Wednesday, August 17, 2016

A New Decade

I'm afraid.
In a few days it'll be my birthday. 
A. Whole. New. Decade.* see footnote
For the sake of sanity, let's not go into details about which decade, but lets just say I'm not a teenager anymore.
It's kinda surreal. After all there was a time in my life I thought being 24 was "old".
And now, I find myself referring to twenty year olds as "those kids".
And you slowly have to acknowledge the signs that you're no longer a spring chicken. Things like how you develop random joint aches. Or how your hair thins and your children always draws their daddy with short spiky hair in their drawings- all 5 spikes. Or how you've gone from finding grays on your scalp, to finding gray nose hairs, to finding gray pubes. How you find plaid jackets and bow ties fashionable. Or how you think 50-something postmenopausal women to be more attractive than a 21 year old. And how your idea of driving too fast is 76 mph.
Yes, folks, it's that time.
And I'm not sure if I'm just going to wake up that morning to find my scalp totally clean ala Jean-Luc Picard (minus the charm).
A long time ago, I had some pipedream goals for this decade of life. Things like being married and having my own children. Owning a Porsche 911. Having more than 20 publications. Having more than one million dollars in my retirement/investment portfolio.
Hah- most of them will remain pipedreams for now. But here's to the next decade* of life....

* though to be mathematically accurate, the next decade actually starts the following year. Just as how the new Millenium began not in 2000, but 2001, or how we begin counting at 1, not zero. But what's the fun in that?

Sunday, August 14, 2016

Of DRGs and BS

I was frustrated recently by the system and how in some situations it fails the patient.
I was asked to see a hospital consult recently. 78 year old man found to have an incidental thyroid nodule.
It was a 3 cm hypoechoic solid nodule with some microcalcifications on sonogram. The team had already ordered an FNA to be done- results came back suspicious for follicular neoplasm.
Traditionally, with this result, the next step is surgery, as you've exhausted the capabilities of the dainty 25G needle of the FNA- cytology alone cannot differentiate between a follicular carcinoma versus an adenoma. Often, our surgeons would do a lobectomy and frozen section; and if there is no cancer they would leave the intact lobe behind.
Now, with the option of using molecular markers, there is potential for second-tier tests to restratify the nodule into a benign versus suspicious nodule- if it comes back the former, then the patient is spared from surgery as it has good negative predictive value. In a case like this- elderly man with comorbidities who is a higher risk surgical candidate, this would be a good test to try to avoid surgery.
And so when I saw the patient and read the pathology results. I was curious as to why they did not run the additional test. I called the pathologist up to enquire. Frankly I was quite put off by his answer.
This was a Medicare patient, admitted for chest pains. His DRG would not cover the 2nd tier test which means they will end up forking out the cost of the test itself. So it was felt to be unjustifiable.
The DRG. Diagnosis Related Grouping. Essentially, it you are admitted for condition XYZ, Medicare pays the hospital a set amount. Anything else on top of this, regardless of length of stay, the reimbursement is the same. A system to incentivize hospitals to not to do too much of keep the patient too long. But in situations like this, backfires on the patient.
My initial thought was- if that was the case WTH did they even biopsy this in the first place? It could have been done as an outpatient. I was a bit miffed that it seemed that the bottom line superseded proper patient care.
And so, I'm left with choices I don't like:
a) Consult a general surgeon for thyroid surgery- something I try to avoid for elderly patients with thyroid nodules as there is a good chance the nodule is no longer clinically relevant. The risk of surgery arguably may be higher than the risk of leaving a small speck of differentiated thyroid cancer in the neck
b) Attempt a 2nd biopsy as an outpatient with the molecular markers- something I do routinely in clinic- but it seems illogical to put him through a 2nd procedure, and it's certainly not the recommended step in a case like this, as the concern is the 2nd FNA might not procure cells from the same location accurately enough to reassure even if the 2nd set of results came back OK
c) Leave things be. Which I'm most tempted to take- given his cardiopulmonary comorbidities. Indeed, when I see clinic consults for nodules, I ask myself if this patient is likely physically fit enough for surgery- if he/she is not in good health I often try to dissuade FNA. After all, if the test isn't going to change my management, why run the test?
And so, I'll be seeing him for follow up in a few weeks. But yet another clear example of why a needlessly complicated system, coupled with money-minded administrators, end up failing the patient.