What's Wrong with Healthcare?

Thinking inside and outside of the healthcare box. After 41 years of family practice, what's happened to Canada's healthcare system?

Monday, February 25, 2013

Iron Deficiency in the Elderly, the Silent Killer

    Once more our laxidasical healthcare system has struck my family. My favorite aunt, well into her 80's but living independently with her husband and enjoying life, suddenly goes into congestive heart failure. With encouragement from me, she agrees to go to the emergency, gets the urgent intervention to reverse the failure, and is referred to a cardiologist. Keep in mind she had just been to a cardiologist six weeks before and was told everything was fine----but that is another story.
     During her stay in the emergency it was found that her blood was down several pints and she was given blood transfusions and arangements made to see both a gastroenterologist and a cardiologist. Six weeks later her cardiologist proclaimed her congestive heart was doing well once again and a colonoscopy by the gastroenterologist showed no cause for blood loss from her colon-----and here is where I get confused!!! -----a gastroscopy was not arranged. Now even fourth year medical students know that when considering iron deficiency anemia in the elderly, malignancy of the gastrointestinal tract should be high on our differencial diagnosis with the colon being the number one culprit and the stomach the number two culprit. So when the number one culprit is ruled out as a cause for this ladies iron defiency anemia, would not the stomach move up from the number two slot to the number one slot as the site for pathology?
      This particular gastroenterol;ogist, instead of proceding with a gastric endoscopy (having a look in the stomach) refers this patient to a hematologist (blood specialist). This specialist confirms that the patient has an iron deficiency anemia and instead of referring her back for the much needed gastroscopy (which I had encouraged the patient to press her doctors to do on several occassions), puts the patient on iron tablets to build up her blood and states that if her blood improves a gastroscopy can be delayed.
      Now consider this: My primary responsibility as a physician when a patient presents to me is to ask myself "Could this patient have something going on, which, if I don't intervene, could cause them their life or serious harm?" If I am sure the answer is NO then my job is simple--- address the symptomatic concerns of the patient in the least invasive and safest way. However, in this case:
1) Onset of heart failure because of new onset iron deficiency anemia
2) Stools for occult blood positive indicates probable Gastrointestinal loss of blood
3) Colon and stomach comprising at least 90% of gastrointestinal cancers in this age group and Gastointestinal cancer high in causes of GI blood loss in this age group.
4) A very positive family history of cancer
5) A negative colonoscopy.
    Now, is there anyone out there, medical or non medical, that thinks this patient is not at risk for a diagnosis of stomach cancer?
     Needless to say, eight months later, this patient sees her family doctor because of abdominal pain and he can feel an abdominal mass. Gastroscopy reveals a large stomach cancer that is partially obstructing the stomach and requires surgery. At this point the surgery is considered to be palliative, not curative. But could it have been curative ten months ago?
     Some of you may say "No one is infallible". But consider how many physicians were involved and had knowlege of this patient and her circumstances; her family doctor, the cardiologist, the gastroenterologist, and the hemotologist. This is not a case of one physician having a temperary lapse of common sense and medical accumen, it would seem to me to be more an endemic attitude of medical indifference to the elderly in our healthcare system. Could this patient and love ones seak retribution though the courts? Probably. Does it do my special aunt any good at this time----absolutely not. Will it change the direction of our monopolistic healthcare system in Canada to take this to our courts? Absolutely not. The unfortune fact is that death is cost effective and there is a pervasive attitude within our society (and yes, within the medical community itself) that rationing of healthcare in Canada is an acceptablr way of dealing with its unsustainability. And the rationing is most logical in the high consumer end----our elderly.