Thursday, July 02, 2009

Converting people into patients !

I recently received this email from an infertile couple. Her gynecologist had recommended a routine vaginal ultrasound scan, which was reported as follows.

Both ovaries are normal in size and shape. There is a well defined hypoechoic cystic lesion in both ovary measuring RT - 11x12.5x10.3 mms with volume 0.7ccs and LT - 12.8x14.3x15.4mms with volume 1.5ccs. It shows marked low level internal echoes and small focal calcification. No evidence of free fluid in pelvic cul-de-sac.Hence bilateral small ovarian lesion -endometrioma.

Their gynecologist had advised them medication to resolve the cyst; and a repeat scan after 6 weeks to confirm the cyst had disappeared.

They wanted a second opinion, as to whether this was good advise.

Please read the report carefully again. Don't worry about the gobbledygook or the medical jargon. My point is that medical scan reports are often deliberately full of this, in order to worry patients and send them scurrying to their doctors. The cyst is about 10 mm in size - this means it's only about 1 cm ! It's extremely small - and the only reason it can be detected is because the ultrasound machines today are high resolution machines, on which the images can be zoomed, till normal anatomical structures can be interpreted as "lesions" which need treatment ! Unfortunately, most people are innumerate ; and not sophisticated in enough to interpret the report. Others trust their doctor blindly - and expect him to do what is needed. This is why George Bernard Shaw said that all professions are a conspiracy against the laity !

The beauty of this scan is that the doctor has done everything by the book ! He has simply reported everything he saw - in excruciating ( and unnecessary ) detail ! So why am I finding fault with him ?

Many reasons ! For one, this report is "pseudo-accurate" ! It's simply impossible to measure structures in terms of 0.1 mm ! While it's possible to position electronic calipers and read off their readout, this simply shows that the doctor is not applying his mind ! This is false accuracy and precision which misleads the patient.

Secondly, the interpretation is highly suspect. The ovary is normally a cystic structure, and this tiny "cyst" could just as well be a normal ovarian follicle, which contains a mature egg , rather than a "lesion".

Thirdly, he has deliberately reported his measurements in mm rather than cm - thus making the "lesion" appear larger. This can mislead poorly informed patients !

So is the radiologist not very bright ? On the contrary - he is very smart - he is a willing accomplice in the game being played by the referring gynecologist !

Doctors often send patients for scans. This is often to rule out problems - and to show patients how careful and thorough they are. Most patients are happy do these scans - after all, what's the risk of doing just a test ?

The trick is that the radiologist then "finds abnormalities" - even though he knows they are of no importance, and may be just normal anatomic variants. The patient reads the report - and then worries because of all the abnormalities which have been picked up. Off he goes back to the gynecologist, for treatment. The doctor is happy to comply , because this means more follow up visits - and additional income !

It's possible to milk this for many months because the new ultrasound machines can pick up tiny fibroids and cysts for practically all women, because these are such common findings ! The woman has now been converted into a patient - and she is now stuck on a game which shuttles her back and forth from radiologist to gynecologist, and it's extremely hard to escape this.

The danger is not just that of the money being wasted on the overdiagnosis and overtreatment - or on the unnecessary anxiety which is created. The bigger risk is that sooner or later some trigger happy gynecologist will decide that the cyst is not responding to medical treatment - and needs to be removed surgically. This unnecessary surgery will actually reduce the woman's fertility - thus making her an infertile patient who will need to come and see me !

I have discussed gynecological scans in this post - but the tragedy is that this charade is played out in practically all fields today !

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