Tuesday, August 29, 2006
You can't test everyone for West Nile
Apparently some doctors "have to be prompted" to test:Lisa, who declined to give her last name for privacy reasons, said her physician thought her symptoms were typical of the virus that causes mononucleosis, and only tested for West Nile when she prompted him to do so.
Dr. Henry Lim, who operates a family practice on the Mountain, said he did not initially recognize the symptoms despite having seen a case of West Nile virus a couple years ago.
"It's a very difficult diagnosis to make. You don't want to test everybody who comes in with a cold," Lim said in a telephone interview. "Other doctors are missing it too."
Posted by Kevin |
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Comments:
No, you can't test everyone but a little bit of common sense and knowledge can go a long way.
I note that this article is from a Canadian newspaper. WNV has been slower to spread through Canada than it has in the United States; the overall incidence of WNV has also been lower in Canada. OTOH, some states such as Colorado have been hit quite hard with WNV, so the index of suspicion needs to be higher when a patient presents in Colorado with these symptoms.
Rather than just flinging up our hands and saying, "Well, gee, we can't test everyone," why not develop a list of criteria? Such as sx, potential exposure, regional prevalance of WNV and so on.
One of the functions of testing is to maintain public health surveillance. The majority of people infected with WNV do not develop life-threatening problems, hence these cases can be missed when reasonable testing is not done, and the opportunity to gain an accurate picture of the prevalence of WNV is lost.
I note that this article is from a Canadian newspaper. WNV has been slower to spread through Canada than it has in the United States; the overall incidence of WNV has also been lower in Canada. OTOH, some states such as Colorado have been hit quite hard with WNV, so the index of suspicion needs to be higher when a patient presents in Colorado with these symptoms.
Rather than just flinging up our hands and saying, "Well, gee, we can't test everyone," why not develop a list of criteria? Such as sx, potential exposure, regional prevalance of WNV and so on.
One of the functions of testing is to maintain public health surveillance. The majority of people infected with WNV do not develop life-threatening problems, hence these cases can be missed when reasonable testing is not done, and the opportunity to gain an accurate picture of the prevalence of WNV is lost.
# posted by 
: 2:35 PM
: 2:35 PM
And for her troubles what did testing produce?
The most important conditions to have a high index of suspicious and to pursue aggresive confirmatory testing are things that are both serious and have some available remedy. In the case of West Nile, it is most often mild and self limited; no specific therapy is indicated but to treat symptomatically any complications that result. Knowing that a patient with flu like symptoms in fact has West Nile provides no health care benefit; you might have significant encephalitis, but there is nothing to do but go home and let things run their course. If health deteriorates later then supportive care for whatever organ or organs affected can be instituted.
Failing to diagnose West Nile is a non-failure.
The prevelance benefit cited in the above post is largely irrelevant in the case of the patients presenting to physicians offices. This is a self selected sample that contains only a small portion of those who actually contract West Nile. Unless random population based sampling is done for epidemiologic surveylance, there is no meaningful picture of the prevalence of West Nile infection.
The most important conditions to have a high index of suspicious and to pursue aggresive confirmatory testing are things that are both serious and have some available remedy. In the case of West Nile, it is most often mild and self limited; no specific therapy is indicated but to treat symptomatically any complications that result. Knowing that a patient with flu like symptoms in fact has West Nile provides no health care benefit; you might have significant encephalitis, but there is nothing to do but go home and let things run their course. If health deteriorates later then supportive care for whatever organ or organs affected can be instituted.
Failing to diagnose West Nile is a non-failure.
The prevelance benefit cited in the above post is largely irrelevant in the case of the patients presenting to physicians offices. This is a self selected sample that contains only a small portion of those who actually contract West Nile. Unless random population based sampling is done for epidemiologic surveylance, there is no meaningful picture of the prevalence of West Nile infection.
You can give her TID amoxicillin for the "bug" just to "nip it in the bud", that way when the patient dies at least "we did everything we could" and the lawyers have to put in back in their pants.
# posted by : 8:46 PM
: 8:46 PM
"Rather than just flinging up our hands and saying, "Well, gee, we can't test everyone," why not develop a list of criteria? Such as sx, potential exposure, regional prevalance of WNV and so on."
Problem is, that wont help at all with legal liability. Lawyers love to get hired gun whore "experts" who testify that the "criteria" are wrong and can not be trusted.
This is exactly what happened with ACOG and CP lawsuits. ACOG published a list of criteria for "standard of practice" regarding preventing CP during difficult deliveries. The lawyer cadre found a lone wolf "expert" who disagreed with the criteria and they've been winning lawsuits against doctors who followed the criteria for years.
Criteria for standard of practice defined by professional organizations are just as easy for lawyers to get around as those pesky written contracts that are supposed to be legally binding.
Problem is, that wont help at all with legal liability. Lawyers love to get hired gun whore "experts" who testify that the "criteria" are wrong and can not be trusted.
This is exactly what happened with ACOG and CP lawsuits. ACOG published a list of criteria for "standard of practice" regarding preventing CP during difficult deliveries. The lawyer cadre found a lone wolf "expert" who disagreed with the criteria and they've been winning lawsuits against doctors who followed the criteria for years.
Criteria for standard of practice defined by professional organizations are just as easy for lawyers to get around as those pesky written contracts that are supposed to be legally binding.
# posted by : 9:26 PM
: 9:26 PM
As Gasman says, there is no treatment for West Nile virus.
Therefore Lisa only added expense without benefit, apparently for bragging rights about having WNV.
Therefore Lisa only added expense without benefit, apparently for bragging rights about having WNV.
If it was like any other business. The price should be posted then the patient could decide whether to get it. Everyone wants useless, clinically irrelevent "tests" as long as they aren't paying for it.
# posted by : 10:26 PM
: 10:26 PM
I just wanted to say that I'm not surprised at all - I used to be a patient of Dr. Lim.
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# posted by : 10:30 AM
: 10:30 AM
