What To Do If Your Doctor Has Medical “Tunnel Vision” And Will Not Order The Tests You Need

This is a sad story. 42-year-old man has a malfunctioning heart. The rhythm is off. This medical condition is sometimes referred to as atrial fibrillation. His electrophysiologist (a type of cardiologist) decides to perform an ablation procedure on the heart to restore normal rhythm. This involves putting a catheter through the femoral artery up into the heart and delivering focused doses of energy to the heart to create scar tissue. By selectively creating scar tissue in a malfunctioning heart, normal rhythm can be restored. (There are hundreds of thousands of ablation procedures performed every year in the United States.) For a couple of days after the ablation, all goes well. But then the patient starts experiencing chest pain, difficulty swallowing, fevers and chills, and numbness and tingling in his hands. The doctor had unintentionally delivered so much energy to the back of our client’s heart that a small part of his esophagus had been burned. (The esophagus is right next to the heart.) Our client had something known as an “atrial esophageal fistula,” a rare but potentially fatal complication of an ablation procedure. (Roughly 1 patient in 500 will develop a fistula.) An atrial esophageal fistula (“A.E.F.”) is a ticking time bomb. The tissue doesn’t break apart immediately. The burn becomes infected. The infection leads to tissue necrosis. Necrosis leads to eventual tissue breakthrough. When our client finally had an open hole between his esophagus and his heart, which took 28 days to occur, he suffered a massive air embolism stroke. He died 2 1/2 weeks later. The doctor’s problem was not the burn. That’s a known complication of an ablation. The problem was the physician’s medical “tunnel vision”–a conscious or subconscious unwillingness to consider the possibility that he had made a mistake during the ablation surgery. Within eight days of the ablation, our client was so sick he had to go to the emergency room with chest pain and other problems. There were 4 more trips to the emergency room before the fistula broke through: Every time, the emergency room doctors called the electrophysiologist and asked for guidance. Every time, the electrophysiologist focused on restoring our client’s heart rhythm. In fairness to the doctor, our client often had tachycardia (an elevated heart rate) when he went to the ER. The therapy our client received made him feel temporarily better. Hence the medical tunnel vision: When you carry a big hammer (the specific ability to restore heart rhythm by virtue of your training as an electrophysiologist), everything looks like a nail. It never occurred to the doctor to get a CT scan, which would have shown the developing fistula. (If the fistula had been discovered in time, our client’s life could have been saved with emergency surgery to repair it.) The doctor ignored many signs of a developing fistula: Fever and chills (our client got so cold during the last month of his life that he was constantly rubbing his hands together and wearing extra clothing), chest pain, difficulty swallowing, fainting spells (syncope), and eventually an elevated white count (leukocytosis). All the doctor had to do was order a $900 CT scan. But he had tunnel vision. He forgot that one of the first rules of medicine is to come up with a differential diagnosis list. Doctors are supposed to list all possible explanations for a patient’s symptoms. Even if the doctor is convinced that there is a harmless, relatively benign explanation for the patient’s symptoms, he or she is obligated to entertain the possibility that there may also be a life-threatening, alternative explanation for the symptoms. If the unlikely-but-life-threatening possibility may kill the patient, the doctor has to rule that possibility out with the right test. (In this case, a CT scan.) Doctors have an expression: “Rule out the worst first.” What do you do when your doctor insists on doing the same thing over and over again no matter how many times you go back to the hospital with the same symptoms? You get a second opinion. You ask questions. You run the risk of ruffling the doctor’s feathers: “Is there a test we could do that hasn’t already been ordered to figure out what’s going on?” We recommend against trying to overrule a qualified physician because of what you read on the Internet. Sometimes the Internet makes us smarter. Sometimes the Internet makes us dumber, because we think we suddenly have expertise we don’t really have. But no patient ever died because he insisted on getting a second opinion from another qualified doctor. If you think your doctor has developed “tunnel vision,” don’t be afraid to get a second opinion. It’s better not to get a second opinion from your doctor’s office partner. The further away you get from a doctor you no longer trust, the more likely you are to get the right medical answer. Don’t be shy. Don’t be afraid to drive a hundred miles if that’s how far you have to go to get a true second opinion. Good doctors don’t resent it when you tell them you want a second opinion.