Only in America would a patient request a bone marrow biopsy

I recently wrote how it’s OK to do nothing when asked to evaluate a patient as a subspecialist.

An oncologist responded with this unbelievable comment: “I am an oncologist. Recently, I had a patient sent to me for a mild lab abnormality. Two years ago, she had been seen by another oncologist, and told that it was a benign process. Now, with two additional years worth of labs showing absolutely no change, I concurred with the initial evaluation and told her no additional testing was needed. The patient told me ‘my PCP told me that he will feel better, I will feel better, and you will feel better if you do a bone marrow biopsy to make certain.’ ”

The oncologist continued: “I don’t feel better doing better marrow biopsies….especially when they are for very weak indications. It is that unveiled threat of failure to diagnosis that drives so much inappropriate testing. I discussed the case with the PCP. We agreed that a bone marrow biopsy was not indicated (and he had never made the above statement to the patient). Unfortunately, in our now-is-when-I-want-it-done society, watchful waiting doesn’t go over well (plus or minus that “irrational fear” of legal liability).”

I can’t think of any rational reason why a patient would want to subject themselves to a bone marrow biopsy after two oncologists suggested, in their expert medical opinion, that one was unnecessary. This procedure is not without pain. In fact, it can carry a significant amount of discomfort. It is not cheap. It carries with it highly specialized pathological processing and interpretation. Why would a patient subject themselves to such an ordeal? May I suggest that they wouldn’t, if they had to pay for it, even a portion of it. FREE=MORE

I might add that from a legal standpoint, physicians establish the standard of care. If everyone with a mild abnormality gets a bone marrow biopsy because physicians say they should then not doing one would establish a practice outside the standard of care. However, I have a problem with using standard of care as the basis for making determinations of negligence.

Just because it is common practice to do bone marrow biopsies on everyone with an abnormal lab, does not make it appropriate care. Take for example McAllen, Texas, a place that appears to have a culture of excess when it comes to testing and intervention. Is that standard the right standard? Would not doing a bone marrow on everyone with a lab abnormality open one up to negligence because everyone else is doing them? It does, but it shouldn’t.

If the standard of care in a community is just wrong, how can one defend oneself against allegations of negligence when they went against the grain of what other physicians in the community would do?

I don’t have a good answer for that. Guidelines have been heavily infiltrated by specialty societies. Many aspects of guidelines carry suspect recommendations based on suspect financial motivations. So much of medicine is based on medical judgment. There simply aren’t guidelines. Many guidelines are based on a nice pretty package of healthy white men between the ages of 19 and 65. Many guidelines cannot be extrapolated across diverse populations. Many guidelines differ widely between different specialty societies and other nonprofit organizations.

So where does that leave the physician? They are stuck. Damned if you do and damned if you don’t. If every doc in town is doing bone marrows on patients with slight abnormalities, you can be assured a lawyer will come knocking on your door if you don’t do one on a patient you don’t think needs one AND a delayed diagnosis is ultimately made.

By falling into that trap, you doctor are establishing an irrational standard that can never be achieved. A standard that is bankrupting our country out of a fear of preventing a bad outcome. When in fact, by doing more, we are actually causing more harm than good. Every study you find shows poorer outcomes in areas with a higher percentage of subspecialists and lower percentage of primary medical doctors.

It’s time physicians take back their profession and establish standards based on sound scientific principles, personalized for every patient based on their extensive medical training, and stop making medical decisions based on a fear of deviating from irrational standards of care which they themselves create. The only folks getting rich off the brilliant legal scam known as standard of care are the lawyers filing claims and the unscrupulous doctors doing highly lucrative procedures (as determined by RVU/RUC) under the guise of standard of care. While patients are getting harmed and the Medicare National Bank is going bankrupt.