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Michael is 12 years old. “Not hungry?” I ask when I enter the room, eyeing the plate. He doesn’t answer my question, but instead remarks with a lopsided grin, “You look funny.” I look sideways at [my reflection in] the mirror and see a yellow-gowned creature fumbling around. Michael is right. I do look strange, but these precautions are necessary because he is undergoing chemotherapy for metastatic Ewing’s sarcoma. He was diagnosed 3 months after he first saw his physician for leg pain. At the time, his pediatrician told him that he was having growing pains, and instructed Michael to call back if the pain worsened. Surprisingly, Michael’s pain went away after the visit. However, some weeks later, his pain returned with a new, burning intensity. Concerned, Michael’s mother made another appointment with their pediatrician. This time, the pediatrician attributed Michael’s pain to a sports injury and advised him to, “Ice the leg, take some Tylenol and call back if the pain persists.” While Michael felt somewhat better, a few weeks later when the pain began awakening him from sleep, Michael’s mother took him to the emergency room. The doctors ordered an x-ray of his leg, which showed “onion-skinning” lesions on his bone, a classic finding in Ewing’s sarcoma. A subsequent CT scan showed that the tumor had metastasized to his lungs.
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In medical school, we are taught cost-effective care. On a population basis, x-raying every child with leg pain is not cost-effective. But on an individual basis, which parent given the choice would forego an x-ray even if the likelihood of their child having a tumor were small? Most children with leg pain do not have tumor, but what if he or she is in the minority? And even with the most rigorous of algorithms, some patients may have atypical presentations, and we may still miss the diagnosis. Michael’s mother blames herself. She believes that if had she pushed more aggressively for an x-ray early on, the tumor might have been discovered sooner.
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In medicine, a perpetual struggle exists between preventing the most serious outcomes while not incurring too much costly, unnecessary testing. On my pediatrics rotation, one of my attending physicians taught me that the most important test was the “pillow-test.” In short, would I be able to fall asleep that night knowing that I had done everything that I could have for my patient? If I had been Michael’s pediatrician, would I have passed the “pillow-test?” Encounters with patients like Michael leave us wondering if cost-effective care for the population is at odds with delivering the best care for individuals. We can never “do everything possible” for a patient; we can only do our best—which is to order tests and services thoughtfully guided by outcomes from clinical trials. Ultimately the joy and challenge of being a physician is “doing everything possible” for our patients with limited information and resources.
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