Wednesday, October 28, 2009

A tale of two doctors

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.


  1. Oh wow! Yet another reason why we need to be active participants in our own medical care! You showed far more restraint than I, as I am fairly certain I would have walked out on Dr. F and told him what I thought of his shoulder touching!

  2. How very interesting! I'm so glad you got the second opinion!

  3. I always think it's interesting to see how two different doctors address the same problem. My sister developed a blood clot during her first pregnancy and her doctor told her she MUST be on injectable blood thinners for all subsequent pregnancies. So she has been on them now for her whole second pregnancy (EDD Monday) even though she hasn't had any problems this time around. I was tested and found out I have the same clotting risk factors she has (heterozygous Factor V Leiden and a homozygous MTHFR mutation) and my doctor recommended baby aspirin as a precaution. Makes you wonder.

    In this case it sounds like a very good thing that you got the second opinion!

  4. WOW. I'm stunned at the vast difference in juts two doctors. I'm so glad you got that second opinion. Really. Just wow.

    Also, I've never heard about not BFIng after general...I was put under general to repair my cervical tear and I don't recall a word being breathed about not BFing. I pumped like crazy all day long and then nursed my newborn when my husband brought him in after work.

  5. WOW. Amazing. Crazy. I'm incredulous, yet... not. I'm so glad you happened to have that conversation w/ your friend who recommended the 2nd doctor to you. Also... this won't work if you're bf'ing through any subsequent pregnancies, but my OB had me take a "baby" aspirin -- low dose 81 mg -- throughout the length of my pregnancy, and had me stop 2 weeks before my baby was due. It was absolutely amazing how greatly the low-dose aspirin reduced the pain of my varicose veins. He also recommended to me to take care of my severe varicose veins after I'm done bearing children... which I think I am, but I'm not 100% sure. (This past pregnancy, I developed such bad varicosities that they were up into my labia and even into my vaginal canal. It was AWFUL.)

  6. Wearing compression hose during the summer does indeed suck.

    I developed painful and itchy varicose veins prior to my pregnancy due to a series of jobs where I was standing most of the time. I did have a consult about having sclerotherapy but the request was denied by my insurance because I hadn't had the condition and tried "other therapies" for at least 6 months (never mind that I had discussed it with my doctor 2 years prior to that, she hadn't written it down so it never happened). Then I moved and once I switched jobs they got a lot better to the point where I didn't feel like I needed surgery. They got bad again during my pregnancy so I was considering having something done before getting pregnant again. I'm glad to know that isn't a good idea.

  7. Hi Rixa, there's a woman dr in Montreal,Que. who is a vein specialist. She has written a book called "Medical Mafia". She talks about all the surgery and pharmaceuticals she prescribed for her patients as per her training. She discovered that the only ones who got better were ones who did "alternative" treatments like acupuncture, vitamins, shiatsu, etc. When she incorporated these practices into her work, the College of Physicians & Surgeons came down on her hard. They don't want you to get better with anything but surgery/pharma. Her name is Guylaine Lactot. Search her. Gloria in Vancouver

  8. Ugh! I'm sorry about the compression hose, but at least you don't have to worry about general anesthesia. Yuck!

  9. I'm sorry, too, about the compression hose. But thank goodness for second opinions!

    Your experience with the first doctor reminded me of my experience with an oral surgeon to evaluate having my wisdom teeth removed. The ads for all the cosmetic surgery (and the question on the intake form inquiring if there was any other "work" I wanted done) were huge red flags to me.

    But I went ahead and had the evaluation, and had the same recommendation to wean. I hadn't even thought of it (my nursling was 2 1/2 at the time) but later researched it. You're right, no need to wean or even pump and dump if you're alert when the child wants to nurse. Needless to say, I didn't go with that surgeon and later found a new (holistic) dentist.

    Anyway, I wanted to thank you for sharing your story! I enjoyed reading it.

  10. I have a similar experience with my daughter who has a very minor cosmetic defect of her ear. I received a thousand different suggestions on what to do.

    "I'd call it "dangerous"and "radical" to recommend weaning, not "conservative."***

    I would call it ignorant and arrogant. It drives us who work in OB/Neonatal care crazy, when "consultants" give misguided advice on breastfeeding without even consulting us first. The easiest and fastest thing to say is "Don't breastfeed." I have heard it in all areas of care. Mom tired..."don't breastfeed." Had general anesthesia..."don't breastfeed." Baby crying...."don't breastfeed." I could write a whole post on this....hmmmm.

  11. Hey sounds like the first doctor was pretty much a jerk. However I just wanted to point out the term "acute distress" does not actually pertain to your emotionally well-being in that context. It actually pertains to your physical well-being, meaning something needed to be done right now. Honestly it didn't sound like you were in acute medical distress either though.

  12. Yeah, I know that...but it makes for a better story, right?

    I wouldn't be so hasty to say "well Dr. F is just a big jerk" and "Dr W is the bomb" because it's not so black-and-white. The urge to overreact is dangerous and keeps widening the chasm between physicians and their patients. Now I'm voting with my feet and those feet aren't going to Dr. F again, but I am going to send him a packet of information so he won't ever recommend weaning a baby if the woman is going under general.

  13. I can't get over this sort of thing. I saw this with a relative who was in ICU and the main physician made radically different (e.g. slower) decisions than I would see at a bigger hospital. And I saw this with the pediatric heart kids whose parents were initially told their situation was hopeless, and sought a second opinion.

    I don't know what's more astounding, that doctors are nowhere near uniform in their judgments and recommendations, or that I always assumed they would be. Always seek a second opinion if it means making a drastic in your case, going under general anesthesia for something non-life-threatening!

  14. Wow! If it weren't so uncomfortable for you, this would be funny.
    E-patients, that is where it is all heading. People like you demand transparancy. I'd go back and have fun discussing it all with Dr. F LOL

  15. I have a relative by marriage who developed a rare type of cancer in her leg. Very few doctors are experts in it. She went to see the closest one, who was arrogant, unkind and insisted the only way to treat the cancer effectively was to amputate the entire leg. Luckily, she decided to travel to another city, to see another expert. He was absolutely willing to consider trying a less invasive surgery. Today, she is cancer free and has two functioning legs. But only because she went for the 2nd opinion.

    I tell this story to pregnant women all the time when they say, why would I do my own research, my OB is the expert. Well, sure, but doctors are human too, and fallible. You can't give up responsibility for your own care. You need to consult more than one source to determine your options.

    This stuff IS truly scary. No joke.

  16. Interesting! I developed varicose veins in one leg during my first pregnancy and two superficial clots postpartum. I have an appointment with a thrombosis specialist next week to check the extent of my varicosities this time (and they're so bad this time that the varicosities are extending around my legs, onto the bottoms of my feet and into my labia/vagina) and to rule out the formation of any clots.

    Unfortunately, if I were to develop a clot and need to go on heparin, my care would be transferred to an OB and I would have to have a hospital birth :(

  17. So frustrating! I once had two doctors diagnose me with a torn meniscus in my knee and that I would need surgery. Not feeling peace about it, I went to a third doctor who said "No way do you have a torn meniscus! I can clearly see it on your scans." He drained off the excess fluid, gave me one shot of cortizone and that was the end of my knee pain - that was 5 years ago. To think I almost underwent surgery for that!!!

    By the way, I do have to share my fourth homebirth with you. It was so amazing and I was fortunate enough to have a photographer. What a blessing it was!!

  18. No bf after general? What about emergancy c-sections? I've never heard there shouldn't be any bf for 3 days after that. And to suggest weaning as a first option, rather than 'pump and dump' is pretty lame too.
    As for the shoulder pats--I find that if I'm sitting when the doctor comes in and he's older, then it's more likely to happen. It's hard to shake hands when one person is sitting and the other standing.
    I don't know much about varicose veins, but could you rig up a compression stocking that is just for the affected area? Or a tensor bandage? And, did it really work anyway?
    I think patients should always get to see their own records!

  19. Was the report typed or handwritten? I am a medical transcriptionist, and it is a very common error in text expanding for the MT to mix up "in no acute distress," which is a very, very common medical term, most likely said in every consultation report, and "in acute distress," which is very rarely said. Sometimes what is in the report can be an error in the dictation/transcription process.

    Good for you getting a second opinion!

  20. I have a 9 month old daughter (4rth child) that is on 100% breastmilk and I just saw a doctor this week about the same procedure. The problem is NOT with the anesthesia (as the doctor misinformed) but with the chemical used for the scelerotherapy. No one knows the affects of that chemical or how it could affect the milk. I can't find any info out there about it except that it is not recommended during breastfeeding. I am at a loss of what to do because I don't want to stop breastfeeding so soon but I am not sure if pumping and dumping milk for some length of time will be safe enough.

  21. Wow. It sounds like we have a lot of similarities. I went to a dr who had a similar opinion to Dr. W. I think our clots were even in the same spot. I was wondering if you have gotten pregnant again and if they have put you on any low molecular weight heparin? I am nervous about getting pregnant again. I have to 2 amazing kids and have always wanted 3 but don't want to ...not to be overly dramatic... leave them too early in effort to get a third when I should have just been happy with the wonderful two I had.

  22. Dr. W knew I was nursing and would still be if I had the sclero/EVLT done, and he said nothing about the sclero negatively affecting breastmilk. I think the sclero uses a saline solution, which wouldn't be harmful for a breastfeeding relationship.

    None of the people I've seen have suggested heparin. Superficial clots are painful and obnoxious, but not dangerous like deep vein thrombosis.

  23. LMAO!!! Acute distress puts you on the ventilator... not in compression hose. What an idiot.


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