Sharon Astyk's post A Tale of Two Hospitals inspired me to write this post about two physicians' wildly different recommendations for the same problem.
About two months ago, I visited a vein clinic for my varicose veins. I developed spider veins when I was pregnant with Zari, but during Dio's pregnancy varicose veins popped all over both legs. I had to wear thigh-high compression hose every day, and one of the varicose veins even developed a blood clot.
I met with Dr. F, a distinguished looking gentleman in his sixties with graying hair and a neatly trimmed beard. His vein clinic, located in a wealthy suburb of a very large metropolitan area, was filled with glossy advertisements for cosmetic procedures of all kinds: legs, face, skin, breasts.
My first visit with Dr. F was a very short consultation. I told him the history of my vein problems, that I wanted to have several more children, and that I was hoping to address the varicose veins now so they wouldn't be such a problem in future pregnancies. I'm especially concerned about getting blood clots again in my veins, since it happened when I was about 7 months pregnant with Dio and is likely to reoccur. I was able to schedule an ultrasound examination of my veins and a longer consult for the same day.
When we met again after the ultrasound, he presented his findings: both of the great saphenous veins had malfunctioning values and blood was flowing backwards as a result (no surprise). He recommended a minimally invasive vein surgery for both legs. In his practice, this involves undergoing two outpatient surgeries under general anesthesia, one surgery for each leg. They collapse the top of the vein with a catheter that emits radio waves, then remove all of the smaller branches through tiny incisions. He said they only do one leg at a time because the risks increase the longer you're under anesthesia. Insurance would cover the treatment, but with my 20% copay it would still be quite expensive. I'd have to pay for everything twice: anesthesia, surgery center, physician's fees, etc. In addition, he charges a cosmetic fee of $400 per leg "because we're very meticulous with our surgery and take great pains to get all the small veins out."
I asked Dr. F if other therapies would be effective, such as sclerotherapy (injecting a small amount of solution into the vein, which causes it to collapse). He said that there's a high likelihood of recurrence with sclerotherapy and my best bet is to remove the great saphenous veins entirely. Sclerotheraphy is also not covered by insurance, even if it would correct a medically indicated problem--and I wondered how much that had to do with his recommendation. I asked him what the chances were of getting varicose veins in future pregnancies if I did the surgery, and he said it was not likely to reoccur.
Dr. F said I'd need to wean my baby before the procedure, or pump & dump for three days, because of the general anesthesia. I was quite surprised to hear this, since I had read that it's safe to breastfeed after GA. I mentioned this to him, and he said "if your pediatrician or midwife says it's okay, then go ahead. But I tend to be conservative and recommended weaning, just to be safe." (I later asked my CNM, who is also an IBCLC, and she said that I was absolutely correct. You can breastfeed after general anesthesia as soon as you're awake enough to hold your baby.)
***Is it "conservative" to recommend weaning before general anesthesia, even when the medical literature indicates that you can safely continue breastfeeding right after the surgery? I'd call it "dangerous"and "radical" to recommend weaning, not "conservative."***
And here's where my visit got really weird. He kept patting me on the shoulder, in a grandfatherly "don't worry your pretty little head, we'll take care of you" manner. It seemed very much like an act to me. And then Dr. F said that he would--this is an exact quote--"work hard to preserve the youthful appearance of your legs."
I replied: "I don't care at all about that."
He had committed a grave miscalculation, assuming that I was distressed by the appearance of my legs. I don't care one bit about how they look. I just want them to stop hurting. I don't want to have to wear support hose during every future pregnancy. I don't want to get blood clots again.
I went home to think about his recommendations. I was glad to know that insurance would cover the treatment, although not happy about having to go under general anesthesia twice, let alone the cost and hassle of two procedures. But I was also under some time pressure; if I was going to do something about my veins, I wanted to get it done before the end of this year. If not, my insurance deductible would kick in again at the start of the year and it would be even more expensive.
I was talking about this visit--especially the "preserving the youthful appearance of my legs" part--with a friend. She recommended talking to her OB, Dr. W, who recently became specialized in varicose veins. She told me he was really upfront, matter-of-fact, and wouldn't try to sell you on anything. I could use some of that after being patted on the shoulder by Dr. F. I scheduled an appointment and had my records sent over.
Yesterday was my visit with Dr. W. His clinic had dark plum colored walls, floral upholstery on the chairs, and no advertisements or brochures except one TV monitor displaying women's health advice and occasional ads for things like breast pumps or flu shots. I met with Dr. W first in his office. Dio came with me, while Zari was playing with her cousins at the children's museum. While I was waiting for him to arrive, I scanned his bookshelves. I noted the familiar obstetric classics such as Williams Obstetrics and laughed at the thought of adding Holistic Midwifery to his collection. He came in and said hello, reaching and touching my shoulder. Not again! I thought. I quickly extended my hand to shake his.
*** Is there something in my demeanor that inspires older men to pat my shoulder?***
I introduced myself and my vein issue briefly, and we moved to an exam room. He took a look at the veins in both legs, then spent several minutes reading through my records from Dr. F's clinic. He looked up and said, "This is going to sound cynical, but..." He gave a long explanation of how insurance only pays for certain varicose vein treatments, and that physicians often look for a problem with insurance reimbursement in mind. He said my case was a classic example of that. Yes, both my legs DO have varicose veins and hence the malfunctioning values, back flow of blood, etc. But the bundle of veins behind my left leg--the ones that got the superficial blood clot--is most likely not part of the greater saphenous vein. He saw nowhere in Dr. F's report any procedure that would have fixed that area at all--the part that gives me the most grief! There's a bundle of nerves right behind the knee, and in order to avoid hitting those nerves, vein specialists will usually avoid vein ablation in that area in favor of sclerotherapy (which, if you remember, isn't covered by insurance even if it is medically indicated).
It kept getting better. Dr. W said, "You said that you could live with this if you knew you weren't having any more kids. But honestly, I'd advise you get get it fixed once you're done having kids. There's a very high chance of reoccurence. Even if you remove the entire vein, the compensatory veins might very well develop varicosities." Darn. And he told me: "I know you're not going to want to hear this, but you'll probably need to wear compression hose every time you're pregnant." Double darn.
And then he asked about what procedures the vein clinic had suggested. I told him that it would involve minor outpatient surgery, under general anesthesia, in a surgery center, and that I'd have to do both legs separately. Dr. W seemed about ready to fall off his chair. "Really? There is NO way I'd do general anestehsia for this kind of thing! We do a similar procedure right here in our office with tiny injections of local anesthesia. And going under general incresases the risk of deep vein thrombosis!"
I asked him what he'd suggest doing next. He wants to take another look at the varicosity behind my knee and see how/where it inserts into the venous system and then we can go from there. He also said to go ahead and get a 3rd, 4th, or 5th opinion if I wanted. I scheduled the ultrasound for next week and am curious to see what he suggests. It seems, though, that I might just need to live with my varicose veins until my childbearing years are over. Which really stinks because it is no fun wearing compression hose. It was bad enough in the winter and early spring, but I simply cannot imagine wearing those and being pregnant in the summer.
The icicng on the cake, though, was when I glanced at my records from Dr. F's office. I was reading them upside down, and one particular phrase caught my eye:
"...the patient came to me in acute distress..."
Seriously? Acute distress? Those of you who know me personally can vouch for the fact that I am very level-headed and not inclined to overt displays of emotion.
Sorry, Dr. F, but I am not your damsel in distress.