A Choice of Doctors

August 10, 1994|By LINCOLN CAPLAN

WASHINGTON — Washington.--In 1990, my daughter, Molly, was almost two years old when we discovered that the roll in her gait was the result of a serious hip problem. She was among a tiny faction of children with a condition called hip dysplasia.

In a normal hip, the head of the upper bone of the leg fits into a socket of the pelvis, giving the hip strength and mobility. In Molly's right hip, the socket in her pelvis wasn't fully shaped. The upper leg bone was deformed and dislocated. If Molly's problem wasn't fixed, her limp would become progressively worse. By her late teens, she could be crippled. My wife, Susan, diagnosed the problem using a nurse's manual, after a friend said that she thought Molly's toddle might not be normal.

Molly was among the even smaller fraction of children whose dysplasia happens gradually after birth -- it was developmental, not congenital. In the United States, doctors are taught to look for the problem at birth and, if they catch it, to fix it by splinting the hip with a double diaper. Molly's pediatrician was an admired, well-liked member of the Washington, D.C., medical community who took good care of her in other ways. He had checked her hips after her birth and at every check-up afterward, but didn't catch the problem as late as a 16-month check-up. When we called to tell him of our concern (we'd mentioned her gait once before), he dismissed it as a worry of first-time parents. To humor us, he helped arrange an appointment with TC children's bone surgeon in the area. The doctor took X-rays, diagnosed the problem quickly, and laid out a course of surgical treatment. The treatment involved a complex procedure to reconstruct her pelvis and reset her bone, six weeks of healing in a body cast, and a recovery period in which Molly would have to learn to walk again.

In the following days, we got a second opinion. The second doctor took issue with the precise diagnosis of the first, and prescribed a surgical treatment that was significantly different from the first doctor's course. We were left reeling.

Doctor friends advised that we consult other specialists to choose between the recommendations. One expert offered a rule of thumb that for this unusual procedure we shouldn't engage any surgeon who hadn't done at least 25 similar operations. (The two in the Washington area had each done fewer than half that number.) A renowned children's bone surgeon at Johns Hopkins Medical Hospital offered statistics that surgery to reconstruct a child's hip at Molly's age succeeds only three of four times and, if it has to be redone, only two of three. If it were his child, he said, he would go to the most experienced doctor available. He pointed us to Boston.

John Emans is an orthopedic surgeon at Boston Children's Hospital, one of the finest medical centers in the world. He has the mind of a scientist and the hands of a sculptor. The day we first visited him, he looked at Molly's X-rays, asked Molly to walk for him, described what he saw, and prescribed a course of treatment as if we were learning about dysplasia for the first time. When I asked how many operations he'd done to repair hips with this kind of problem, he said, ''I've never counted. I did three last week. I've probably done over 300 in all.''

Although it meant uprooting our family to Boston from Washington for four months, while Molly was launched on the path to having a right hip that functions normally, we asked Dr. Emans to do the surgery.

What if the health-care system that some HMOs envision had been in place in 1990, and my family was a member of an HMO? In Molly's case, the HMO would probably have offered us treatment by a local children's bone surgeon -- if we were lucky, as good as the two we initially visited.

It would have been hard to criticize their skill or credentials. But by the standards of some accomplished doctors, while they may have had the skill to try to treat Molly, they lacked the experience. Unless we could have afforded to pay for the specialist of our choosing, Molly would have had less than first-rate treatment -- less than treatment that gave her a good chance of walking normally as an adult.

The HMO position about specialists boils down to this: A good HMO will hire or affiliate with the specialists it needs. The argument is that, in some instances, settling for second best is a price Americans will have to pay for controlling health costs. In Molly's case, that argument doesn't hold up. I suspect it wouldn't in many others.

The fee that Dr. Emans charged for his services, including surgical procedures and everything else, was 85 percent of the fee of one surgeon we consulted, 67 percent of the fee of another. My family is insured by Blue Cross and Blue Shield, which covered most of our other medical expenses and most of the doctor's fee. (We covered other costs related to our move to Boston, stayed with generous family members, and benefited from the help of friends there, too.)

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