What's Wrong with This Picture?

At first, nothing seemed wrong. It all turned out fine, so why did I have the feeling that something terrible had happened? Perhaps, I thought, all the talk of guidelines and protocols was causing me to question a good, if somewhat fortuitous, result.

An 82-year-old man came to my office because he had passed out in church. He had been healthy all his life. A few years before our first encounter, he had had a similar experience but had never made much of it. He had told no one about it and had felt fine when he regained consciousness. He attributed the syncopal episode to hunger or anxiety and never considered “bothering the doctor.”

His history of syncope and his loud systolic ejection murmur, however, gave me great cause for concern. If he had aortic stenosis, as I suspected, syncope was a bad prognostic sign.

My first step, of course, was to check his insurance. Would prenotification be required before I began spending? Miraculously, he was not a managed care patient but was covered by Medicare and secondary insurance. His wife mentioned that …