Posts Tagged medical blogosphere

I’m Baaack!

Super Fail Sorry for the long hiatus, faithful one reader remaining. Sorry for the holiday lapse in posting, busy with family and presents and eating and then working and working. But I have a lot of new ideas for the new year, and I’m ready to start ranting again!

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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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My Favorite Emergency Medicine Blogs

In order of me never having mentioned them first:

  • Ten Out Of Ten, my favorite of the list (and okay, I put it first): fairly recent residency graduate blogging experiences from the frustratingly funny to the sad to the everyday (sometimes all three). Recent favorites: the widely read (and if you click one link, click this one) Pain Scale, and Proposition Disposition.
  • My Emergency Medicine Blog: Frequent learning point posts on a variety of subjects, dependent upon what the author has been learning about himself in his daily practice; for example, How long should a person with influenza-like illness stay home from school/work?, complete with references and sources. I actually keep a similar private blog of “things I’ve learned,” but it’s not sourced and would be scared for anyone else to use it (but find it very helpful!)
  • Academic Life in Emergency Medicine, by Michelle Lin, of ACEP News’ “Tips and Tricks” fame. Had the opportunity to meet and work with Michelle while in med school at SF General. What a superstar, and the blog is no different.
  • Emergency Medicine Forum is a blog with each post being a case, the doc’s thought process/differential, workup, and conclusion.
  • GruntDoc was one of the first EM bloggers on the scene. Been in a bit of a lull (as all bloggers seem to reach eventually) and wish he’d post more. Come back, Alan!

Guarantee I’m missing a bunch. Post a comment and I’ll add yours.



Doctoring Like A Lawyer

courtesy wikimedia commons

courtesy wikimedia commons

A bunch of good thoughts, stories, and controversy about malpractice this week that are worth a look:

  1. If you’re not reading Trial of a WhiteCoat, you’re missing out. WhiteCoat’s Call Room, probably my favorite EM blog out there, stuck his neck out by deciding to post his account of his malpractice trial. It’s fascinating, nerve-racking, and well-written. It all starts here, and the next installment looks like it’ll reveal who won the case.
  2. KevinMD features Robert Ricketson, a former neurosurgeon involved in a high profile malpractice case in 2003 where Dr. Ricketson gives his side of the story, minus all the sensationalizing from the media. Not surprisingly, it’s not “evil, reckless neurosurgeon puts patient safety at risk.”
  3. And finally, Stuart Swadron talks about Teaching to the Tort, at an up-and-coming EM blog with a bunch of big names, appropriately named, *ahem*, EM Blog. The point is this: should residents be learning about the latest evidence, and how to, as far as we can tell, best care for patients, when the “classic teaching” says otherwise, because of malpractice concerns? Are academic programs freer to practice in ways that community physicians aren’t? Dr. Swadron gives the example of pretreating children with atropine for intubation: while the “available evidence contradicts” its use (and note: the latest version of Ron Wall’s airway bible does not recommend it), is not using it going to be a red flag in a malpractice case for an expert witness?
    I asked a similar question to several colleagues and was told this: “Do what you think is right and best for your patients. Malpractice cases come down to one expert versus another: yours will support you, and the plaintiff’s will support the plaintiff. Your job is to do right by your patients as well as you can; while our books certainly provide expert guidance and management strategies, Tintinalli is not “the standard of care” for the patient in front of you. You are.”
    I don’t know if “medico-legal” was part of the curriculum 10 years ago, but I certainly feel it today. I know to document, how to communicate with families and patients, and how to discuss medical decision-making. I can’t help but feel some level of angst that not only am I going to make a mistake that will harm someone, but I’m also going to make one that may cost me my personal, professional, and financial lives. I think I’m more of a fatalist about it, and perhaps my generation is the same: I’m going to be sued sometime. It’s out there. Be prepared for it, do your best, but don’t spend all your time worrying about it. Document well, work hard, think and care, but it’ll happen, no matter how perfect you are. Am I wrong?


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The Social Admission Service

courtesy jamesfischer of flickr

courtesy jamesfischer of flickr

Well, as is bound to happen in the medical blogosphere, a minor kerfuffle has erupted in response to Jesse Pines’ piece about a social admission in the WSJ last week.

In one corner, the respected internist, Robert Centor (yes, of the Centor strep criteria fame) complaining about Dr. Pines admitting an uninsured woman for a cancer workup. GruntDoc, another EP blogger, fires back across the bow that Dr. Centor hates EPs, and Dr. Centor writes back, bringing up an interesting point: why are we paying so much for social admissions? Shouldn’t we have some sort of other option for the uninsured–or the social placements altogether?

I definitely don’t want to give any ammunition to the “the uninsured get all the medical care they need” crowd, (partially because it’s simply untrue) but we all certainly admit people for primarily social–not medical–reasons. (This probably would come as a surprise to the majority of the American population, who luckily aren’t reading this blog. And thank you, our tens of readers, for keeping this such a secret.)

If you look at pretty much any disease, under “Disposition” or “Indications for Admission,” there’s always that teensy tiny little caveat of “If the patient cannot care for himself/herself,” or “Expected clinical decline upon discharge.” From the teen with PID who just won’t take the meds or follow-up to the early-demented patient without help at home, you know they’re coming in. It’s kind of like any psych diagnosis: you can be as crazy as you want to be, talking about the demons in the lightbulbs, but as long as it doesn’t affect your ability to function in your life in any way, it ain’t a disorder. The social really does matter in medicine, just like it does in psychiatry.

Probably too late to tack this on to Congress’s health care financing bill, but what the hell: I hereby propose… THE SOCIAL ADMISSION SERVICE. Dr. Centor’s right; we probably shouldn’t be spending an expensive hospital bed on patients who don’t need hospital care, but GruntDoc is right too; we can’t simply turn away people who will get lost in the system or who can’t care for themselves. So we have a social admission service. Maybe it’s a doctor, some social workers, and a case worker–some sort of “comprehensive care team” that understands there may be a few simple medical issues, but the primary issue is placement, emergency Medicaid, or some simple labs tests/imaging/procedure. Quick admit, quick dispo. Maybe they only need vital signs once a day, maybe they can eat their own food. Maybe they don’t even need to stay overnight, if they’re safe going home. We save ourselves (and our country) some money, ourselves and our colleagues some valuable time, and best, of course, help our patients out of a bad situation.

Pipe dream? Maybe. Awful, terrible idea? Certainly possible. But I’d love to hear better ones, different ones, and solutions. No one’s going to deny that our health care system is in trouble–and not just because of the uninsured, or medico-legal liability, or the aging population, or any one thing in particular–and it’s going to take creative ways to fix it. Outside the box.

Today’s hospital system is based on an acute care, acute illness model, while our patients’ diseases have become almost completely chronic. Who knows? Perhaps acknowledging that “Admit/Discharge” is a bit too binary for today’s patient is the answer that we need.

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