When the doctor needs a doctor
Early Friday morning, I got cancer. Bad cancer, the kind that can colonise your bones. Mine had spread to one bone in particular: a rib in the middle of my chest. To diagnose myself I took a history, questioned myself about the nature of the pain and did a physical examination. The pain woke me up, it was grinding and rated seven out of ten when I moved or breathed. There was “point tenderness” over my fourth rib just medial to the mid-clavicular line, and crepitus (a distinctive crackling feeling when shards of bone grind together). The invaded bone curved right over my heart’s left ventricle. A terrible click vibrated through my chest whenever I took a breath. Given that I hadn’t fallen from a ladder, I knew this was a “pathological fracture”: one caused by something bad happening inside your own body, such as spreading cancer. I lay down on the lounge room floor, staring at the ceiling, wondering if it was a breast or lung primary, and how many months I had left. Then I called my workmate, Harry.
I’ve had a lot of diseases over the years – Hashimoto’s thyroiditis, hepatitis, a ruptured spleen and multiple episodes of lymphoma – with peak incidences around the time of my final med-school exams and then, six years later, the specialist exams. There are millions of diseases, and a body can generate a lot of sensations: who’s to know for certain if the pain in your gut is the result of too much hummus and not actually a huge tumour in your pancreas? Who can know for certain without having a long, hard look at your internals with a high-resolution scanner?
There’s a lot of talk in the media and around the wards about “over-investigation”. That is, looking for a disease that is highly unlikely to be present. Take lower back pain, for instance. Each year Australia spends about 220 million Medicare dollars on X-rays, CT and MRI scans for lower back pain. Most people experience back pain at some point in their life, which makes back pain “normal”. Though normal, pain makes us anxious: we want to know why we are feeling it, if it is a sign of something dangerous, something that may leave us permanently incapacitated. After all, every nerve that allows you to move and feel your body travels through the spine; what if one of the bones has moved and compressed a nerve? So you go to the doctor, who engages you in a strange dance: she raises your leg, asks you to bend it, presses and pulls, taps your knees and ankles, bounces a pin across your skin. “All good,” she says. “Heat packs and paracetamol, and don’t take to your bed,” she says. Your heart thumps. You picture severed nerves, surgical interventions; your future in a wheelchair. And in the face of all this she asks you to trust her tendon hammer?
There are clear international guidelines outlining the limited circumstances in which it is appropriate to scan a patient with back pain. If we followed these guidelines we’d spend only a fraction of that $220 million. But we don’t. Health economists, researchers and politicians wag their fingers, cry waste, and then chuck their reports in the air. Why won’t we listen?
But, you say to your doctor, what if? Anxiety courses from your eyes into hers, which for a microsecond display the tiniest flicker of uncertainty. You grasp your flank. Maybe you feel your left foot tingling. She looks from your right eye to your left to your right, wondering if she trusts her tendon hammer, remembering that one case that one time. The most powerful anxiety-relieving item on the market is not Xanax. The most powerful anxiety-relieving item available is a high-tech scan.
I open a detailed picture of chest anatomy on Google to check that I haven’t neglected any possible sites of disease, while Harry and I consider the differential diagnoses over the phone. We come up with a fractured bone or a separation of the cartilage and rib.
“You probably did it rowing,” he says.
“How do you know?”
“Because you row.”
As I’ve advised dozens of patients over the years, if you break or dislodge a rib, there is nothing to be done except swallow painkillers, apply ice packs, and not row, swim, run or lift heavy objects until the bones re-knit. I reassure myself, follow my own advice, for a day. Then I order an MRI.
In my defence the scan is – quite rightly – not covered by Medicare, so I pay for it in cash. As punishment for over-investigating myself, the tech makes me lie rib-down on the scanner bed for the entire 30 minutes.
A magnetic resonance scanner is a gigantic humming electromagnet that spins and excites all of the hydrogen nuclei in your body. Then it lets them relax, and turns this into pictures. The magnets generate sounds much like a painfully loud industrial experimental garage band. Unlike X-rays and CT scans there is no ionising radiation exposure involved in MRI. You’re just bathing in an incredibly powerful electromagnetic field, having your atoms manipulated for half an hour.
The problem with increasingly sophisticated medical investigations is that they sit in their expensive suites like coin-operated gurus. We know they’re in there and they can tell us the answer to everything, even the things we already know, don’t need to know or would be better off not knowing. So it’s helpful to be able to tell a patient that I don’t think they need a test, and neither does Medicare. It’s like trumping an argument with “Because Mum says so.” Some patients, however, stubbornly resist their doctor’s reassurance.
I get dressed and go backstage where the radiologist sits in front of a bank of screens, searching for anatomical anomalies. He shakes my hand and then points his mouse to the aberrant gap between my fourth rib and its cartilage. Despite the fact that I’d made no mention of cancer on the request form, he smiles and says, knowingly, “Rest assured, there’s no sign of any underlying mass.”
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