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Just To Be Sure: The Most Expensive Phrase In Medicine

Kevin, MD linked to this, and I really must comment.

Here’s the abstract, and I hope you’ll read it all:

200910290120.jpg For years I’ve heard friends describe experiences of being caught in a web of excessive and unnecessary medical testing. Their doctors ordered test Z to investigate a seemingly incidental finding on test Y, which had come about because of a borderline abnormality on test X.

I often wondered why test X was done in the first place. As a primary care physician, I would have treated them for the likely diagnosis and done diagnostic tests — especially a series of diagnostic tests — only if they didn’t respond as expected….

Naturally, I’d express sympathy or outrage, whichever the speaker seemed to expect, but internally I’d pat myself on the back. I felt fortunate that there was absolutely no way I’d ever be stuck in such a scenario. After all, I’m not only an experienced physician but also an advocate — in fact, a teacher — of standard-of-care practice. When I get sick, I told myself, they’ll have to do it by the book.

That was before last Easter.

Short version: Easter Sunday an experienced physician realized he was breaking out with shingles on his face, and decided that instead of bothering his internist with it he’d go to the ED. What he got there was, to put it mildly, terrible. After the obvious diagnosis (which the patient no doubt gave everyone from the triage nurse up, he’s smart and knew the problem):

“Before you go,” my colleague mused, “just for completeness’ sake, maybe we should have an ophthalmologist and a neurologist take a look at you. What about it, just in case?”

“I don’t know . . . I don’t think so . . . well, okay . . . maybe it’s a good idea.”

No, it turned out to be a terrible idea. Acquiescence to this obvious weakness on the part of the EM doc resulted in two senseless consultations (three if you add in the residents’ time) and a pointless MRI, then read as abnormal, though there was no significant abnormality.

Eventually the patient went home with the correct medications, but with a 9,000 dollar bill. Which was, and is, terrifically stupid.

After an EM doc’s period of contemplation, here’s my opinion:

First, if you have a regular doctor, call them (especially if you are a doctor and know what the problem is. Rx called in, see me Monday, problem solved). However, as most people aren’t, and my patients don’t have regular doctors…

Second, I’m at a loss to explain the actions of the EM doc. All the blame lies with them. Yes, I’m taking issue with the EM doc.

I’m of two minds about this weird consultology on the part of the EM doc. Right diagnosis, sounds like a thorough exam, so where’s the problem? Either it’s fear of suits, or it’s a junior EM doc taking care of a Senior doc.

Fear of suits: New York is rated “F” by the ACEP EM Report Card for their medical liability climate. That’s not an excuse, but a reason. I personally am guilty of getting tests for my lawyer (which were also medically indicated). Mea culpa.

The Junior doc taking care of a Senior doc is also at work here, and is magnified at an academic center (where there are always more tongues clucking about the idiotic decisions / misses in the ED). Add in any perception that the ED is a scapegoat, and there’s going to be a tremendous amount of testing on ‘one of their own’ to preclude an awkward and embarrassing Morbidity and Mortality meeting. Trust me, docs will go a long way to stay away from that spotlight.

I have no idea which drove this horrible decision. I hope everyone involved, especially the EM doc, learned a lesson.

By the way: “Just to be sure“. Therein lies half the evils in medicine. Get a test, just to be sure. Get another test, a consult or two, and admission, just to be sure. Look, if you’re unsure, then fine, do what it takes to care for the patient. Just to be sure, though, is the path to ruin for our profession, and our country.

*This blog post was originally published at GruntDoc*

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One Response to “Just To Be Sure: The Most Expensive Phrase In Medicine”

  1. Ellen Hoenig says:

    Being in the healthcare industry, I couldn’t agree more with the point of the blog in principle about all the waste and ‘just in case’ testing.

    However, instead of ‘just in case’, more doctors might be more diligent to ask other questions to explore and help rule out other possible causes of outbreaks etc. For example, my Mom came down with a terrible case of shingles, and doctors rushed to treat the shingles, but never explored and asked her if anything else might be wrong. Not until my sister (a doctor) asked my mom, given that shingles is a marker for compromised system, did we find out that she had spotting…which unfortunatley resulted in an immediate diagnosis of a rare and very serious endometrial cancer…

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