Providing Optimal Care

Responding to Man Saves Wife’s Sight by 3D Printing Her Tumor

My name is David, and I am an internal medicine resident at Stanford. I spend my time taking care of patients, learning medicine, and daydreaming about the process of healthcare. I am very excited the progression of technology in medicine and want to work towards a healthier and smarter world, however every once in a while, I see something where medicine is so misrepresented that I feel obligated to put on my curmudgeonly hat and try to explain what’s wrong.

Aside: Before I go on, I want to preface that this post is solely my option — it does not represent my employer, my mentors, or my professors. I mention that I am an internal medicine resident at Stanford more as an appeal to ethos and to suggest that I have training relevant to the discussion. I also studied statistics for undergrad and will use some statistical analogies to hopefully make it clearer for a non-medical audience.

This morning, I read a very exciting article entitled “Man Saves Wife’s Sight by 3D Printing Her Tumor” which detailed a couple’s journey with a meningioma and how he used 3D printing to advocate for his wife and ultimately recommend a minimally invasive surgery to remove the mass. I came across the article through a link aggregator/community called Hacker News and the reception was great. It seemed like a triumph for technology in medicine, and a great example of patient self-advocacy. At the end of the article, we learn the husband is starting a company/business selling 3D printing applications in healthcare. However, my reaction was skeptical, and I am not convinced that his advocacy resulted in providing optimal care.

In fact, another way to interpret the story is such:

An 1) incidentally found, 2) benign, 3) asymptomatic, 4) slow or non-growing mass was removed despite the recommendations of multiple neurologists and after fishing for a neurosurgeon who was willing to cut it out. I definitely don’t have all the information in this case (I’m making conclusions from the information provided by the article), but I want to systematically describe why these bolded adjectives raise alarm bells in my mind about the decision making process. I am super impressed by 3D printing, however I just want to show how this is not an unequivocal case of beneficial applications of technology in medicine.

My worries are such:

The story starts with an accidental, incidental finding. The wife recently underwent thyroid surgery, and the husband pressures the wife to get an MRI of a different anatomical location when the patient feels well and did not have any symptoms. This mass is an incidentaloma — something found on a fishing expedition and not by looking for a particular cause to a problem. The problems with such an approach are well described in this old New York Times article, however the synopsis is such: When we look for problems with very precise tests, we can always find something to intervene upon and see something wrong. This is a problem well known in the statistics of screening tests in that even very good laboratory tests have significant harms when applied indiscriminately to everyone and everything. For people not in medicine, this can be analogous to not adjusting in frequentist statistics when one does multiple hypothesis testing and simply using one p-value of 0.05 to make decisions.

The article describes the management of a meningioma, of which the vast majority of cases are entirely non-malignant, either non-growing or slow growing, and asymptomatic (often only found on autopsy or incidental imaging). The wikipedia article on meningiomas says this:

In a retrospective study on 43 patients, 63% of patients were found to have no growth on follow-up, and the 37% found to have growth at an average of 4 mm / year.[23] … In another study, clinical outcomes were compared for 213 patients undergoing surgery vs. 351 patients under watchful observation.[24] Only 6% of the conservatively treated patients developed symptoms later, while among the surgically treated patients, 5.6% developed persistent morbid condition, and 9.4% developed surgery-related morbid condition.

The very fact that the article mentions the surgeon thought that a partial resection of the mass was a success suggests that there was little to no concern for malignancy. One does not try to take out only part of a malignant neoplasm (with the potential to grow significantly) without offering chemotherapy or radiation as adjunct therapy. In fact, I would rather argue that the husband’s big triumph was realizing that the two MRIs had shown the meningioma had little to no interval growth — and such a conclusion would recommend against rapid, aggressive surgery.

From all appearances, the article suggests the wife did not have any symptoms. She could have had the meningioma since birth — a harmless birthmark that was hidden until she underwent a superflous but expensive and highly sensitive imaging test. While it is true the meningioma is close to her eye, I would be surprised if a surgeon could intraoperatively tell the progression of the mass more than multiple MRI imaging studies. While it is true that there is always a small risk that a meningioma will grow, the slow progression on MRI suggests to me that symptoms would only slowly occur and there is a low likelihood that she would ever need emergent surgery. Finally, surgical resection causes inflammatory changes in the area which could exacerbate mass effects at the site and there is a high chance that it would come back (particularly with a partial resection).

As a physician, I want to provide the best possible care to my patients. Particularly in the Bay Area, I take of many highly intelligent and motivated patients — and it is an absolute pleasure to take care of patients who are engaged and asks thoughtful questions. I would not be offended if a patient asks me why I chose to do or not do a particular test, however I’m not acting as gatekeeper if I say I don’t think a particular test or procedure is in a patient’s best interests. I think that is one of the great tensions in American healthcare — how do we optimally use the right tests for the right patients when healthcare is not only expensive, but can also hurt patients — but that’s also why I chose to do medicine and why medicine in broad strokes is hard.

I don’t have all the answers and I don’t have all the details. I am only responding to the picture painted by this article and I’m not privy to the discussions that the patient had with her physicians. There are also many reasons why a surgery would be reasonable — there probably was very long and thoughtful discussion on the risks and benefits of this procedure. I simply want to say I don’t think this story is shining example of how technology is best used in our healthcare system, and how even with cutting edge technology, we (physicians and patients together) are still faced with difficult decisions with imperfect information.

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