12 July 2013

A new era

A young woman came into clinic because of a rash. Thumbing through her chart, I noticed that another doctor had referred her to a cancer center for genetic testing. As it turned out, the patient's father had recently been diagnosed with breast cancer, which is rare in men. Some men with breast cancer have the BRCA2 mutation, a rare genetic mutation that can be passed on to children. Those who inherit the BRCA2 gene are at significantly higher risk of developing certain cancers, particularly breast cancer.

I asked the patient if her father had been tested for the BRCA2 mutation. She replied that her father had indeed been tested, and it showed that he didn't have the mutation.

I gently pointed out to the patient that since the BRCA2 mutation is inherited, and since her father didn't have the BRCA2 mutation, she couldn't have inherited the BRCA2 mutation from her father. But the patient was steadfast. She and her siblings were all planning to get the genetic test regardless (their health insurance was paying). I moved on.

The doctor who serves as my preceptor later pointed out to me that the BRCA2 test costs over $3000 per person. Thousands of dollars were about to go down the drain. And no one besides my preceptor and me cared.

A couple of hours after examining the young woman, I climbed into my preceptor's car and we drove through the countryside to a patient's home. The patient was not old. He was dying of metastatic cancer and was on hospice. We said hello to the patient, and the doctor performed a brief exam. Then the family invited us into their living room. As soon as I plunked down on the sofa, the family dog hopped up next to me, begging to be petted. No one had been paying much attention to her these past few weeks.

I scratched the dog's belly while the doctor offered the family his support, adjusted the patient's pain medication, and helped the family plan for what lay ahead. The patient's wife cried while she told us how difficult these past few weeks had been, how shockingly quickly the disease was overtaking her husband. She could not bear to leave the house for more than an hour for fear of being away from her husband's side when he finally succumbed. We reassured her that she was taking good care of him and urged her to make some time for herself. When it came time to leave, the family was incredibly grateful. "I didn't realize doctors made house calls anymore," they said.

Although the doctor would like to do more house calls, he can only volunteer so much of his time. Our home visit wasn't compensated at all. Even the cost of gasoline came straight out of my preceptor's pocket.

What if we canceled our patient's worthless BRCA2 test, and instead spent the $3000 on paying for house calls? My preceptor could probably visit 30 more dying patients at their homes.

Within the span of a few hours, I witnessed both medicine's past and medicine's future. The era of the house call has given way to the era of genomic sequencing. Which of them offers people more healing? And which of them have we decided to pay for?