Entitlement

Anyone who has ever taken a class in medical ethics knows about the concept of 'justice' as it applies to medicine. Justice is one of the four prima facie principles of ethics (the other three, if you're interested, are autonomy, beneficence and non-maleficence). Justice can be described as the fair adjudication between competing claims. And what does this have to do with what I'm rambling about today? I'm glad you asked.

Recently, I've noticed an increasing sense of entitlement when it comes to Canadians and their health care. Many Canadians living today don't remember a time when there was no universal health care system. I know I don't. And I'm thankful for it. Although it has its flaws and omissions, I love the fact that everyone walking into the emergency room is treated the same. Basic health care is guaranteed for all-- at least in theory. And serious illness or accident doesn't automatically mean a six figure bill.

Recently one of Canada's national newspapers ran an article hidden deep in the first section about a 40-something year old man who had been diagnosed with terminal lung cancer. The article focused on his delayed diagnosis. Apparently, after a lifetime of being otherwise healthy, he developed a chronic cough. Although he had none of the symptoms that are often considered the 'red flags' that would raise suspicion for cancer, this cough persisted through various failed treatments and investigations. Early in the investigation of the cough, a chest x-ray was performed. It was clear. By the time the cancer was diagnosed it had metastasized throughout his body. The article concluded with the man's family doctor apologizing to him for missing the diagnosis, and the patient lamenting the health care system for not investigating his cough aggressively enough to diagnose his cancer.

Another example I heard of second-hand. A woman's husband had been diagnosed with esophageal cancer and she was understandably devastated. She was angry with their family doctor, who she believed had been 'covering up' his cancer with anti-reflux drugs rather than taking his complaints seriously. Had the doctor acted sooner, she believed, her husband would have been diagnosed while the tumor was much smaller and more easily resectable.

These two cases have a lot in common. In both cases, the eventual diagnosis was a rare condition-- particularly in the age group in which these two men were diagnosed. In both cases, there were many diagnoses that were much more likely. And in both cases, the standard of care was met. The first case could have been easily explained with a diagnosis of chronic allergic rhinitis. Particularly after the initial chest x-ray was clear, without any weight loss, night sweats, fevers, smoking history or other aspects that would be more likely to suggest serious illness, a chronic dry cough in a healthy young man is many times more likely to be an allergic rhinitis or reflux. Both of which, although there are treatments available, can sometimes be very difficult to control.

In the second case, again the red flags just weren't there. Although the wife complained that the family doctor just 'covered up' the problem with medications, if the reflux responded to medication that should be diagnosis enough. The standard of care is not to scope everyone who comes in with symptoms of reflux, but to save the invasive testing for people with other worrisome symptoms-- trouble swallowing, weight loss, a history of lye ingestion (okay, now I'm reaching). But the reality is that most people with early esophageal cancer DON'T show any symptoms. That's one of the things that makes the survival rates for esophageal cancer so poor. My favorite source of clinical practice guidelines, the GAC Guidelines, clearly states that in the absence of dysphagia, bleeding, weight loss, choking, hoarseness, and chest pain, no further diagnostic testing is indicated for cases of GERD that respond to medical therapy.

In both of these cases, the patients felt that they deserved further testing. They feel angry and cheated by the system that is supposed to ensure their health. And although I understand that people given diagnoses such as this (and their loved ones) often have a knee-jerk reaction to find someone to blame, it makes me sad that this blame always seems to fall on the shoulders of family doctors.

One of the many problems with a universal health care system is that it is, by definition, universal. Everyone should be treated equally, in theory. So every 40-year-old with a cough should have a right to the same investigations. Depending on the situation, that often starts with eliminating the scary things and fixing what can be fixed. In someone who doesn't have any red flags, and who has already had a clear chest x-ray, expecting the medical system to pay for a bronchoscopy or equally invasive low-yield test is unrealistic. In the second case, a system that sent everyone with symptoms of GERD to a surgeon for endoscopy would not only create horrendous wait times for endoscopy, but would also be prohibitively expensive. A system which allowed everyone to be investigated without compelling indication to do so wouldn't be sustainable. This will mean that some cases will be missed. But it will also save much unnecessary testing, particularly invasive testing which isn't without risk itself. The key to screening for disease is to balance out the sensitivity of the test with the specificity. That means taking into consideration things like the prevalence of the disease, the potential for meaningful intervention (i.e. there's no point in detecting a disease early that we can't do anything about anyway) and the cost of the test. This doesn't mean much when the diagnosis missed was you or someone you love, but that's the way it works.

And unfortunately, the family physician is the gatekeeper. The one who decides who warrants further testing, and who doesn't. Although there are guidelines to fall back on, in the end it often comes down to a gut feeling-- is there something about this person's complaints that just doesn't sit right?

The problem is, what's best for society isn't necessarily what's best for the individual. And medicine isn't just a science, but an art. But in my opinion, both of these patients were treated appropriately. What happened to them sucks, no doubt. I wouldn't wish cancer on anybody, particularly not lung or esophageal cancer. But there is no one here to blame. So maybe we should stop looking.