THE WAY I SEE IT

Tracy should still have her gallbladder

"More testing, less thinking" is no way to treat patients, says this physician.

By Richard L. Sribnick, MD
Internist/Columbia, SC

Tracy came to see me unexpectedly. "How are you today?" I asked. The young woman sat on the exam table, her eyes darting about. She seemed more nervous than usual.

"Not too well," she answered. "My side still hurts from the accident." Not remembering an accident, I flipped through her chart.

"Is that why you're here, because your side hurts?" I asked.

"No," she said. "I went to a doctor in Augusta, and he told me I may have a fleck of something in my breast. I'm worried sick and want you to check it." "Why did you see a doctor in Augusta?" I asked as I began reading my entries from her July visits:

7/8: Pt in MVA yesterday; feels fine; wants checkup; physical exam normal.

7/21: Pt complains of sharp pain, right lower rib cage; began 1 week ago; pressure over site reproduces symptoms; no radiating tenderness; suspect musculoskeletal; no evidence of rib fracture; will treat with aspirin; pt to call if problem persists.

"The pain in my side didn't go away, and then my back started hurting," she said. "A friend of mine told me about a bone doctor. He sent me to physical therapy with heat and stuff, but it didn't help. He took X-rays and did a bone scan, but he said they didn't show anything, so he ordered a sonogram of my stomach. That showed I had something wrong in my gallbladder. Then a surgeon took my gallbladder out."

"He took your gallbladder out?!"

"He was supposed to call you about it," Tracy said sheepishly.

"Well, he didn't," I said. "Did he say why he took it out?"

"He said there were two polyps in there, and I needed it out," she said. "I feel better now that it's out. I can't say why, but I just feel better with it gone."

I must have looked incredulous because a look of doubt came over her face.

"Well, what's this about your breast?" I asked. I wanted to change the subject. The gallbladder was out. Why make her question that now?

"Well, I still hurt," said Tracy, "so the bone doctor sent me for an MRI."

"Okay. What did that show?" I hadn't received reports from any of these doctors.

"Nothing on my back," she said, "but the doctor said there's a fleck in my breast and I should see you about it. My side still hurts, but not as much as it used to. Do you think I just have a bruised rib, like you said?"

I didn't answer, but I suspect she knew what I was thinking—before the X-rays, bone scan, sonogram, MRI, and gallbladder removal, I had indeed felt she had a bruised rib.

"Do you think that doctor was just trying to make money, so he took out my gallbladder?" Tracy asked suddenly.

"No, I don't think that at all," I answered, and I really didn't. I suspected the problem was a medical one. Did the doctor really believe that two polyps in the gallbladder were causing a localized, trigger-point constant pain? Or had he not really questioned Tracy enough about the type of pain she was feeling?

"What is a gallbladder anyway?" Tracy asked. "I never heard of it. You don't need it, I guess, do you?"

"The gallbladder is an organ that concentrates bile, and No, you don't have to have it," I answered. Why go through all the details now? I thought. Maybe it was enough for her to think she wasn't going to suffer because it was gone.

I left the room for a moment while she undressed, then returned to examine her breast.

"Well, Tracy, I don't feel anything wrong," I said. "Probably what they saw on your MRI was a fleck of calcium—not to worry. Still, I think we ought to get a mammogram just to be sure."

How ironic, I thought to myself. Here I was ordering yet another test based on the equivocal results of an unsuspected finding on an unnecessary study. Would the mammogram lead to an unneeded breast biopsy, just as the unnecessary sonogram had led to an unneeded cholecystectomy?

Tests have a way of demanding that we doctors do something more whenever they vary from what we perceive to be the norm. In Tracy's case, test results were allowed to override clinical judgment. The outcome was more than just a gallbladder gone missing. Tracy endured pain, expense, worry, suspicion, and risk at each successive misstep.

We now have so many tests to offer patients that we sometimes forget that a few pertinent questions and a focused exam can give us all the information we really need.

Of course, the problem isn't ours alone. Patients are too often suspicious of a conclusion given without a test, perhaps because of news reports about patients who suffer when managed care denies authorization for expensive tests. Also, as highly advertised screening procedures are done with increasing frequency, equivocal test results on asymptomatic patients will lead to a profusion of further testing.

Insurers bear some responsibility as well. As reimbursements fall while office expenses rise, doctors are more likely to order a test than take the time needed for a careful exam.

I suspect that if Tracy and all the doctors she saw had considered things more carefully, spent a little longer on the history and physical, her gallbladder would still be inside her, where it belongs.

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Richard Sribnick. The Way I See It: Tracy should still have her gallbladder. Medical Economics 2002;16:65.