Healing Our Health Care: Doing Less

Often in Emergency Medicine, we have multiple influences pushing us to do one thing, when we know the other is right for the patient. Part of it might be fear — of lawsuits, of bad outcomes — part of might be a demanding patient who “knows antibiotics always work for me,” part of it might be access to a new CT scanner, so “I might as well check.” But we all know of patients who’ve had one workup, which has led to another, which has led to some complication — a botched cath, a nosocomial infection — and you can’t help but wonder what if that workup had never been done, and was it really necessary in the first place? What if we were just chasing our tails with incidentalomas? What was our pre-test probability before the test, and even if the test is positive, how much did it really increase our post-test probability, anyway?

We’re in a tough place in the Emergency Department. People have come to us for evaluation, and our job is to Rule Out Badness ™. They’re in the Emergency Department, so we need to make sure they’re not having an emergency. Sometimes, however, I wonder if many patients weren’t better served at a walk-in clinic instead of a walk-in ED, where the mere lack of access to instant lab results and imaging studies might make for a better course of action (combined with watchful waiting as the workup progresses over days to weeks).

In last month’s EMRAP (2 hours of Emergency Medicine I look forward to every month), Jerry Hoffman, NEXUS Criteria creator and EP at UCLA-Oliveview talks about how he approaches these influences, and I think it’s absolutely worth 3 minutes and 53 seconds of your day:

[wpaudio url=”http://thecentralline.org/wp-content/uploads/2009/08/jerryhoffman-doless.mp3″]

(Thanks to Jerry and Mel Herbert of EMRAP for their permission to use this clip!)

Sometimes Jerry’s methods don’t work — but for most people, most of the time, they will. Sure, it’s easier to write the script for cough medicines or order the CT scan than have a discussion, “teaching moment” or even argument with a patient or his parent — but if the two minute discussion saves the patient from a medication side effect they may come back for, or allows us a faster discharge with less brain radiation, then it’s probably worth it for both doctor and patient, right?

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  1. #1 by Surgery - August 14th, 2009 at 14:32

    Preventing is better!

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