Time to stop with medical shortcuts

Samira* was dissatisfied with my advice. She made no secret of it, sitting back sighing dramatically to express her displeasure.

Samira had come for a second opinion. At 38, she had been diagnosed with uterine fibroids three years earlier. Though she had never given much thought to having babies, the diagnosis of fibroids was enough to make her know she did not want to have that choice taken away from her.

She saw a gynaecologist with complaints of heavy, painful periods; and the ultrasound scan done confirmed she had a huge fibroid in the posterior wall of her uterus. She was taken through the available treatment options and surgery was recommended. However, she kept putting it off for the three years before she came to see me.

She had started dating seriously and she wanted to have a child with her partner. She needed the fibroid removed urgently so she could heal and start on the motherhood journey. I first sent her for a repeat ultrasound scan and a blood test to evaluate her blood levels to ascertain her suitability for surgery.

The scan showed the fibroid had grown even larger, distorting her uterus. The uterus already felt like she was 24 weeks pregnant on her physical examination. However, Samira had a condition; she wanted her surgery done laparoscopically. We talked about the procedure at length. I explained to her about the process, the likely duration of surgery, the recovery, and finally, I explained to her that I would have to refer her to a different specialist to perform the procedure, as I was not competent enough to perform a laparoscopic myomectomy by myself.

Additionally, I cautioned her that despite having very competent surgeons available to grant her wish, the procedure was likely not to be successful in her case. This was because, in the final step of the procedure, the fibroid would need to be removed in small strips, after it has been separated from the uterus. This is done using a special piece of equipment called a power morcellator. It is small enough to fit through the small surgical incisions made during the surgery, but must fragment the large fibroid into small strips that can fit through too, on their way out.

Long-standing fibroids sometimes end up with calcium mineral deposition in the core, becoming stone-like. This makes it impossible for the morcellator to power through. The scan had already demonstrated this feature in Samira’s fibroid. As a result, Samira was not the best candidate for laparoscopic myomectomy.

Samira did not want to hear this. She wanted the benefit of a quick recovery because she wanted to resume work as soon as possible. She was due for appraisal and a much-awaited promotion and she did not intend to miss this because she was at home on sick-off. She pursed her lips petulantly but I reminded her that she had the option of a third opinion.

The next time I saw Samira was a year later. She sought me out for an honest opinion about her fertility options. Samira had, upon the recommendations of a friend, sought out a laparoscopic surgeon and demanded for a laparoscopic myomectomy. The busy doctor granted her wish without a thorough review of her scans.

Intraoperatively, having easily and successfully separated the fibroid from the uterus, found it impossible to morcellate. He ended up opening the abdomen to extract the fibroid. He had to make quite an extended incision in order to successfully extract the huge calcified mass, which was smoothly rounded and almost impossible to grip and drag out through a smaller incision.

Due to the extended manipulation of abdominal tissues during the extraction, Samira ended up with injury to her small intestines, which was missed, until the symptoms manifested two days later. She ended up with a severe infection and a repeat surgery to repair the damage. She was an invalid for several weeks, complete with a stint in the intensive care unit!

Samira was a shadow of herself, cursing her past stubbornness, and the doctor’s momentary lapse in judgement. She was afraid of what the future held with regard to her ability to have the child she so desired when she started this journey.

Samira is not alone in this journey of technological impropriety. Last week, a family member was admitted to the hospital as an emergency, due to sudden onset headache, vomiting and visual blurring. In emergency situations, the immediate response of the medical team is to rule out all possible life-threatening conditions first. Therefore, the tests done are not only to establish a diagnosis, but to also rule out all other life-threatening conditions.

Within a span of six hours, the young man had undergone a battery of blood tests and not one, but two head CT scans. None of these are diagnostic for meningitis, which was one of the most concerning diagnoses for him. You would think that once the CT scans had confirmed that he wasn’t bleeding into the brain, nor did he have increased intracranial pressure, that a lumbar puncture, an uncomfortable but cheap investigation that would rule out meningitis, would be done.

Instead, the young man was scheduled for yet another expensive imaging test the next day, a brain MRI. The young man remembered having had a head-on collision with a friend while playing a contact sport, pointing to the likelihood of a mild concussion causing his symptoms. It did not matter, a substantive amount of money had been spent out of his insurance, for unnecessary tests.

Advances in health technologies have improved care all round, resulting in safer, more comfortable treatment interventions, better treatment outcomes, better diagnostic accuracies and availability of a wide range of treatment options, ensuring something for everyone’s preference. This is the equivalent of being able to progress from old locomotive engine trains as the sole mode of transport, to an array of options from aircraft, to electric trains, luxury vehicles for road transport and even luxury cruise ships.

However, abuse of the availability of technology in the practice of medicine must be reigned in. Practitioners must be able to employ technology judiciously and appropriately, with proper patient selection for who needs what, in order to realise the full potential of the technology. It is not an ego trip.

Further, technology is not to be used for machine gun therapy. Access to advanced diagnostics does not replace good old common sense.  It is the reason medical training takes years. These tests don’t replace the doctor’s brain, or the ability to thoroughly take a patient’s history or examine them as part of diagnosis. They must be justified and rationalized, to minimize harm to patients, while enabling diagnosis in the most efficient manner.

Irrational abuse of technology is slowly putting medical care out of reach for many patients, whether the cost is paid for out of pocket or by a third party. Otherwise, how will we afford social health insurance for all if we are busy wasting the meagre resources we have?

Dr Bosire is a gynaecologist/ obstetrician