March 9th, 2011 by Bryan Vartabedian, M.D. in Better Health Network, Opinion
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How comfortable are we with uncertainty? I struggle with this question every day. I treat children with abdominal pain. Some of these children suffer with crohns disease, eosinophilic esophagitis, and other serious problems. Some children struggle with abdominal pain from anxiety or social concerns. I see all kinds.
But kids are tricky, and sometimes I can’t pinpoint the problem. Trudging forward with more testing is often the simplest option since it involves little thinking. And some parents perceive endless testing as “thorough.”
The question ultimately becomes: When do we stop? Once we’ve taken a sensible first approach to a child’s problem and judged that the likelihood of serious pathology is slim, when and how do we suggest that we wait before going any further? This requires the most sensitive negotiation. It’s about finding a way to make a family comfortable despite the absence of absolute certainty. This is easier said than done. Parents can unintentionally advocate for themselves and their worries by insisting on the full-court press. Alternatively they may refuse invasive studies when absolutely indicated.
All of this is for good reason: You can’t be objective with your own kids.
Pediatrics is tricky business and managing parental uncertainty is perhaps my biggest preoccupation. As I’ve suggested before, sometimes convincing a family to do less represents the most challenging approach.
*This blog post was originally published at 33 Charts*
February 15th, 2011 by KevinMD in Better Health Network, Opinion
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Abdominal pain is the bane of many emergency physicians. Recently, I wrote how CT scans are on the rise in the ER. Much of those scans look for potential causes of abdominal pain.
In an essay from Time, Dr. Zachary Meisel discusses why abdominal pain, in his words, is the doctor’s “booby prize.” And when you consider that there are 7 million visits annually by people who report abdominal pain, that’s a lot of proverbial prizes.
One reason is the myriad of causes that lead bring a patient to the hospital clutching his abdomen. It can range from something as relatively benign as viral gastroenteritis where a patient be safely discharged home, to any number of “acute” abdominal problems necessitating surgery.
But more importantly, we need to consider how limited doctors actually are in the ER. Consider the ubiquitous CT scan, which is being ordered with increasing regularity:
The pros: CT scans are readily available, able to look at every organ in the abdomen and pelvis, and very good for ruling out many of the immediately life-threatening causes of belly pain. CT scans can also reduce the need for exploratory surgery. The cons: Often, CTs can’t diagnose the actual cause of ER patients’ abdominal pain. Worse, CTs deliver significant doses of radiation to a patient’s abdomen and pelvis (equivalent to between 100 and 250 chest X-rays). Over a lifetime, patients who receive two or three abdominal CT scans are exposed to more radiation than many Hiroshima survivors.
Add that to the fact that patients expect a definitive diagnosis when visiting the hospital — one that doctors can’t always give when it comes to abdominal pain. Read more »
*This blog post was originally published at KevinMD.com*
January 3rd, 2011 by Michael Kirsch, M.D. in Opinion, Research
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The medical profession’s ability to diagnose far exceeds its ability to effectively treat the conditions discovered. Consider arthritis, Parkinson’s disease, irritable bowel syndrome, strokes, emphysema, and many cancers.
When a physician orders a diagnostic test, ideally it should be to answer a specific question, rather than a buckshot approach. A chest X-ray is not ordered because a patient has a cough. It should be done because the test has a reasonable chance of yielding information that would change the physician’s advice. If the doctor was going to prescribe an antibiotic anyway, then why order the chest X-ray?
Physicians and patients should ask before a test is performed if the information is likely to change the medical management. In other words, is a test being ordered because physicians want to know or because we really need to know the results?
Does every patient with a heart murmur, for example, need an echocardiogram, even though this test would be easy to justify to patients and to insurance companies? If the test won’t change anything, then it costs dollars and makes no sense. Spine X-rays for acute back strains are an example of a radiologic reflex. Read more »
*This blog post was originally published at MD Whistleblower*
January 3rd, 2011 by KevinMD in Better Health Network, Research
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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*
August 16th, 2010 by KevinMD in Better Health Network, Health Policy, Opinion
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I’ve written previously that many doctors are finding the physical exam obsolete, and are favoring more technologically-advanced, and expensive, tests. In fact, I alluded to traditional physical exam advocates as “arguing for staying with a horse and buggy when cars are rapidly becoming available.”
In a recent piece from the New York Times, internist Danielle Ofri says we need to look past the lack of evidence supporting the physical exam. The benefits of touching the patient, and listening to his heart and lungs, cannot be quantitatively measured:
Does the physical exam serve any other purpose? The doctor-patient relationship is fundamentally different from, say, the accountant-client relationship. The laying on of hands sets medical practitioners apart from their counterparts in the business world. Despite the inroads of evidence-based medicine, M.R.I.s, angiograms and PET scanners, there is clearly something special, perhaps even healing, about touch. There is a warmth of connection that supersedes anything intellectual, and that connection goes both ways in the doctor-patient relationship.
Great point. Read more »
*This blog post was originally published at KevinMD.com*
