A simple panel used by an ER physician to rule out the diseases that may come back to bite you if you miss them:
I have devised a simple, cheap and quick “reassurance work-up” for these folks which consists of:
an ECG, an i-Stat, a D-dimer, and a troponin. Sometimes I add a chest x-ray if it seems helpful.
PCPs I talk to are ordering more D-dimers as well “just in case” that chest pain or shortness of breath in the office turns out to be a PE. However, there are plenty of things that can also elevate the D-dimer, and this invariably leads to more CT scans. Of course, patients are reassured with more testing:
Again, it’s surprising how happy this approach makes people. I get genuine thank-yous and (generally) they leave smiling and reassured. And my patient satisfaction scores stay high and the bed is quickly opened up for the next poor soul languishing in the waiting room.
The joys of defensive medicine.
Related posts:
- Unnecessary workup in the emergency department
- More tests is better medicine: Why the myth is hard to break
- Does your patient really need another chest CT?
- More tests does not mean better medicine
- Do home fetal heart monitors give mothers false reassurance?
- Lung cancer CT screening produces false positives and isn’t ready for prime time
- Are MRI results accurate?
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{ 5 comments }
Who exactly loses in that scenario? The doc is still getting paid, the hospital is still getting [aid, and the patient is satisfied.
If docs don’t like it, why don’t they promulgate some national standards of care that they can adopt?
The real source of defensive medicine is public demand for it. People want a lab number or a picture–clinical judgement is not sufficient. Americans are in love with technology.
Medicine is not an exact science, there are good standards but not for every condition and situation.
For exmple, I had a patient with asthma. She had frequent exacerbations. One day, it was a pulmonary embolism with wheezing and shortness of breath and not her asthma. No risk factors for pulmonary embolism. So, what guidelines should you apply for such a patient ? D dimer in every asthm patient “just in case” ?
Everybody loses in this scenario. The doctor may get paid but is unhappy with his job and on the long run, he becomes a less efficient doctor. the society ends up paying for these useless tests. Because on the long run these tests do not improve life expectancy or life quality in the general population.
When we talk about “universal coverage”, we have to understand that this kind of medicine and these kind of expectations have to stop in a universal coverage system. Otherwise, the system will go bankrupt very fast. We would have to be much more frugal with testing, in order to offer basic coverage for everybody.
“The real source of defensive medicine is public demand for it. People want a lab number or a picture–clinical judgement is not sufficient. Americans are in love with technology.”
So do you ask your patients if they want these tests, or do you just assume they do?
My guess would be that this issue is pretty closely tied to the doctor-patient; if you take the time to build one, the patient is more likely to trust your “clinical judgment”. Limit consults to 5 or fewer minutes and yes, you may have a trust problem.
Anybody remember the PIOPED data? The issue is clinical suspicion. IF you have have a mod-high pretest clinical suspicion then order it. If it is being ordered in the setting of a low clinical suspicion then don’t order it. A D-dimer has it’s uses but it has no purpose on an ER rainbow panel.
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