The $50,000 Physical

In a recent editorial in the Journal of the American Medical Association, a physician related the story of his 85-year-old, reasonably healthy father who had relocated to an assisted-living facility and visited his new primary care physician for a “checkup.”1 On the routine physical examination, the doctor palpated the patient’s abdomen and noted that the aorta appeared to be too prominent. The patient was therefore referred for an abdominal ultrasound, in order to rule out an aortic aneurysm. The ultrasound demonstrated a normal aorta, but it also revealed a suspicious lesion around the head of the pancreas, so a CT scan was recommended. On the CT scan, the pancreas was found to be normal, but a lesion strongly suggestive of hepatocellular carcinoma was seen on the liver. The patient therefore underwent a liver biopsy, to confirm the diagnosis and to determine whether an effective treatment was available. The liver biopsy revealed that the lesion was not cancer. Rather, it was a hemangioma, which bled profusely during the procedure, requiring transfusion of 10 units of blood and 7 days of hospitalization. Another complication of the biopsy was severe pain requiring treatment with morphine, which resulted in urinary retention and the temporary insertion of a urinary catheter. The total hospital bill for this fiasco was $50,000.

The author of this report acknowledged that, after the doctor’s initial examination, every test and every intervention was medically appropriate. And yet, these “appropriate” tests and interventions nearly caused a healthy 85-year-old man to bleed to death, caused him great physical pain and emotional trauma, and cost the medical system a large amount of money. The author also rightly pointed out that the only way this catastrophic outcome could have been avoided would have been if the doctor had not conducted the initial physical exam. As one of my medical school professors liked to say (only half facetiously), “If you don’t take a temperature, you don’t have to worry about a fever.”