Would I make the right choice?

Should he order an X-ray, or just wait and watch? This FP wished he didn't know what insurance his patient had.

Do you ever get that funny feeling in the pit of your stomach just thinking about a particular patient? That's how it is with Amanda. Even though years have passed, I'll never forget her.

Amanda, a vibrant 8-year-old, came along with her mother for her baby sister's well-child check. After I'd completed the visit and was ready to move on to the next patient, her mom halted me with the dreaded, "Oh, by the way, Doc . . ." I fought the strong urge to glance at my watch, knowing all of my exam rooms were full.

Her mom explained that Amanda (I've changed her name) had had a stiff neck for several days without an apparent injury or illness. On examination, she wouldn't move her head or neck readily and complained about it. No other physical findings were present; she appeared otherwise healthy.

It certainly was odd and needed investigating. That's what brought me to the brink.

You see, I knew that Amanda and her family were HMO members. In that plan, I'm paid per member per month, not according to services rendered. And the plan compares my rates of ordered tests to my colleagues', then reveals these numbers to all of us to enhance peer-pressure.

Now, I had to make the precarious decision: Do I order the X-ray or just wait and watch? I wished I didn't know what insurance they had.

Going with my gut, I explained the need for an X-ray of Amanda's neck (convincing myself, too), since her symptoms had been there much too long for a simple wryneck. Her mom took her for the test, and the ensuing months changed our lives. A series of tests and referrals confirmed the suspicion of a rare intraspinal malignant tumor (medulloepithelioma) growing up and down the spinal cord. It had started in the neck region, causing her presenting complaint.

Eventually, Amanda succumbed to the disease. Just thinking about her makes me feel like I've been punched in the stomach. But I'm thankful I had been able to tell her father that there had been no delay when he'd asked me, "Could we have caught it any earlier?" He'd been reassured by my answer, but I felt only slightly better. What if I'd had to give a different answer?

The lessons strike so deep that I retell this grim story to every medical student, intern, or resident who rotates through my office: First, absolutely, do not let the form of payment get in the way of making the right decision. Second, follow your clinical gut reaction: We get those for a reason.

Gerald Harriman. Would I make the right choice?

Medical Economics

Mar. 5, 2004;81.