Demystifying Medicine One Month at a Time

Cruel Shoes

GlassHospital is on vacation this week, writing to you from vibrant Toronto.

Toronto is home to the Bata Shoe Museum, well worth a visit if you’re ever here on a Thursday night when admission is free. In addition to a display featuring shoes of Elton John and Shaquille O’Neal (among others), there is a nice historical series featuring shoes from the ages that seem very strange to someone from the 21st century.

Well, at least to me.

A Pair of Italian Chopines, circa 1600.

My family was intrigued by the tiny shoes that Han Chinese women wore during generations of the practice of footbinding. Beside those doll-like appendages, I haven’t been able to get over the chopines, foot high platform shoes worn by upper class women in Renaissance Italy.

All of this reminded me of a story about feet that shows some of the craziness of our technologically-driven health care system.

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A thirtysomething friend of mine, let’s call her Sally, started running last year in an effort to get in better shape.

As often happens in these scenarios, Sally developed some foot pain. So she went to a “foot” doctor (I’m not sure whether she meant a podiatrist or an orthopedic surgeon specializing in feet).

Reasonably enough, the doctor ordered an x-ray of her foot. The official reading showed no fracture, but there was a “questionable” finding on the edge of one of the midfoot bones such that the doctor couldn’t rule out some more insidious process. A stress fracture, perhaps? Those can be awful, and take a long time to heal.

So, again in reasonable fashion, the doctor ordered a CT scan of Sally’s foot. This is the logical next step if a plain old x-ray is abnormal. Heck, a lot of the time, even when an x-ray is normal, we still order the CT scan looking for something that we can’t see on the x-ray.

And though I said this was a reasonable choice, if you really think about it, was it so reasonable?

I mean, did Sally really need a $1000 test to see what was causing her foot pain? If you’re Sally, you sure might think so. You want to know what the heck’s wrong. You want to know why you’re having pain when you run. You want to keep running. After all, as a primary care doctor, I LOVE it when a patient tells me that they’re serious about exercise. Aside from not smoking, that’s the best thing I can hear from a patient.

But Sally hadn’t traumatized her foot. She hadn’t dropped a bowling ball on it. She probably had an overuse syndrome. A repetitive stress injury. A running “tweak.”

The x-ray showed that, for heaven’s sake. We knew there was no broken bone. No smoking gun. [I told you, we hate smoking.]

So a week after sitting for the CT, Sally still didn’t know the result of her scan. She called the doctor’s office to no avail. She was put off by the staff, even told by a nurse she’d have to come in for an appointment to discuss the results with the doctor.

By this point, she’s worried. “Is there something terrible that he’s waiting to tell me?” she wondered. “Do I have foot cancer?”

Sally adjusts her schedule, dutifully shows up for the appointment, to hear the doctor tell her that her CT is normal. Did she really have to wait a week and have an office visit to find this out? That is one shoddy patient experience in my book.

Nevertheless, she reasonably asks the foot doctor what she should do about her pain.

Physical therapy? Low impact exercise (use an elliptical trainer, perhaps, or bicycling)?

She doesn’t get much of a concrete answer.

She decides to buy some new shoes.

She goes to a local shoe store that caters to runners. Let’s call it Fast Feet.

There, they measure her feet. No charge. Lo and behold, her feet have grown 1/2 a size.

Sally was running with shoes that were too small! That was the source of her pain. No CT was needed. In fact, probably even an x-ray was unnecessary.

Now, this story shows how when a patient comes to see a doctor, we often go right to diagnostics. We want to get you an answer, after all. We’re not shoe salesmen, for heaven’s sake. We don’t even have those thingie-dingies that measure feet. [Do foot doctors?]

Next time someone comes in complaining of foot pain, I’m going to ask them when the last time they had their feet measured.

[Editor’s note: re: the title of this post, google Steve Martin and read about his books.]

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[Editor’s note #2: If you haven’t been over to Slate to see the Medical Examiner column from last week, check it out here. Thanks for reading!

9 Comments

  1. Alex @ Happiness in this World

    John,
    Great, great post that so well illustrates what’s really driving the out-of-control costs in our health care system: uncontrolled overutilization of medical resources by doctors and patients both.

  2. rosemary nadolsky (rose)

    Hi, John–
    Really enjoyed reading this. Thanks. You’re the best! xo, Rose

  3. rosemary nadolsky (rose)

    P.S. I’ve always loved that Steve Martin bit about “cruel shoes!”

  4. Cynthia

    Not sure I agree with you. As a foot pain sufferer (apparently I dislocated a joint in my foot jumping across a creek in a race last year, though I didn’t know this until after the x-ray), I can tell you that my injured foot is now definitely longer than my non-injured foot (again, about 1/2 inch). This is causing stress on the plantar fascia, which you can see is pulled tight when the toes are pulled back, compared to the non-injured foot. I believe that a lot of PF cases are in fact caused by minor foot remodeling due to injury or athletic stresses. I probably didn’t need a CT scan to tell me this, but the podiatrist was able to at least explain what was happening to me so that I knew there wasn’t a stress fracture and what I could get away with as far as training.

  5. Dara

    The question for me is whether Sally should have started at the running shoe store instead of with the doctor. If she had, would the doctors, x-rays, ct scan, foot molds, stress, cost, etc.have been avoided. Those new shoes were a whole size larger! I guess we can’t know. (And, how many other health problems can be solved at the running shoe store?)

  6. Dara

    Thank you for the thoughtful piece.

  7. Dr. Grumpy

    Cruel Shoes was a great book. I still have my original copy, albeit falling apart.

  8. DMar

    Great mix of humor and thoughtfulness. Your posts are always interesting to read.

  9. Charlotte Genetta, RD, CDE

    As a Diabetes Educator I can also tell you that 60% of those with type 2 diabetes have sleep apnea though many have not been diagnosed- but that is what our literature indicates.Sleep Apnea can lead to type 2 diabetes so its important to treat not just to get a good nights sleep. Lack of sleep increases insulin resistance in several ways via cortisol and other stress hormones and a general lethargy that slows physical activity.

    Losing weight ( or more importantly shrinking our waistlines as fat in this area is mostly to blame) will solve MANY health issues. I’m all about getting to the heart of medical issues:-).

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