A friend of mine recently finally got from their doctor something they had been seeking for almost 8 years with little results: an actual diagnosis.
This person began having symptoms of tingling in their fingers and pain in their shoulder almost a decade ago. During this time they worked as a nurse which is a labor intensive job that requires frequent use of arms and hands and regular heavy lifting. As time passed her symptoms got worse and worse and she experienced little relief.
Over those 8 years this person visited their primary care physician for this problem about a dozen times, got 3 MRI studies, 2 Electromyograms (a test where doctors test nerve functioning by running electrical currents down nerves), saw 2 neurologists, 3 occupational medicine doctors and 3 orthopedic doctors. She had several work related shoulder injuries and missed several weeks of work for shoulder related problems during the decade. The cost of all this, which we all contribute to paying, is exorbitant.
This process continued with little relief until recently she saw a shoulder specialist who at long last diagnosed her with a disease of her shoulder called “Thoracic Outlet Syndrome.” Thoracic outlet syndrome occurs when nerves and blood vessels exiting the shoulder are compressed causing symptoms of pain, tingling and occasionally vascular insufficiency in the shoulder, neck and arm.
The good news is that almost all patients respond to the specific kind of physical therapy appropriate for this problem and experience an improvement in functioning and symptoms. For those that don’t respond effective surgical and non surgical treatments (like botox or steroid shots) exist that can lead to improvement.
The bad news for my friend and all of us is that it took the health care system 8 years, dozens of office visits, a half dozen expensive tests (MRI tests cost approximately $2000 a scan and EMG’s $1000-$1500), numerous specialist referrals and several weeks of work disability to reach the diagnosis. The cost of the system’s failure to diagnosis this injury could easily be estimated to be several tens of thousands of dollars. The cost for mistakes like this are absorbed by us all.
When one individual fails we can look to that responsible person and chalk the mistake up to deficiency or chance, but when several extremely competent and well trained individuals all fail I believe we need to look at the system that they function in to explain the shortcomings.
In this the failure to me is simple: None of of the half dozen or so physicians she saw before this final one had the necessary expertise to diagnose her problem in spite of a collective decades of training. No test or study should have been needed to make this diagnosis. To me this is reflective of a larger problem in medical education. Medical education biases towards training doctors at treating really, really sick people which is a good thing, but there is little emphasis on taking care of the problems that commonly occur in healthy adults.
Shoulder injuries are among the most common complaints that people visit doctors for. Studies estimate that 1 in 20 visits to primary care providers are for shoulder problems. As someone who is going through medical education I can state definitively how little I have been educated in shoulder injuries now in my 7th year of medical education. I know about rare enzyme deficiencies and strange infectious diseases I will never likely encounter, but for something that composes 5% of all doctors visits I know little about.
The same could be said for many of the other problems that healthy adults commonly experience. Doctors know shockingly little about how to properly manage many things that are relevant to healthy adults like back pain, musculoskeletal problems, pain syndromes, anxiety/depression, nutrition, vitamins and minerals, physical fitness, common skin and eye problems and psychosomatic problems (which one study by Kaiser Permanente estimated to be responsible for 70% of visits to primary care clinics!). Taken together these problems routinely come up but medical education simply does not emphasize them.
I think Doctors generally feel more comfortable taking care of really, really sick people than they do taking care of people who are mostly healthy. The kicker is that by the time people are really sick our expertise in stabilizing them is often times not going to make much a difference in the quality and quantity of their lives and will cost a lot a money. Clinically effective care of the problems that arise in healthy adults, on the other hand, can make lives better, prevent disease, minimize suffering and, as evidenced by the case of my friend, reduce unneeded or harmful treatments, prevent prolonged suffering and save tons of money.
Taking care of healthy adults is an important part of medicine that is underemphasized. Doctors lack expertise to do this even though it has the ability to reduce cost and improve lives. Integrating expertise in this is an important part of medical care with major public health implications that should be emphasized.
