In another case I discussed an elderly woman whose giant-cell arteritis was discovered during pathological examination of her aorta following grafting for an aneurysm (October 2007 TR, p. 6). The question was whether or not to give steroids in the post-op setting. In this case, while the rheumatology team favored their use, the surgeon wanted to hold off until the graft had healed and the risk of dehiscence had abated. My question to the readers was “What would you do?” Thank you to everyone who wrote in and I very much appreciate your thoughtful answers, which we’ve published on page 9.
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The problem, of course, is that there was no agreement on the treatment recommended. Clearly, as in sports, there are those who use steroids and those who don’t, although in rheumatology drug use does not reflect cheating but rather preference and a reasoned assessment of the risks and benefits in situations where choices are murky and the data sparse. For those of you who said to use steroids, I know where you are coming from. The same is true for those of you said to keep the Medrol safely in its vial and far away from the fragile veins of a nice old lady.
For my part, I probably would have waited on the use of steroids until the surgeon gave me the green light. I would, however, have exhorted the rheumatology service to check on the patient every day and query her—indeed, pester her—with questions about vision loss, fever, and other symptoms of arteritis, recognizing that after surgery just about every patient feels lousy, has a skyrocketing sed rate, and gets headaches from everything that goes on in a hospital—including her physician who keeps asking her whether she has a headache.
You Be the Judge
For today, I have two sets of questions. The first question concerns rating the responses we received (I promise we will not post grades on a Web site). In response to my question about steroid use for arteritis, who should get an “A” and who should get an “F”? Who should get the gold stars and who should get none—those who recommended steroids or those who did not? Should I be the judge or should we take a vote?
The second question is more practical and concerns how consumers could use a physician rating system. Let us consider a hypothetical patient called Mrs. Jones. Like the other patient with arteritis I described, Mrs. Jones has an aortic aneurysm. At her computer at home, she scopes out surgeons on a Web site called PhysiciansRatings.com or something like that. Mrs. Jones types in vascular surgeons and gets a list. She chooses Dr. Smith at St. Elsewhere General and goes off confidently, anticipating a successful outcome because Dr. Smith has the top rating among patients of her insurer. (Alas, he was only the third best with another insurer, but no one is perfect.)