By JOHN HENNING SCHUMANN, MD
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).
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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.
Sounds like a failure of primary care to refer appropriately.
This 1990 cartoon from the New Yorker sums it up:
http://www.cartoonbank.com/1990/well-bob-it-looks-like-a-paper-cut-but-just-to-be-sure-lets-do-lots-of-tests/invt/106384/
Sounds like this case would have been handled better, and at half the cost, by a sports medicine chiropractor.
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 SECONDS – common injury and profile fits (EITHER athlete, high mileage runner with falling arch OR new runner not used to impact on ball of foot). 2nd metatarsal getting too much pressure from impact being directed onto it due to mis-alignment of foot caused by inadequate arch support (for new women runners, heels to running shoes = ouch!). Need to balance the load otherwise will develop a stress fracture – basic foot mechanics. Wow – simple yet makes incredible sense. I thought my doctor was as much of a quack as the doctor you describe in the article, but I gave him a shot. He offered me the $35 insoles and said they would work as well as the $300 ones. I gave him that “whatever” smirk as I shook his hand and headed out of his office, convinced I’d be back with a big “told you so smarty pants doc” opportunity.
OUTCOME – Fixed. I didn’t believe he was going to be right. I’m not a doctor. I have run pain free for over a month now. Amazing difference. No X-Ray taken, no scan needed. Be diligent about getting those supports in all your most used shoes or (no surprise) your foot will sag back into poor alignment. Oh, and my knees and back feel better too.
MORALE – An honest doctor with the right experience in the right field can make an incredible difference in our health system. Over-reliance on fancy technology creates more opportunities for doctors to doubt themselves and others.
Amazing batters can read a pitch before it leaves the pitchers hand – and they don’t need video analysis or speed guns to figure that out.
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.
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.
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, much less. Her MRI was not as expensive as in the US since it was in Switzerland where they control prices but still it was overuse of testing. (For that matter, I probably didn’t even need the x-ray since it resulted in no change in treatment or outcome.)