The Paper Patient

There is no substitute for laying eyes on a patient.

In the quest to cut medical costs with paper reviews, we risk becoming a medical society that spends less time seeing patients in the office and more time looking at them on paper. Just how accurate is a paper review of a patient? Second opinions based solely upon review of the treating physician’s records and diagnostic reports such as MRIs and CT scans seems illogical. How does one base an opinion upon the dictation of the physician whose opinion is being contested? How does one assess the opinion of a radiologist who qualifies his assessment with “these results should be correlated with clinical findings”?

I reviewed the medical records of a man who had hurt his knee in a compensable injury three years earlier. He had fractured that same knee one year prior to that and thus, there was the element of pre-existing and exacerbated damage. His compensable injury (a tibial plateau fracture) was treated conservatively with medication, a brace, and physical therapy. The pain continued. After 18 months, his physician sent him to an orthopedic surgeon for another opinion.

The second surgeon looked at the initial MRI and CT scan with a very different interpretation than the first physician. He found a completely torn ACL, comminuted tibial plateau fracture extending 4 cm into the proximal bone, and no sign of a meniscus. With extensive arthritis that began with the first injury, continued laxity, and inability to bear weight, this 51-year-old patient needed a knee replacement.

The second surgeon’s recommendation sparked the insurer to send his medical records to a remote physician who did not see the patient. This third physician opined that even if the patient needed surgery, he was a high risk candidate because he took more pain medication than advised. You think?

I met this patient at a psychological evaluation to determine the validity of his complaints and assess his use of pain medication. The swelling in his knee, proximal tibia, and distal femur was pronounced. When I asked him if knee replacement was being considered he said “No no. They tell me it would be too dangerous.” He did not know why it would be too dangerous. At the age of 9, he had fallen from a tree with residual and significant brain damage. His spatial reasoning was intact enough to weld, and so he had lived his life. He did not and could not question the authority of physicians who denied surgery.

The process of second opinions and paper reviews is not entirely the fault of the medical community or insurance system. Patients share responsibility when they are not honest in describing their true level of pain, emotional suffering, medication intake, or ability to perform activities of daily living.

In a perfect medical world, treatment would proceed based upon valid complaints. Functional capacity would be a true evaluation. The only need for a second opinion would be to confirm the treating doctor’s accurate diagnosis of the patient’s valid complaints. In the real medical world, insurers put a priority on cost containment, patients are not always honest, and physicians are not always competent. Second opinions are not always unbiased and medical records do not reflect the totality of the patient. At a minimum, we should strive to correlate medical records and objective diagnostic findings with physical examinations before we deny a needed service.

0 Comment   |   Posted in Blog July 09, 2010

Comments are closed.