Thursday, February 26, 2009

Pulling Teeth

I biopsied a patient last week. A youngish guy who hadn't the foggiest clue that he had a visible 5 cm lump on his thyroid until his doctor asked him about it (probably typical for us men. He probably thought he had 2 Adam's apples!). He had a thyroid ultrasound showing a goose egg in his thyroid. Anyway, it looked suspicious to me on the scan, with irregular margins and some microcalcifications. I biopsied him, specifically aiming for the areas of calcification.

The pathologist called me up today to say it was suspicious for papillary thyroid cancer. And so, I reviewed this with him. Even if this was PTC, there is a good chance his survival won't be significantly affected. I assured him that this is very treatable and that with proper care, I expect him to do very well. I set him up to have a formal neck ultrasound done to look at the lymph nodes, and for him to see a surgeon for thyroidectomy +/- lymph node dissection. And this is where the headache begins.

His insurance company calls, complaining about the ultrasound, because he had had a thyroid (I reviewed the notes and spoke to the radiologist myself; they only did the thyroid previously) ultrasound already and that they were not too keen on paying for another ultrasound, never mind that we were looking for something else. After 3 mins of arguing with my nurse, she got flustered and asked if I could talk to them. I had to bite my tongue, and be civil about things.

I asked the customer service rep:

"If I told you you probably have thyroid cancer, and that a surgeon was going to have to go into your neck, wouldn't you want to know beforehand, if he needed to also take out your lymph nodes?

Would your company prefer to pay for a 2nd surgery for this patient, then?"

Especially with PTC. Especially since with the discordance in practice, not all surgeons routinely do a central compartment dissection as is done in my alma mater. Especially since we overabuse post-surgical radioactive iodine ablation to 'clean up' whatever gross nodal disease the surgeon left behind because we didn't look at the nodes in the first place. One thing I'm struggling with, being new out in private practice, is how much time we (the patients and the healthcare team) expend trying to get medications and procedures approved by private health insurance companies. It's almost like pulling teeth; and you begin to wonder if these insurance companies really have the patients' best interest in mind.

(Never mind, stupid question. Obviously their priority is profits).


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