Monday, July 5, 2010

Set 'Em, and Forget 'Em

The fear of missing something weighs heavily on every doctor's mind. But the stakes are highest in the ER, and that fear often leads to extra blood tests and imaging scans for what may be harmless chest pains, run-of-the-mill head bumps, and non-threatening stomachaches.

Many ER doctors say the No. 1 reason is fear of malpractice lawsuits. "It has everything to do with it," said Dr. Angela Gardner, president of the American College of Emergency Physicians.

The fast ER pace plays a role, too: It's much quicker to order a test than to ask a patient lots of questions to make sure that test is really needed.

"It takes time to explain pros and cons. Doctors like to check a box that orders a CT scan and go on to the next patient," said Dr. Jeffrey Kline, an emergency physician at Carolinas Medical Center in Charlotte, N.C.

Patients' demands drive overtesting, too. Many think every ache and pain deserves a high-tech test.

"Our society puts more weight on technology than on physical exams," Gardner said. "In other words, why would you believe a doctor who only examines you when you can get an X-ray that can tell something for sure?"

Refusing those demands creates unhappy patients. And concern that unhappy patients will sue remains the elephant in the emergency room.

Associated Press, June 21, 2010

Lots has happened in medicine in the 21 years since I finished my training in emergency medicine, but the changes in our field are probably less than in other medical specialties. Because of the limitations of the ED setting, we most often don’t have access to all of the advanced tests, tools, and techniques that can be used in diagnosis and care during normal daytime hours. But that’s okay, because with the exception of emergency cardiac catheterization for heart attack and drug therapy for early stroke, things like MRI’s, serum levels of just about anything, and advanced surgical techniques rarely make much difference in the care we provide. Lives are saved by doing old-fashioned stuff like giving oxygen, keeping airways open, and use of fluids and maybe a dozen select medications which are essentially the same as they were two decades ago. One of the fun things about ED work is that there’s still some room to be a medical detective, as long as the investigation is limited to looking for an emergency and not definitively diagnosing everything else.

But that doesn’t mean technology isn’t invading our practice. It’s more than just tests and x-rays we do for medicolegal purposes, although that’s one of the most commonly held notions. (And realistically, while extensive lab tests and CT scans may find more things might expect, they often don’t affect the actual disposition of the patient; you usually already knew what needed to be done. A surgeon I respect…and for me that’s saying a lot…once told me that CT scans in trauma patients find a lot of injuries, but nothing you’re going to do anything about.) The article cited above is one of the few that talk about other reasons for excess testing, including effects on workload and patient demands.

Here’s an example of what I mean. A couple of weeks ago I saw a very pleasant 28 year old woman with pain in the right lower part of her abdomen. The basic approach to the problem…a history and physical exam…haven’t changed. You ask a set of questions, listen to the answers, and then poke, prod, and have a look around.

During my residency, the initial workup after exam would have consisted of a urinalysis and a urine pregnancy test. The one major emergency you always watch out for in a woman with one-sided lower abdominal pain is an ectopic (tubal) pregnancy. If the pregnancy test was positive, the patient had a possible ectopic until proven otherwise. Ultrasound was relatively new, and even when available you weren’t going to get one in the middle of the night. So you’d next get a blood pregnancy test, because most of the time levels of the pregnancy hormone b-HCG don’t rise above 2500-5000 with an ectopic pregnancy. If your clinical suspicion was still high, and if the b-HCG level was very low considering the date of the patient’s last period, you would call up the obstetrics resident who would come down to the ED and explain to the patient the need to do a culdocentesis. A culdocentesis is a needle puncture through the back wall of the vagina just under the cervix to see if there’s any free blood floating around the pelvis suggestive of a ruptured and bleeding tubal pregnancy. If it’s positive, the patient needed to go to the operating room for repair. That being said, most women would understandably decline the procedure (I’m not a woman, but it just sounds painful), and there would be some extensive patient education and counseling about the uncertain nature of her pain and the need to return immediately if worse in any way.

Today it’s different. Same patient, same presentation. But now once the pregnancy test is positive, we get an MRI to look for an ectopic (and avoid radiation exposure to a potential fetus). If it’s negative, we get a CT scan to see what else might be going on. Most of the time, we find nothing, and the patient is discharged with a diagnosis of “pelvic pain of unknown cause.” It’s a more definitive process to actually be able to visualize the area of pain. But is it better medical care?

There is no question that a CT scan or MRI is less invasive and less painful than a culdocentesis. Direct imaging does take the guesswork out of medicine, which is probably a good thing as well. Perhaps it provides a more definitive diagnosis (or at least a more definitive way to say there’s nothing wrong), and maybe there’s some reassurance value in that. There’s no question that medicolegally, you’ll be taken to task for not getting a test no matter how much time you devote to patient education and discussion. (And this is in a sample case where the test might actually be indicated, but physicians run the same risk if patient demands are not met regardless of clinical need. And believe me, it’s easier to give in to testing than explain why not.)

But sometimes I wonder if the sheer ease of getting tests and scans is a way of excusing ourselves as clinician, making us sloppy, and makes us really unable to communicate and talk with patients in the ways we used to do. Maybe we use the medicolegal excuse as a crutch for not wanting to make the physician-patient connection, but I doubt it. I don’t know anyone who went into this business purposefully to not talk to people. I think what testing does allow us to do, especially in high-volume ED’s where speed of patient turnover is often prized over compassionate and personal patient care, is to allow us to keep the system moving. I can spend twenty minutes talking to you, or I can order a CT scan and your case becomes a Showtime Rotisserie Oven. I set you and forget you until the timer on the CT scanner dings and then we sample the results in front of a studio audience. And all for three easy payments. But wait! There’s more…


  1. In the clinic I have access to urinanalysis and pregnancy tests, and patients whose major fear of the ER is bankrupcy. Last friday at 4pm I saw a 22 yr old female with pelvic pain, + UA (leucocytes), and a temp of 104 !! She refused to go to the ER.
    I did what I could (Bacrim) and sent her home pleading with her Mom to take her to the ER. She ddnt go. I guess Ill know tomorrow if she did.

  2. The patent I tried to convince to go to the ER, ended up there 48 hours later. Pnemonia, +- TB, likely Hep C. Boy oh boy