Favorite Quotes
"For every complex problem, there is a solution that is simple, neat, and wrong." - HL Mencken
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"I hear and I forget. I see and I remember. I do and I understand." - Confucius
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"The good physician treats the disease; the great physician treats the patient who has the disease" - Sir William Osler
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" The best test of a person's character is how he or she treats those with less power." - Bob Sutton
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"Those are my principles, and if you don't like them - well, I have others." - Groucho Marx
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"The difference between genius and stupidity is that genius has its limits." - Albert Einstein
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"It is hard enough to remember my opinions, without also remembering my reasons for them" - Friedrich Nietzsche
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"Anyone can make the simple complicated. Creativity is making the complicated simple." - Charles Mingus
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"Not everything that can be counted counts, and not everything that counts can be counted." - Albert Einstein
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"A foolish consistency is the hobgoblin of little minds, adored by little statesman and philosophers and divines. With consistency a great soul has simply nothing to do." - Ralph Waldo Emerson
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"This ain't no party, this ain't no disco, this ain't no fooling around." - Talking Heads, Life During Wartime
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"What is hateful to you, do not do to your neighbour. This is the whole Torah; all the rest is commentary. Go and learn it." - Hillel, Talmud, Shabbath 31a
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"You will never understand bureaucracies until you understand that for bureaucrats procedure is everything and outcomes are nothing." - Thomas Sowell
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"An idealist is one who, on noticing that a rose smells better than a cabbage, concludes that it will also make better soup." - HL Mencken
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"If you only have a hammer, you tend to see every problem as a nail." - Abraham Maslow
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"A great teacher is one who realizes that he himself is also a student and whose goal is not to dictate the answers, but to stimulate his students creativity enough so that they go out and find the answers themselves." - Herbie Hancock
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"There are no facts, only interpretations." - Nietzsche
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"An education isn't how much you have committed to memory, or even how much you know. It's being able to differentiate between what you do know and what you don't." - Anatole France
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"In character, in manner, in style, in all things, the supreme excellence is simplicity." - Henry Wadsworth Longfellow ====
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Just to be sure – an ER slippery slope
29 Oct2009
Both Kevin and Gruntdoc have weighed in on this article
Incentives promote unnecessary, excessive tests in the ER – Kevin
Reviewing the Great ER Caper: Just to be sure.
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.
I wish this story – A Battery Of Tests. For What?
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.
The author, a medical professor emeritus, tells a tale of too much care. I wish this was an unusual story. Unfortunately, we see such stories too often.
How should we blame? Medical “educators” are partly to blame. Too many academic attendings order tests just to be sure. We need more teachers who ask the important questions. Why order that test? What could we learn that would change anything? How could a consult help us?
GruntDoc very fairly looks at this issue from an ER perspective, but this is not just an ER problem. We have the same problem in the hospital. I encourage everyone to read both blog posts and the Washington Post article. If we are serious about decreasing health care costs we should pay attention to the lessons we can learn from this story.
Related posts:
- One more thought on rationing
- False positives – from 6 years ago
- How slippery is this slope?
- Beware the slippery slope
- How do patients define quality physicians?
Related posts brought to you by Yet Another Related Posts Plugin.
- In: Medical Rants
9 Responses to Just to be sure – an ER slippery slope
cory
October 29th, 2009 at 7:30 am
Good story. Important, but let me throw a wrench in to it.
The doctor got too many tests/consultations but how often do we see the exact opposite, a key test not performed?
And was the ophtho consult really wrong?
And what are the indications for for an MRI in this situation?
And why did specialists, presumably more knowledgeable ask for tests that are (probably) not indicated?
I submit the answer to these questions is a little more complex than the analysis we saw in the posts.
My problem is with the patient’s conclusion in the WaPo:
“The only way is an approach to health-care reform that encourages well-coordinated, standard-of-care practice and simultaneously discourages the irrational, shotgun approach to medicine.”
Standard of care, legally, doesn’t tell you what to do, it outlines a spectrum of care that one should fall within.
I will guarantee you that won’t fix the problem (you would think that neurologist would know the standard of care).
I don’t know what the indications are for an optho consult, a neuro consult or an MRI in (presumably trigeminal neuralgia) and I doubt we have the study today that answers any of those questions definitively. The literature is only a guideline- we need educated, experienced physicians to augment that.
Perhaps we need more medical education and debate between and among specialists and primary care givers on when to do things and when we might wait and what to do and why. Again, more of a return to patient oriented medicine.
My point: Don’t throw the studies away, continue to do them but learn what they tell us and what they don’t and where experience and knowledge inform us what to do and why.
med student
October 29th, 2009 at 3:38 pm
What about the JCAHO “bundles?” Seems like we’re encouraged to order tests regardless of clinical judgment on a regular basis. In addition, it is possible for a hospital to boost its JCAHO compliance scores by censoring what goes into the chart to avoid getting dinged by JCAHO for what may be reasonable guideline violations in a given circumstance. This behavior may not be pervasive, but I imagine it one day will be because it directly affects hospital survival.
Even when the JCAHO requirements improve patient care and outcomes, they encourage the mentality that we should blindly order tests and follow certain practices to comply with standard rules (or to cover our proverbial rear ends) — even if we’d probably forgo some of these invasive or expensive tests ourselves or in a family member.
I’d greatly appreciate hearing your thoughts about why I’m wrong about this. I love medicine and caring for patients and I want to do what is best for them, but the thought of practicing in this way makes me want to find a better way.
Hal Dall,MD
October 29th, 2009 at 4:09 pm
Excellent post once again, thank you.
“What could we learn that would change anything? How could a consult help us?”…the $9000 questions.
To Cory:
“Standard of care” has lost its original meaning and value in this litigious age. If 999/1000 doctors order an unneeded Coverglutealogist Consult, the 1/1000 fails to perform “standard of care” and dons a legal hospital gown for any unrelated complication.
“why did specialists, presumably more knowledgeable ask for tests that are (probably) not indicated?” Neurologists usually consider an MRI part of the neuro exam, see above.
The whole episode, repeated thousands of times a day in US medicine, results from replacing thinking with rote functioning and fear.
cory
October 29th, 2009 at 9:26 pm
Hal:
In reverse order:
I agree with your last point completely.
Your second point- “neurologists consider MRI part of the neuro exam”. I’d like to hear from some neurologists on that- I doubt it’s true but for the sake of argument consider for a moment that neurologists think we should be getting more MRI’s. Why do they think that? Money? Covering themselves? More diagnoses because of the limitation of the neuro exam?
I mean if they have a good reason, should we be looking at bringing down the cost of the procedure. And if they don’t, where are their leaders saying this is wrong?
First point- sorry I can’t go with you there. If 999 out of 1000 get the consult, it’s the standard of care, doesn’t matter what the reason is. It may not even be right but all things being equal the onus would be on the 1 out of 1000 to show the others are wrong. I’m not saying it couldn’t happen but in any profession 1 out of 1000 doing it differently is more likely to be wrong than right. You make a point of an “unrelated” complication. If your defense team is even barely adequate the fact you did what 999 out of 1000 would do and the complication was unrelated, you will have an extremely strong defense. The guy I’d worry about is the 1 out of 1000 who doesn’t do it and suffers a “related” complication.
Hal Dall, MD
October 30th, 2009 at 1:31 am
Cory:
First, I was being facetious about neurologists, kinda. For many the shoe fits.
Regarding standard of care:
“If 999 out of 1000 get the consult, it’s the standard of care, doesn’t matter what the reason is”
Exactly.
The reason should matter. The reason should not be (for example) laziness, fear or greed.
The consult or test should be ordered as necessary for the patient. Consults and tests are not without complications, ambiguities or errors.
The original article describes an MRI overread leading to significant ionizing radiation with potentially nephrotoxic contrast. There was also some risk of incorrect diagnosis whereby he might not have received correct treatment.
I would not dare question the multiple test/consult/procedure automaton approach if it always gave the correct answer without risk. I have (more than once) followed that path to the wrong diagnosis and to the detriment of my patient.
cory
October 30th, 2009 at 8:37 am
Regarding standard of care:
“If 999 out of 1000 get the consult, it’s the standard of care, doesn’t matter what the reason is”
Exactly.
The reason should matter. The reason should not be (for example) laziness, fear or greed.
The consult or test should be ordered as necessary for the patient. Consults and tests are not without complications, ambiguities or errors.
This is a beautiful point. And you know what? Surprisingly most lawyers I know would acknowledge it. The standard of care isn’t always the best care. The problem is it is the only thing they have to work with.
Think about it, what else can they do in front of a judge and jury? Both sides, defense and plaintiffs.
Standard of care is all they can argue, even if it is done for the wrong reason in our eyes (it’s basically what a reasonable practitioner would do).
How do you change the standard of care ? By getting a lot fewer of those 999 to stop doing that stuff if they are doing it for the wrong reason. And there are several ways you can do that. Studies that demonstrate there are better ways, consensus in the medical community or even just a healthy debate in the medical community -but I fear that what is being proposed will be the exact opposite- fewer debates and studies that look at immediate rather than overall costs (if one CT out of 100 saves a subdural, then the cost is not the cost of 100 CTs, it’s that cost minus the savings of the one subdural -to say nothing of the saved patient). In my experience, and I may be wrong, EBM is discouraging that kind of approach.
(by the way in this particular case, a little bit of reading suggests the optho consult was probably appropriate given the high complication rate – it’s that neuro/MRI that looks a little funny. I wonder fi they did a conference on it).
So on the overall point we agree.
Michael Kirsch, M.D.
October 30th, 2009 at 2:10 pm
Here’s a ‘Whistleblower’ that generated more white heat than any other posting. http://bit.ly/exk8R
“How much unnecessary testing goes on in the ER?”
November 5th, 2009 at 10:05 am
[...] Monthly, White Coat, WSJ Law Blog] Relatedly: “Just to be sure: an ER slippery slope” [MedRants, WhiteCoat] And yesterday, from the [...]
WhiteCoat
November 5th, 2009 at 12:23 pm
Standards of care rarely result in a 999 to 1 ratio. What about a practice in which 60% of docs think an action should be taken while 40% of docs think it should not be taken? What's the "standard of care" then?
Unfortunately, the "standard of care" can amount to one doc in court that is testifying against the practices of the other 999. Jurors have little way of knowing which side of the coin the other 998 non-testifying practitioners would act. To them, it looks like a 50/50 case because other witnesses with the same opinions are excluded based on "cumulativeness."
Old saying in neurology: "A squirt of dye is worth a roomful of neurologists." In other words, at the time, a cerebral angiogram could give you more information than a bunch of educated opinions. Now that the MRI is the test of choice, perhaps we should update the saying to reflect Teslas or some other magneto-measurement.
Problem is that the practice of defensive medicine is so pervasive that the line between "doing what is best for the patient" and covering one's buttocks has been blurred. Those who engage in critical thinking about the pros and cons of performing a test get dragged through a lengthy trial if the patient suffers a bad outcome while those with little critical thought processes who just order the testing or consult are regarded as "good" physicians regardless of the utility of the testing.
Easiest way to solve the problem is to involve the patient in the decisionmaking process. "You have an "X" chance of having the disease process that we are testing for. Would you like to go with the treatment plan I recommend or would you like to do confirmatory testing which will cost you "$Y" more in out of pocket expenses?"