Thursday, October 10, 2013

Have Physicians Lost Their Backbone?

What ever happened to courage?

Jim came through the choleycystectomy beautifully. In fact, he did so well that in no time he was back on the basketball court. Three weeks later he was in my office with a sore, swollen leg. He thought it was from twisting his ankle the day before. And indeed, it had all the appearances of a sports injury. I examined the extremity carefully, and decided to get a venous doppler to evaluate for DVT given the recent surgery.

My suspicions were confirmed when the technician called to tell me that he had found a clot in the deep veins of the thigh. Shortly after hanging up, my phone started to ring again. Jim was calling on his mobile. He was having chest pain when taking deep breaths, and his heart was racing. He was struggling to catch his breath. Certain that he was having a pulmonary embolism, I instructed him to walk down the stairs from the doppler suite to the emergency room.

I phoned ahead and talked to the ER doc on shift for the evening. I let him know of the positive study and my suspicion of a pulmonary embolism. We needed to start anticoagulation and admit overnight. He informed me that the ER was full, and likely it would be late evening before a bed was assigned.

I fell asleep early, awaiting the call from the floor nurse to give admitting orders. It never came.

I woke up the next morning disoriented and rushed to the hospital. Apparently Jim was accidentally admitted to the hospitalist on call. After reading the chart, I started to feel the blood rise to my forehead. The hospitalist ordered a cat scan of the chest as well as hypercoaguability studies. I was seething.

Why ever would he needlessly expose my patient to the radiation of a cat scan when the diagnosis of a pulmonary embolism was all but certain given the positive lower extremity doppler? And why would anyone order hypercoaguability studies when we had two perfectly good reasons for a clot to form: recent surgery and a sports related injury?

The cat scan showed a pulmonary embolism and the hypercoaguability studies were negative. Duh! I called the hospitalist to ask why he ordered such expensive and possibly dangerous studies on my patient when they weren't necessary. After much bickering back and forth, it became clear that although the diagnosis was certain, he didn't feel comfortable without having proof. The hypercoaguability studies were done "just to be extra careful".

I was pissed!

Now more then ever, in this time of economic upheaval and floundering medical quality, we physicians have to have the courage to practice responsible, parsimonious medicine. We can no longer offer costly or dangerous medical care just to "reassure" ourselves. We have to make the tough decisions.

We must have the courage to not treat minor bronchitis with antibiotics.

We must have the courage to not use narcotics for run of the mill back pain.

We must have the courage to use palliative care and hospice effectively when appropriate.

We spent years developing the knowledge and skill to efficiently and effectively treat our patients in a sound and thoughtful manner.

When will we develop the backbone?


jimbo26 said...

When a hospital is used as a hospital and not a source of income .

Anonymous said...

When you get rid of sue happy patients, the administration earns the same amount as your lowest paid doctor, and when you get people going in and coming out of medical school with common sense.

QuiltDoc said...

You are SO RIGHT Dr. I too have the same frustrations. I had a patient who was pregnant and went to the ER for SOB. She had pain in her BACK with deep breath or certain movements and it was reproducible!! They thank god, could not do a CT on her because she was pregnant. The ER could also not get a doppler done because of some staffing issues. They called me and I told them to check an ABG and if NORMAL then send her home and I would follow up with her the next day. When I spoke with the patient it turns out that she had been washing windows the day before and had caused an osteopathic lesion to her mid thorax. I found it easily, pressed and asked it this was her pain, she said yes. I fixed it and ALL of her pain and and SOB and pain with deep respiration where gone!! It took me less than 5 minutes to get the history, examine her and treat her!! I then patiently explained to her that she did not need the ultrasound, nor did she need the CT Scan. She had no leg symptoms or swelling and with treating her back lesion, she was now completely asymptomatic!! Thank God she was pregnant or a great deal of unnecessary tests would have been done!

Anonymous said...

When physical assessment skills are taught instead of looked up on an iPad; when we are no longer afraid of lawyers & getting reported to the NPDB; when experience is something you actually gain by seeing & doing it instead of reading about it or watching a Youtube video. A patient will tell you what is wrong with them if you take the time to listen.

Anonymous said...

"A patient will tell you what is wrong with them if you take the time to listen." What a profound statement! While I may "only" be an NP, my years as a nurse and EMT have taught me that we must listen to patients. We must listen to their story. We listen with our ears, hands, minds, and intuition. As a wise physician friend taught me, we will screw up, and we should be afraid of that as it helps keep us grounded. But we should always listen to our patients and our gut, as they will always provide more information than tests. Diagnostics should be used to confirm our suspicions and not hunt for the diagnosis.