I met my newly admitted patient in the quiet of his private room. He was frail, elderly, and coughing up gobs of green phlegm. His nasal cannula had stepped its way across his cheek during his paroxsysms and was pointed at his right eye. Although the room was uncomfortably warm, he was shivering and asking for more blankets. I could hear his chest rattling across the room.
The young hospitalist dutifully ordered a chest X-Ray (which showed nothing of particular interest) and reported to me that the patient was fine as he was afebrile and his radiology studies were unremarkable. He would stop by and check in on him in the morning.
I shook my head in wonderment. One look at this man and you could tell he was teetering on the verge of sepsis, with a dangerous and rather nasty pneumonia on physical exam, complicated by dehydration. I started antibiotics at once, oxygen via face mask, IV fluids and drew labs to follow his white count and renal function. He perked up nicely as we averted catastrophe overnight. By the time the hospitalist arrived the next day, the patient was looking significantly better. The hospitalist left a note in the EMR about a chest cold and zipped off to see his other new consults.
Similar scenarios have played out in countless cases that I’ve encountered. Take, for example, the man whose MRI was “normal” but who had new onset hemiparesis, ataxia, and sensory loss on physical exam… The team assumed that because the MRI did not show a stroke, the patient must not have had one. He was treated for a series of dubious alternative diagnoses, became delirious on medications, and was reassessed only when a family member put her foot down about his ability to go home without being able to walk. A later MRI showed the stroke.
A woman with gastrointestinal complaints was sent to a psychiatrist for evaluation after a colonoscopy and endoscopy were normal. After further blood tests were unremarkable, she was provided counseling and an anti-depressant. A year later, a rare metastatic cancer was discovered on liver ultrasound.
Physicians have access to an ever-growing array of tests and studies, but they often forget that the results may be less sensitive or specific than their own eyes and ears. And when the two are in conflict (i.e. the patient looks terrible but the test is normal), they often default to trusting the tests.
My plea to physicians is this: Listen to your patients, trust what they are saying, then verify their complaints with your own exam, and use labs and imaging sparingly to confirm or rule out your diagnosis. Understand the limitations of each study, and do not dismiss patient complaints too easily. Keep probing and asking questions. Learn more about their concerns – open your mind to the possibility that they are on to something. Do not blame the patient because your tests aren’t picking up their problem.
And above all else – trust yourself. If a patient doesn’t look well – obey your instincts and do not walk away because the tests are “reassuring.” Cancer, strokes, and infections will get their dirty tendrils all over your patient before that follow up study catches them red handed. And by then, it could be too late.
If you want to create an outcry of indignation, just inform people that certain screening tests are of no value and do not increase time on this earth. People love the idea that if they do all the right things and get all the medical tests at the right time, they can prevent disease ( ….uh…no, tests don’t prevent anything) or catch cancer early and cure it.
The furor over the lack of benefit for men of the screening Prostate Specific Antigen test (PSA) is still being heard. It seems everyone knows someone who was “saved” by getting a PSA and don’t try to tell me there is evidence to suggest otherwise, dammit!
There is a new report in the Journal of the American Medical Association (JAMA) that Read more »
*This blog post was originally published at EverythingHealth*
In a large multicenter study enrolling over 70,000 women, annual screening with transvaginal pelvic ultrasound and ca125 blood testing did not reduce deaths from ovarian cancer, and in fact led to an increase in complications due to screening.
Investigators in the NCI-sponsored Prostate, Lung and Ovarian Cancer (PLCO) Screening trial randomly assigned over 78,000 women age 55-64 years of age to either annual screening with transvaginal pelvic sonograms for 4 years plus CA125 testing for 6 years or usual care at 10 study sites across the US., and followed the groups for up to 13 years. Over that time period, ovarian cancer rates in the screened group were 5.7 per 10,000 person-years vs 4.7 per 10,000 persons-years in the usual care group, with 3.1 deaths vs 2.6 deaths per 10,000 person years, respectively. Over 3000 women had false positive screening results, a third of whom had surgery and 15% of those operated on had a complications from their surgery. Deaths from other causes did not differ between the groups.
The investigators concluded that annual screening for ovarian cancer does not reduce mortality, and in fact caused harms among women with fals positive abnormal results.
This is not the first study that failed to find efficacy for ultrasound and ca125 in reducing mortality from ovarian cancer, but Read more »
*This blog post was originally published at The Blog That Ate Manhattan*
There’s a new study out on mammography with important implications for breast cancer screening. The main result is that when radiologists review more mammograms per year, the rate of false positives declines.
The stated purpose of the research*, published in the journal Radiology, was to see how radiologists’ interpretive volume — essentially the number of mammograms read per year — affects their performance in breast cancer screening. The investigators collected data from six registries participating in the NCI’s Breast Cancer Surveillance Consortium, involving 120 radiologists who interpreted 783,965 screening mammograms from 2002 to 2006. So it was a big study, at least in terms of the number of images and outcomes assessed.
First — and before reaching any conclusions — the variance among seasoned radiologists’ everyday experience reading mammograms is striking. From the paper:
…We studied 120 radiologists with a median age of 54 years (range, 37–74 years); most worked full time (75%), had 20 or more years of experience (53%), and had no fellowship training in breast imaging (92%). Time spent in breast imaging varied, with 26% of radiologists working less than 20% and 33% working 80%–100% of their time in breast imaging. Most (61%) interpreted 1000–2999 mammograms annually, with 9% interpreting 5000 or more mammograms.
So they’re looking at a diverse bunch of radiologists reading mammograms, as young as 37 and as old as 74, most with no extra training in the subspecialty. The fraction of work effort spent on breast imaging –presumably mammography, sonos and MRIs — ranged from a quarter of the group (26 percent) who spend less than a fifth of their time on it and a third (33 percent) who spend almost all of their time on breast imaging studies. Read more »
*This blog post was originally published at Medical Lessons*
I’ve written in the past that more medicine and tests do not necessarily reflect better care.
There is no test that is 100 percent specific or sensitive. That means tests may be positive, when, in fact, there is no disease (“false positive”), or tests may be negative in the presence of disease (“false negative”).
It’s the latter that often gets the most media attention, often trumpeted as missed diagnoses. But false positives can be just as dangerous. Consider this frightening case report from the Archives of Internal Medicine:
A 52-year-old woman presented to a community hospital with atypical chest pain. Her low-density lipoprotein cholesterol and high-sensitivity C-reactive protein levels were not elevated. She underwent cardiac computed tomography angiography, which showed both calcified and noncalcified coronary plaques in several locations. Her physicians subsequently performed coronary angiography, which was complicated by dissection of the left main coronary artery, requiring emergency coronary artery bypass graft surgery. Her subsequent clinical course was complicated, but eventually she required orthotropic heart transplantation for refractory heart failure. This case illustrates the hazards of the inappropriate use of cardiac computed tomography angiography in low-risk patients and emphasizes the need for restraint in applying this new technology to the evaluation of patients with atypical chest pain. Read more »
*This blog post was originally published at KevinMD.com*