Jack Coulehan's ordeal began on a Long Island beach. During an Easter sunrise service in 2008, a pain that had first appeared in his left eye the previous night flared to excruciating levels within a few moments. As he ticked through his symptoms–normal vision, normal eye movement, left side of his forehead prickly and burning–Dr. Coulehan drew upon his decades as a primary care physician to diagnose himself with shingles.
Then he made a fateful decision.
As it was a holiday, instead of bothering his internist, Dr. Coulehan decided to go to Stony Brook University Medical Center for confirmation of his diagnosis, and obtain prescriptions for an antiviral, a steroid to decrease the inflammation and a pain reliever. He would emerge 12 hours later, with a $9,000 bill, and feel like he had become enmeshed in a web of expensive and unnecessary medical testing.
Dr. Coulehan's account of his emergency department (ED) visit, first published in the journal Health Affairs in September 2009, and later the Washington Post, strikingly highlights a fundamental fine line that emergency medicine must straddle: of wanting to be certain of a diagnosis on one side, and perhaps wary of medical liability; yet on the other not wanting to conduct excessive, time-consuming and costly tests in an era when medical expenses are under heightened scrutiny.
“Emergency physicians, more than any other specialty, are dealing with a certain point in time with a patient,” Dr. Coulehan said in an interview. “When I see a patient as an internist, I'm thinking of a time period. I may say, ‘Call me in a day, or 3 days or a week if the pain persists,’ and that kind of takes some of the pressure off of making these urgent decisions. An ER doctor is concerned with the fact that everything has to be done right then because a patient may not come back. I really don't know how they handle that. I recognize that is a difficult position.”
Case in Point
That doesn't make Dr. Coulehan's ED visit less worthy of consideration.
Following retirement in 2007, Dr. Coulehan served as a professor emeritus of preventive medicine and senior fellow at the Center for Medical Humanities, Compassionate Care and Bioethics at Stony Brook University on Long Island. When he arrived at the hospital, Dr. Coulehan said he knew the junior, female colleague on duty well. She agreed with his diagnosis of shingles. She gave him a shot of morphine. She then suggested the same treatment plan he had in mind.
But before he left, the colleague wondered, “for completeness' sake” would Dr. Coulehan mind having an ophthalmologist and a neurologist take a look at his symptoms?
Dr. Coulehan now believes there were no urgent symptoms, nothing that could not have waited had the pain persisted, but he recalled that, even though he trusted his self-diagnosis of shingles, a tiny bit of doubt crept into his mind. Perhaps, he thought, he was missing a tumor behind his eye, or maybe a weird form of glaucoma? He still wonders to this day why he didn't just leave, prescriptions in hand, to spend the rest of the holiday with family.
“As I've looked at it retroactively, I don't think it was the morphine in the sense that morphine actually clouded my judgment,” he said. “I think the primary thing is that I was in a lot of pain, and even though I felt like I was a pretty good diagnostician I was just feeling awful. I think when you're feeling awful and feeling sick, I think that tends to cloud your judgment.”
He waited an hour for the on-call neurology resident to arrive, and another hour for his attending. In the interim the ophthalmologist arrived, diagnosed Dr. Coulehan with shingles, and left. The attending neurologist, however, noticed a mild drooping of Dr. Coulehan's left eyelid. (Dr. Coulehan said he looked in a mirror and didn't see it. Neither did his wife.) The neurologist recommended an MRI to make sure there was not a mass in the brain. An hour later he walked into the MRI room, and then waited 90 minutes for the results. The neurology resident said the MRI showed a “possible” abnormality in Dr. Coulehan's cavernous sinus.
“It was a questionable finding. In other words, it didn't look quite normal, but, at the same time, it didn't have the specific features of a definite abnormality,” Dr. Coulehan wrote in Health Affairs. “But when the attending neurologist returned from her lunch, she seemed absolutely delighted that I might have a blood clot in the sinus—a finding, she said, consistent with the redness around my eye.
‘Did you have any recent dental work?’ she asked, searching for an infection as a possible cause of venous blockage. (I hadn't.) I was gripped by molasses-like passivity. The reasonable part of my mind cried, ‘This is crazy! Get me out of here!’ But a twiggy little nugget deep in my brain asked, ‘What if there is something serious wrong?’”
He stayed. Dr. Coulehan got a CT scan with contrast to get a deeper view of the cavernous sinus. It was completely normal. He got a second MRI. Normal. At this time a faint rash appeared, a distinct early phase of shingles. Dr. Coulehan left a full half a day after entering the ED, with prescriptions for valacyclovir, prednisone and Percocet, the very regimen of an antiviral, steroid and painkiller he'd conceived on the beach that morning.
The Aftermath
So what happened? Dr. Coulehan says he doesn't have a good answer about why he didn't just phone his internist, or why he accepted referrals to specialists and underwent imaging studies that might have been done later if problems persisted.
“It's easier to understand, however, why I—the patient—was faced with them: my doctors recommended services that were simply not indicated at the time,” he wrote. “Unnecessary testing, inappropriate consultation, and uncoordinated care are rampant in ERs, as they are throughout our health care system.”
Those are harsh words, indeed, for a system that ultimately did what Dr. Coulehan wanted, confirmed his diagnosis by ruling out other possibilities.
In a subsequent interview, he added, “I don't want to take myself out of the equation here. What a dunce. If I knew all this stuff, why didn't I stand up and walk out of the emergency department? My only excuse is that I was sick, and part of me wasn't acting perfectly rationally. And I don't think that behavior is peculiar to me in an emergency department.”
Where the blame for this episode belongs, or whether there is any, depends upon whom you ask.
There are some distinctions worth noting, said Bill Barsan, MD, professor and chair of Emergency Medicine at the University of Michigan and an expert on emergency neurology. For instance, the consultant, not the emergency physician, ordered the imaging.
“Sometimes we get the rap on that, but really
…when you call a consultant they can wrap patients up like that,” he said. “We're not the ones ordering it.”
That said, the workup wasn't necessarily excessive, given the hallmark shingles rash had not yet erupted at the outset, Dr. Barsan said.
“This isn't as clear cut as they make it seem,” Dr. Barsan said. “It's clear cut in retrospect, but there was no skin rash when he came in. It's really hard to diagnose shingles before it happens…. I'm not sure I would have done anything different than this woman (the neurologist) did. It's hard to say. I don't think it's that straightforward. If he came in with lesions, I'd say clearly it wasn't indicated, but without the lesions it is a tough call.”
Dr. Barsan recalled a scenario that informs this debate. Many emergency physicians have seen elderly patients complaining of chest pain with all the characteristics of shingles before the rash appears, but few are willing to write it off as that benign viral illness without first testing for coronary disease.
VIP Medicine
Dr. Coulehan said he suspects his status as a local doctor and professor may have made it more likely that he received excessive VIP treatment from the younger physician he knew.
So-called “VIP Syndrome” has been recognized in medical literature since 1964, and occurs when the status of a person, whether a celebrity or well-known physician, affects decisions about his or her medical care. One manifestation of this is the decision to follow up every miniscule abnormality to give the appearance of being a complete and competent physician. Dr. Coulehan acknowledges this may have happened in his case.
It's also possible the emergency physician could have been concerned about medical liability and practiced defensive medicine. (Citing HIPAA, Lauren Sheprow, interim director of media relations for Stony Brook University Medical Center, declined to discuss the case.) On ACEP's most recent National Report Card on the State of Emergency Medicine the state of New York received an “F” in the category of Medical Liability Environment due primarily to the high malpractice award amounts and insurance premiums for practicing physicians in the state.
“Liability would have entered into my thought process,” said Angela Gardner, MD, president of ACEP, who reviewed Dr. Coulehan's account. “If he had come to the emergency department with those symptoms, and he really did have an obscure, life-threatening neurological illness, and the ED had just let him go, I can guarantee you there would have been a lawsuit.”
Dr. Gardner said Dr. Coulehan's experiences are partly explained by the difference between emergency medicine and other specialties. In other practices, physicians approach a diagnosis by looking for the most common cause. In emergency medicine, Dr. Gardner said, physicians look at things from the standpoint of what could kill you, rather than what is most likely causing a patient's illness.
“Our patients self select,” she said. “When they choose to come to an ED, they're declaring it to be an emergency. Emergency physicians are held to the standard of ‘Why didn't you treat this life-threatening illness.’ We're not held to the standard of ‘What is the most likely illness.’ Even among our medical colleagues there's not the knowledge that we do think differently than primary care providers. We assume your emergency is our emergency.”
Perverse Incentives
The litany of medical testing–whether due to defensive medicine, an abundance of caution or an emergency physician treating a colleague like Dr. Coulehan in the ED–has had a substantial impact on the cost of health care. Various estimates, including those by such firms as PricewaterhouseCoopers, have placed the cost of waste in health care spending at between $700 billion and $1.2 trillion due to redundant, inappropriate or unnecessary tests and procedures. Defensive medicine comprises a large chunk of that excess.
Attorney Philip K. Howard, founder of Common Good, a nonpartisan national coalition dedicated to “restoring common sense to America,” says Dr. Coulehan's story embodies a lot of the problems with the modern health care system.
“What's so interesting about the story is it's not insidious,” he said.
Under the present system no one feels empowered to draw the line at testing. Had Dr. Coulehan – rather than his insurance company–been more directly on the hook for the medical charges he might have stopped the testing, Howard said.
“He doesn't have an incentive to draw the line because it's not coming out of his vacation next summer,” Howard said. “The doctors just think they're being prudent, and these high technology tests will always come up with something that might be suspicious.”
The path toward containing costs and reining in defensive medicine, Howard says, lies through the creation of a system where people of means are obligated to pay for a portion of their actual health care costs, which would put the consumer back at the center of medicine. In addition, legal reforms are needed to create a “system of justice” that everyone, from patients to doctors, can trust.
Neither liability reform nor a serious effort at cost containment are part of the health care reform packages being pushed through Congress, Howard said.
But a system that puts the consumer in the driver's seat would come with its own set of difficulties. One could imagine a scenario in which a patient like Dr. Coulehan did have cavernous sinus thrombosis, the mortality of which approaches 30%, but refused the imaging. Even in the current system such tragedies occur. Dr. Barsan recalled a self-pay patient suffering from leg weakness and parethesias who put off an MRI until he had saved enough money to pay for it. By the time the imaging study showed his spinal cord tumor, he was permanently disabled.
“It's a double edged sword,” Dr. Barsan said. “…He waited too long. That's the danger of saying the patient has the choice. They don't always make the right choice. There are a lot of really tough issues there.”
But one could also imagine if Dr. Coulehan had had a fatal contrast reaction during his ultimately negative work-up, and there are other risks to this sort of “completeness,” a subtle drift from using tests to rule disease in or out to a screening test function. And these risks are not insignificant–radiation exposure and the cancers that follow or even surgeries for the “incidentaloma,” the suspicious but ultimately benign mass found on imaging.
Dr. Coulehan doesn't blame the young emergency physician for asking him, “for completeness' sake,” to be seen by a pair of specialists.
“She was actually very supportive of the article,” Dr. Coulehan said. “Maybe a year later, when she saw the story, she says it kind of taught her a lesson.”
‘The Vanishing Oath’
One of the lessons might just be that it's difficult to be a young emergency physician in today's world of exorbitant medical school debt, crowded EDs and medical liability concerns.
Ryan Flesher, MD, who came out of his emergency medicine residency in 2002 in Boston with $240,000 in debt, is illustrative. He soon found that a real-life ED was far from glamorous. It wasn't the patients or medicine that slowly drove him crazy. It was malpractice concerns and administrative issues. Dr. Flesher said for every minute he spent with a patient, he spent 13 minutes on administrative tasks such as documenting and filling out forms.
The frustrations led Dr. Flesher to make a soon-to-be-released film, “The Vanishing Oath,” based on his experience and discussions with hundreds of other physicians. “The main thing I discovered that I wasn't alone,” he said. “There are these kinds of frustrations across all these specialties, from anesthesia to pediatrics.”
But the pressures are especially acute in emergency medicine, he acknowledged, where physicians are under the gun to make an immediate diagnosis, and must get it right because they may never see the patient again.
“Is it a failure of the physician? Yes,” Dr. Flesher said. “But 99.99% of us do it 99% of the time because it's a system failure. As emergency physicians we have to find everything every time. We will be held accountable to every test that's available. Otherwise some jury might say, ‘If he got an MRI, he would have found it.’”
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