Posts Tagged hindsight

It’s All Excessive Medical Care In Hindsight

An 18th Century Diviner, courtesy Wikimedia Commons

An 18th Century Diviner, courtesy Wikimedia Commons

Buckle your seatbelts, kids, it’s going to be a bumpy ride.

In yet another installment of “emergency physicians don’t know what they’re doing,” KevinMD provides a guest post by gastroenterologist Michael Kirsch, entitled Does the bulk of excessive medical care happen in the ER? At its best, the piece is uninformed; at its worst, it’s insulting and unprofessional.

So let me answer you here, Dr. Kirsch: No, it doesn’t.

Read this beauty from the author (I guarantee he has not practiced in an emergency department (yes, department) since residency):

These unneeded medical tests and treatments are black and white, not gray. It occurs every day in every doctor’s office, including mine. The most dramatic example of it, however, is the care rendered in our emergency rooms. The volume and expense of care given there routinely is absolutely astonishing. It is wasting a fortune of money and exposing patients to the risks and anxieties of extensive testing, even for minor medical conditions. Whenever one of my patients sees me in the office to review a recent ER visit, I try to disguise my amazement, as I look through all the lab results, x-ray reports, CAT scan interpretations and EKG tracings – often performed for some innocent complaint that has already resolved on its own.

The clencher, of course, is my bolded text for emphasis. Remove the retrospectoscope, Dr. Kirsch. It’s daylight out! If you’ve figured out how to divine “minor medical conditions” and “innocent complaints” from badness, boy, you should be writing our textbooks, because we dumb emergency physicians can’t!

Yes, the epigastric pain is just innocent GERD after it gets better and the patient doesn’t deteriorate (hint: sometimes it’s an appy, like I diagnosed just last week!). Unfortunately, according to a Lancet study, 7% of patients with ischemic chest pain actually felt better after a GI cocktail. I’ve seen patients with tender abdomens with no other complaints who have STEMIs. I’ve also seen sharp, right-sided tender chest wall pain with an NSTEMI. We all have.

In the Emergency Department, I lack the benefit of knowing my patients. I often do not have the luxury of knowing their medical problems or medications, as they themselves often do not know them; I often have patients who cannot provide history to me; I often have patients who only have non-specific complaints: “weakness.”

I probably do order more tests than your average internist, but two points: don’t you think there’s a referral bias toward emergencies in a patient presenting to the emergency department? And two, how much of adult medicine is a waste? The vast majority of antibiotics for upper respiratory infections are prescribed by primary care physicians, not emergency ones. And we could certainly find an easy whipping boy in the PSA, which is ordered routinely across the country, yet where’s the data behind it? Apparently there’s no risks or anxieties to ordering cancer screening tests (many of which have a ton of false positives).

ER physicians should practice the same style of medicine that we all were taught to do during our medical training. Take a thorough history, perform an examination and then make appropriate recommendations. As a gastroenterologist, I see patients with chest burning in my office several times a week. The medical history allows me to determine if the chest discomfort is innocent or suspicious.

So you’re a gastroenterologist and you see chest burning. So, yeah, with your gigantic referral bias, most of your patients with chest burning probably do have GERD. I take all comers: the rich, the poor, those with a great primary care doctor and those who haven’t said a word to a physician in 20 years. And it’s now up to me to determine if this chest burning is of a concerning nature. (And by the way, the more we’re (we being emergency physicians) learning about acute coronary syndrome, the more we’re recognizing that the classic “crushing chest pain” is just as atypical as “atypical” symptoms of shortness of breath, abdominal pain, or weakness, especially in women or the elderly.) And what if it’s suspicious? What’s the “appropriate recommendation?” Go see your cardiologist? Go back to your primary care doctor? Get a stress test with a 70-80% sensitivity (thereby missing 20-30% of patients with significant coronary disease)?

The recommendation, of course, is simple. According to Dr. Kirsch’s office (which I just called), here it is: “If this is a life-threatening emergency, hang up and dial 911.” To be taken by an ambulance — likely under the direction of an emergency physician — to be evaluated by … an emergency physician.

If an ER physician, or any doctor, thinks his patient’s abdominal discomfort is from constipation, then treat it accordingly and arrange for proper follow-up in the office.

Uh, trust me, we do. I disimpact with the best of them and give enemas when appropriate. But when it’s an elderly patient with a chief complaint of “constipation,” you better be damn well sure of your diagnosis: abdominal pain in the elderly has a 10% mortality rate. And they’re also classic for having 5-7 days of abdominal pain that turns out to be an appendicitis. Funny how they present like that. (Also: “follow-up in the office?” How about our 45 million uninsured patients who lack an “office” to follow-up in?)

Let’s play a numbers game, too.

  • Emergency care costs less than 3% of the nation’s 2.1 trillion dollar health care expenditures. That’s 63 billion dollars.
  • I don’t know what percentage of care Dr. Kirsch considers excessive, but even if all emergency care is excessive, then that means only 3% of medical care is excessive. (If that’s all, I’d say 97% with a purpose is pretty good!)
  • Using some back of the envelope numbers from the 2002 Journal of Gastroenterology, if today we’re doing 20 million colonoscopies at $1,000 a pop, that’s almost 1% of all health care expenditures, just to put that in some perspective for the GI folks out there. Ahem.
  • I’ll concede one point to Dr. Kirsch: I see a lot of “innocent complaints” in the Emergency Department. It’s our nature, thanks to EMTALA. When EMTALA was passed, we certainly started seeing more patients with non-emergent complaints, but now the two are all mixed together and it’s often difficult to tell them apart. If some other physicians are willing to step in and offload the emergency department of some of our patients with “innocent complaints,” please, go right ahead!

    (I didn’t think so.)

    Until then, we’ll continue having the proud duty of caring for all patients with all complaints all hours of the day.

    It’s really easy for everyone to call bullshit on the Emergency Department (my motto: you’re not getting out of here without a troponin!) when they have the benefit of days, weeks, or even just a few hours of observing the patient. Or some basic labs, or an EKG. But there’s no way in hell I’m going to stop putting the dangerous diagnoses in my differential alongside the more common ones. I’d ask Dr. Kirsch where he’d go if a loved one had, say, a bicycle injury. Would he be satisfied with a history and physical and a quick discharge home with a diagnosis of “contusion?” Of course not. When it’s your loved one, you want the x-ray to rule out the fracture. (As I’ve written before, often the physical exam just isn’t that hot.)

    Until I start critiquing polypectomy skills or demanding an endoscopy outside of normal business hours, it’s probably best that you stick to the GI tract, Dr. Kirsch.

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