Monday, August 10, 2009

mammo/sono/MRI (by res ipsa loquitur)

David Kurtz at TPM writes:
My personal experience has been that there remains a strongly conservative core segment of physicians who are wary of [health care] reform for temperamental and financial reasons (not to paint with too broad a brush, but a group that is anchored in the high-dollar medical specialties).
Last week I had my annual mammogram and breast sonogram. (I added the sonogram to my annual screening at the suggestion of my doctor about five years ago. It adds about $400 to the (pre-insurance reimbursement) cost of the annual screening, but the doctor thought it necessary, so I acquiesced without question.

This year, as she was performing the sonogram, the doctor suggested that I add breast MRI to my annual screening, to be done six months after the annual mammogram and sonogram. I have often found that the aggravation about the cost of such procedures is often a proxy for other feelings I have about them (e.g., fear, a desire not to have yet another agenda item to deal with, denial), and this was no exception. My first thought was, “Forget it! Not another test. This one will cost $1,500! Do you think I’m made of money? No way!” But I calmed myself while I dressed and when I went to her office to review the results of both tests (which were happily normal/negative), I asked her, “Why?”

Well, because my mother died in her early forties of metastasized breast cancer. Because two maternal aunts have had breast cancer. Because my breasts are dense. Taken together, these seemed like solid reasons, but I went ahead and asked a few more questions. “Who performs the MRI? Do I get it here?” (Her office has mammography and sonogram equipment on premises.) No. She does not (yet) have that equipment, but will soon. “In what instances does the Mayo Clinic recommend breast MRI?” I asked (because by many accounts, Mayo and Cleveland Clinic are way ahead of the pack in determining what procedures and tests are necessary). This question seemed to annoy her. She admitted that she didn’t know, but could check, and I told her I’d take care of that when I get home (turned out I met two of the criterion on Mayo's “Why It’s Done” list.) Finally, I told her I would like to discuss it with both my general practitioner and my gynecologist. This last statement seemed to really irritate her. She abruptly ended our meeting, by saying, “Fine, well I’m recommending you have one in six months,” and proceeded to write that on the form she asks all patients to sign upon receiving results.

I consider myself extremely lucky. I have good health insurance and, living in a large city, access to many doctors. I know where to find a lot of solid information about things like mammography and breast cancer. I’ve seen this doctor for years. So why bother asking, “Why?” Kurtz’s post reminded me that it was because of this New Yorker article by Dr. Atul Gawande, which is one I’ve recommended to many people since it appeared in early June, and which I wanted to share with you. I’m not pooh-poohing the necessity or effectiveness of mammograms (or sonograms or MRIs): quite the contrary. What I’m trying to say is that health care reform (some version of which I think will pass in the fall) is going to be just as difficult after we get past phalanxes of lunatic dead-enders hell-bent on disrupting congressional Town Halls as it now. I have always tried to be proactive with regard to my health care, yet I still found it very difficult to ask those questions, which were, after all, a series of challenges to an authority figure. And that authority figure, it seemed, found it difficult to answer them, perhaps due to the wariness Kurtz mentions above. I doubt that any of these phenomena -- my anxiety, her irritation, issues in the area of high-dollar medical specialties -- will evaporate with a bill-signing, and so it will remain important to manage all three.

Speaking of breasts: have you seen Hecate’s First of Month Bazooms Blogging?