Megaworkups

I was reading about Dr. Controlfreak on Nurse K’s blog and it made me think.

Doctors need to listen more to what patients tell them and stop ordering all these tests that have a snowball’s chance in hell of being positive.

If some doctors hear the phrase “chest pain” come out of a patient’s mouth, the patient automatically gets cardiac enzymes, a chest x-ray, an EKG, and admitted for more testing. Forget the fact that there are all these little blisters over the side of the patient’s chest. Forget about the clean cardiac catheterization the patient had 8 months ago. The patient *might* just have a heart attack AND the shingles.
Utter the terms “chest pain” and “trouble breathing” in the same sentence and with some doctors you’re getting a chest CT. It doesn’t matter that you have a cough, runny nose, that the chest pain is burning and only occurs when you cough, or that half the people in town have influenza because they didn’t get their flu shots. Even if bronchitis is the clinical diagnosis, there is still a 0.0001% chance that you could have a pulmonary embolism along with your bronchitis and we don’t want to miss it, because if we do, it may cause you to die and result in a lawsuit against the physician. Some doctors aren’t willing to take even the 1 in 1,000,000 chance that they’ll be sued.

Nurse K’s stories reminded me of a physician I used to work with. He also used to be a “megaworkup” kind of guy. Didn’t really listen to the patient’s histories that much, just checked off boxes on the order sheet and went on to the next patient. Room was always backed up waiting for test results and then he’d sign out a chest pain patient that had been in the ED for 6 hours because the UA wasn’t back … because UTIs are a common cause of chest pain requiring a nitroglycerin drip.

One time a patient came in after being shot in the jaw by Deborah Peel. Dang that woman gets around. Anyway, the patient told the nurse that it was a ricochet, but all the doc heard was “gunshot” and “jaw.” The patient was sitting there calm and talking. There was a small entrance wound just below the corner of the mouth, and there was a small lump you could palpate in the patient’s cheek. No exit wound. He complained of a little jaw pain, but that was it. No other complaints.
Checkboxed orders included CBC, complete metabolic panel, amylase/lipase, alcohol level, urinalysis, urine drug screen, aspirin and tylenol levels, ABG, chest x-ray, c-spine x-ray, and pelvis x-ray, and then CT scans of the head, neck, abdomen, and pelvis.
The tech brought back the cervical spine x-rays and handed them to the doc. He looked at them, saw the bullet in the cervical spine, then put the patient to sleep, intubated the patient through the nose, and  transferred the patient to the closest trauma center for an angiogram and surgery.

The ED got a call from the trauma center several hours later. The “bullet” in the patient’s cervical spine was really just an earring in the patient’s ear. You can see part of it at the arrow on the x-ray. The actual bullet was a fragment lodged in the patient’s cheek – right where everyone felt it. The trauma surgeons left it there as a memento. Oh, and in case you were wondering, the amylase and lipase were normal.

I just thought of this patient because Dr. Megaworkup was so worried about the checkboxes on the order sheet that he missed the simple solution to the problem. In other words, he didn’t see the forest because all the trees got in the way.

There aren’t a lot of people who see anything wrong with doing “more” workups. More testing. More medications. More treatments. Do more for me. That’s all fine until there’s a false-positive test that requires additional follow up testing. Then maybe you have a severe allergic reaction to the contrast. Maybe your biopsy site gets MRSA. Or maybe you get a surgery when you didn’t need one and have a complication from the surgery. Suddenly more isn’t better.

Right now, that’s not how society views medicine. Society discounts the brains of a doctor in lieu of procedures and testing. I can tell you that you do not have a broken ankle with 100% accuracy using the Ottawa Ankle Rules. But if I don’t get the x-ray to prove it to you, I’m an “idiot” and you’ll go somewhere else to get your coveted radiation.

If a doctor doesn’t get every conceivable test on a patient and there is a bad outcome, then the doctor gets smacked with a lawsuit because the doctor didn’t do enough. Unless something changes, more and more patients coming to the emergency department will get megaworkups so nothing gets “missed.”

Then I read that some pompous plaintiff’s attorney said somewhere that “defensive medicine” was a myth. His theory was that if doctors do an extra test that catches a disease while it’s still treatable, then it is “good medicine,” not “defensive medicine.” Either he doesn’t get it because he is ignorant or he doesn’t get it because that attitude helps him afford his chalet in the Swiss Alps.

Medicine will never be perfect.

Some docs order too much because patients and their families expect it. Some docs order too much because they are uncomfortable with their clinical skills. Some docs order too much because they’re afraid of being sued.

I wonder how the practice of medicine would change if a patient successfully sued a physician because the physician ordered too much. Unfortunately, a lawsuit like that would never happen because our society values quantity over quality in medical care.

If we keep up with this “megaworkup” mentality, very soon the system will be drained to the point that society will have neither.