Uncategorized

Cruel Shoes

A thirtysomething friend of mine, let’s call her Sally, started running last year in an effort to get in better shape.

As often happens in these scenarios, Sally developed some foot pain. So she went to a “foot” doctor (I’m not sure whether she meant a podiatrist or an orthopedic surgeon specializing in feet).

Reasonably enough, the doctor ordered an x-ray of her foot. The official reading showed no fracture, but there was a “questionable” finding on the edge of one of the midfoot bones such that the doctor couldn’t rule out some more insidious process. A stress fracture, perhaps? Those can be awful, and take a long time to heal.

So, again in reasonable fashion, the doctor ordered a CT scan of Sally’s foot. This is the logical next step if a plain old x-ray is abnormal. Heck, a lot of the time, even when an x-ray is normal, we still order the CT scan looking for something that we can’t see on the x-ray.

And though I said this was a reasonable choice, if you really think about it, was it so reasonable?

I mean, did Sally really need a $1000 test to see what was causing her foot pain? If you’re Sally, you sure might think so. You want to know what the heck’s wrong. You want to know why you’re having pain when you run. You want to keep running. After all, as a primary care doctor, I LOVE it when a patient tells me that they’re serious about exercise. Aside from not smoking, that’s the best thing I can hear from a patient.

But Sally hadn’t traumatized her foot. She hadn’t dropped a bowling ball on it. She probably had an overuse syndrome. A repetitive stress injury. A running “tweak.”

The x-ray showed that, for heaven’s sake. We knew there was no broken bone. No smoking gun. [I told you, we hate smoking.]

So a week after sitting for the CT, Sally still didn’t know the result of her scan. She called the doctor’s office to no avail. She was put off by the staff, even told by a nurse she’d have to come in for an appointment to discuss the results with the doctor.

By this point, she’s worried. “Is there something terrible that he’s waiting to tell me?” she wondered. “Do I have foot cancer?”

Sally adjusts her schedule, dutifully shows up for the appointment, to hear the doctor tell her that her CT is normal. Did she really have to wait a week and have an office visit to find this out? That is one shoddy patient experience in my book.

Nevertheless, she reasonably asks the foot doctor what she should do about her pain.

Physical therapy? Low impact exercise (use an elliptical trainer, perhaps, or bicycling)?

She doesn’t get much of a concrete answer.

She decides to buy some new shoes.

She goes to a local shoe store that caters to runners. Let’s call it Fast Feet.

There, they measure her feet. No charge. Lo and behold, her feet have grown a whole size.

Sally was running with shoes that were too small! That was the source of her pain. No CT was needed. In fact, probably even an x-ray was unnecessary. And the $300 orthotics that she’ been prescribed.

Now, this story shows how when a patient comes to see a doctor, we often go right to diagnostics. We want to get you an answer, after all. We’re not shoe salesmen, for heaven’s sake. We don’t even have those thingie-dingies that measure feet. [Do foot doctors?]

Next time someone comes in complaining of foot pain, I’m going to ask them when they last had their feet measured.

John Henning Schumann, MD, is a primary care doctor at the University of Chicago.

Cost of Care:
On Labor Day Costs of Care, a Boston-based nonprofit, offerred $1000 prizes for the best anecdotes from doctors and patients that illustrate the importance of cost-awareness in medicine. Two months later we received 115 submissions from all over the country – New York to California, Texas to North Dakota, Alaska to Oklahoma. We feel these stories are poignant because they put a face on some of the known shortcomings of our system, but also because they unveil how commonplace and pervasive these types of stories are. To learn more about the contest and read more of our stories please visit www.CostsOfCare.org (Twitter: @CostsOfCare).

Livongo’s Post Ad Banner 728*90

Categories: Uncategorized

8
Leave a Reply

8 Comment threads
0 Thread replies
0 Followers
 
Most reacted comment
Hottest comment thread
7 Comment authors
Ron Lavine, D.C.Graham ChiuLewBetter CareMick Recent comment authors
newest oldest most voted
Ron Lavine, D.C.
Guest

Great post about keeping it simple, stupid.

Here’s my question – back in the day when I went to chiropractic school, we were taught that a stress fracture often didn’t show up on an Xray early on – sometimes a bone scan was needed. Is that still the case? Or do the higher-quality digital Xrays of today a stress fracture early on?

Thanks.

Graham Chiu
Guest

Sounds like a failure of primary care to refer appropriately.

Lew
Guest
Lew
Better Care
Guest
Better Care

Sounds like this case would have been handled better, and at half the cost, by a sports medicine chiropractor.

Mick
Guest
Mick

I am laughing at this article because I feel all the doctors failed on this one (Sorry John). I could be wrong, but read on… THE FIX: Try Ortho arch supports for $35. Had similar issue/pain with similar ‘mysterious’ origin. I run a lot. I know exactly where and what kind of pain she probably has, and now know what might be causing it. Tip of 2nd metatarsal just under the pad of the foot? Nothing on X-Ray or scan? Perhaps a slight knee and back issue too? Keep reading… TRICK – Went to highly recommended Podiatrist. Diagnosed it in… Read more »

rbar
Guest
rbar

No, you are all wrong. Docs compete on patient (and referring doc) satisfaction, not efficient practice. It’s the same as valet parking, birthing suites etc.
Maybe the patient has to be made part of reasonable utilization. The libertarians want patients to use their own bucks with HSA and higher deductibles … but that will prevent a lot of necessary, reasonable care, too. Maybe a cost conscious, evidence based physician run HMO would become attractive if cost is significantly lower.

golfer
Guest
golfer

A friend had a rash. Visits with Internists and Derm and testing resulted in no change in the rash. Discussing with me (retired FP) revealed use of clear fingernail polish. Stopped using and rash resolved. No cost.
I am also allergic to mint in toothpaste. Rash results.

Mark Spohr
Guest

I did have a stress fracture of my foot a few years ago after a long summer of hiking in the Alps. Very painful. However, I didn’t run to the doctor right away but waited a few weeks. By then, an x-ray showed the fracture clearly (3rd metatarsal). Coincidentally, a friend of mine had a similar stress fracture about the same time but went to the doctor right away and had an MRI which showed the fracture. Both of us had the same problem, the same treatment (rest), and the same outcome (fx healed fine). My bill was, of course,… Read more »