupture — with confidence. (Watch TIME's video "Uninsured Again.")

So why is it that the patient I saw today and the one I saw last week both came to me having had MRI scans of their ankles?

Frank is a fit, 59-year-old insurance adjuster who had felt the pop during a kickboxing class 10 days before. He immediately had a pretty good idea of what had happened, so after limping out of the gym, he called an old friend who is a retired orthopedist. "He said he was pretty sure it was my Achilles, but I wanted an MRI to be sure. He just said 'fine' and gave me the prescription." I spoke with Frank and showed him the powerlessness of his ankle — the squeeze test. I even had him put his finger into the divot in his tendon. I tried to be gentle about bringing up the s word — surgery — but when I finally broached it, he shot back with, "But you haven't even looked at the MRI yet. I heard the ads — it's the new stand-up unit. Listen, doc, I know you've treated this before but ..." So I just put up the films and showed him the tear. I could have been showing him a plate of scrambled eggs, but he was happy and we booked his case. (See pictures from an X-Ray studio.)

Paul is a 45-year-old teacher who tore his Achilles in a basketball game two weeks earlier. The first orthopedist he saw went into a long talk about risks and benefits and scared him out of his wits. With a torn Achilles tendon, there are just two things to do: either sew it up (which means doing a small operation) or put a cast on with the foot flexed down. The cast treatment isn't as good — it won't restore normal power — but there are none of the risks of surgery (like scarring and infection). So he demanded an MRI, which he got, then called his internist to ask for another specialist. "You're not playing any more basketball, at least not the kind that requires jumping, if you don't have that tendon repaired" is what I told him after taking him out of the cast and examining the ankle. "Can't we get another MRI to see if it's healing? I've read about them."

"If you're going to trust me to operate on you, you're going to have to trust me on this too — you don't need another MRI. You didn't even need the first one."

There are real savings to be had in cutting down on MRIs — especially unneeded ones. But it's quite hard to keep insured patients who ask for expensive medical tests and treatments from getting them. Blocking a patient who wants something they saw in an advertisement is time-consuming. Teaching the complex truth one on one is a lot harder than convincing large numbers through eye-catching, sound-biting market psychology. It's a money loser too. Most of the time, a patient who has been sold on something you don't want to use will just leave and go to another doctor. (Read about the five big health-care dilemmas.)

We face this issue every day: the pill they saw on TV or in the magazine, the new scan, the diet supplement, even the specific brand of hip or knee prosthesis are difficult, occasionally impossible, to deny to the folks who ask for them. In the American doctors' precarious medico-legal (and fiscal-social) position, career success is increasingly built on cooperation with the corporate and government powers that touch us. Playing along with that sketchy (but expensive) new treatment or being a champion of the wacky new state initiative is more likely to help your career than giving an educated but honest appraisal of actual patients' well being. The only salvation from this might be, strangely, the recession. Traditional medicine, without the consumer marketing or institutional pandering to federal agencies, is cheaper. And if the downturn turns down low enough, we'll need to turn down demand. And stop hawking medicine.

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