by Edwin Leap, MD
It happens over and over. I call a surgeon about a patient with abdominal pain.
‘Well, what’s the white count?’
‘Normal.’
‘Did you get a CT Scan?’
‘Yes, and it was normal. But they just look uncomfortable.’
‘Sounds like nothing for me to do. Call the hospitalist.’
It happens in other specialties. Cardiologists who aren’t interested in a patient with a normal stress test, pediatricians unimpressed with negative chest x-rays and normal labs. ENT’s unconcerned if the neck CT is clear.
Maybe, just maybe, they’re right! Maybe medicine can be reduced to that place; if the test is negative, the physician is unnecessary. Well, the other physician. The important physician, not the emergency medicine doc. We always have to examine the patient. We, the voice-activated, robotic, perpetual residents for every specialty, actually have to lay our hands on the sick.
I know, I know, medicine is different now. Technology is a great asset. And I can’t expect every physician to come to the ER whenever I call, just to examine someone with ‘normal’ labs, X-rays or CT scans. But what does normal mean?
How many terribly ill patients have I seen with normal white counts? How many sick patients, with ischemic bowel, have had normal CT scans? How many MI patients recently had normal EKG’s and stress tests?
What I’m saying is this; medicine is more than tests! Please, my brothers and sisters, my colleagues of other specialties, don’t surrender all of your education and skill to the test! I try never to call for help; it’s too much trouble. Even family medicine residents balk. ‘What am I going to do?’ Hospitalists hedge; ‘I know they can’t walk, but what can we do in the hospital?’
But please realize, if I call, I really want your help. I probably think there’s a genuine problem. And your help doesn’t consist of informing me what I already know. ‘The test is negative.’ I know that. But the patient is still concerning. Please, act like physicians!
We have made medicine into a series of check-boxes. Enough positive boxes and some other physician might get interested. But humans aren’t like that. Humans fool us; they ignore the boxes. And suddenly, they die without warning.
Do we want to remain a valuable profession? Do we want to continue to treat the sick and be trusted? Do we consider our brains, ears and hands, eyes and even noses to be critical assets in our assessment of the sick?
Or do we just need some scanners and automated phlebotomy machines to evaluate every sick person, and let us know if we’re needed?
I hope not. I like seeing and talking to my patients. Maybe I’m just not bold enough to make every decision by phone, and based on objective data of questionable utility.
I hope I’m never that bold.
Edwin Leap is an emergency physician who blogs at edwinleap.com.
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- Will technology kill health care?
- Op-ed: Wasted medical dollars
{ 13 comments }
In nursing school, 23yrs ago, we learned to ” go with your gut feeling” No amount of technology or machinery can ever replace the instincts and feelings a medical professional has when assessing a patient.
While not all of the technology has resulted in a normal result, it has not lead to a diagnosis. Without a diagnosis, there is no treatment. I am discarded.
A well designed computer program could do a better job of differential diagnosis than the doctors I have seen.
This post goes hand in hand with the one about patients’ expectations for every test imaginable. Personally, I’m eagerly awaiting Dr. Leonard McCoy’s Tri-Corder. Faster, Please.
what do the guidelines say to do in these situations?
No. Doctors are making doctors less relevant.
Underutilizing clinical skills and delegating elements of the doctor-patient relationship to others.
Cudos, Doc 99.
A Star Trek reference – and the original doc too – sweet!
The real problem is many of these patients do not belong in the ER. They used to go to their family doctors, the ones that know them well, and who could frequently and efficiently sort the ” wheat from the chaff” and only send the sick to the Hospital ( direct admit) or the unstable to the ER. Now everyone gets sent to the ER ( the primary docs in the trenches don’t have the time to sort through the issues), and the ER does exacty what the ER does, test and image. Then after the myriad of frequently irrelevant labs and radiologic studies come back with a few ” abnormal ” results ( ie. beyond the 2 standard deviations from the mean, ” possible infiltrate in right lower lobe, recommend CT scan to further define”) the ER MD calls the surgeon, hospitalist, cardiologist , etc. to admit the patient for the abnormal findings that frequently have nothing to do with the real problem, which usually resolves with “tincture of time ” and more testing to verify that if you run enough lab tests eventually reversion to the mean occurs. It is not the ER MD’s fault, they are trained to handle genuine emergencies and they do that well. The problem is we have shifted the evaluation of chronic problems to the ER setting and the results are entirely predictable. I know because as a Hospitalist I am asked to admit these patients every day. I would guess that fully 30% of these patients, after study, have no real serious acute issue that would not resolve on its own with enought time and just general care. The problem is no one knows them well enough to make this judgement at the time they are seen in the ER ( eg. the twelfth time they have complained about chest pain to their PCP this year, with multiple negative studies and an unchanged EKG- do they really need to come in for a rule out? Only their PCP may know them well enough to make this clinical judgement) and we can’t assume that the outpatient providers will be able to follow up since the reason the patient came to the ER in the first place is the primary couldn’t see them in the office in a timely fashion. Until you fix the access to good primary care the ER will continue to be frequented by the old, chronically ill, for their non acute issues ( masked as acute complaints). This is not to say that acute issues don’t occur, they do, but our ER’s are becoming the de facto primary care clinics for many patients. With respect to the elderly that ” can’t walk”, we are reluctant to admit because they frequently don’t meet Medicare admission criteria ( the ones with completely normal neuro exams and multiple negative studies) and we have no good “exit strategy”. Unlike the ER MD we have to listen to the daily complaints of the family members about how poorly they are being cared for by staff, how terrible medicare is for not paying for rehab/nursing home care, and why is their loved one confused and agitated in the Hospital? After all they were fine before they came in. You just pray they don’t fall out of bed ( a ” never event” per Medicare) and break a hip. The ” system” we have built is entirely predictable if you examine the incentives to all involved.
Weak and dizzy’s post is superb. It should be read several times. ER docs, patients and society in general are victims of the PCP shortage. A lot of these pts could be easily managed in the regular doc’s office, except that the regular doc is either unavailable or does not exist. ” Oh yeah, Mrs. Jones has been complaining of passing out after dinner for 20 years. No big deal. ” The problem is clear, but the solution is elusive.
If you want my help to reassess a patient or need a second “set of eyes” to re-think a case, I will be there directly.
When the Emergency Department is calling Medicine as the disposition of last resort for a patient who doesn’t want to go home or because it’s 2:00 AM, I may be less inclined to jump all over that.
Emergency Medicine physicians are often placed in a terrible situation: the patient’s homelessness, substance abuse, unfunded status, or lack of citizenship may make it difficult to arrange the optimal disposition home from the Emergency Department; however, if one of the above listed aspects of the patient’s chronic status is the main reason that admission to the hospital is being requested, then I likely will in fact point out that one or several days in the hospital will not change this particular aspect of the patient’s life, and that the difficulty of the disposition is merely being passed to another physician.
Call me when you’re worried, or when you’re unsure — I am happy to lend a hand. It’s when the call begins with “I’m really sorry about this, but…” that we hospitalists tend to grumble just a bit.
I’m not sure if I have the Greek right.
Diagnosis is two people coming to knowledge.
Dia – gnosis .
Meaning the doctor and the patient both coming to understand.
Do I have the etymology correct?
The TriCorder that McCoy waved over the patient. As I recall, it was a salt shaker they painted and put little lights on top of it.
We forget how low-budget the original Star Trek was.
Continuing small-town roots, the Mayberry set was across the street from the Star Trek set, so when they needed Earth-type exteriors for a scene, you got to see the Mayberry buildings in the 24th or whatever it was, century.
Docs need to go back to being docs if they haven’t already. Technology enhances this. If you want to be a glorified clerk, follow your algorithms and check your boxes: pretty soon, Clinical Decision Support Systems will be able to do that better than you. If you want to use personalized clinical judgment, embrace patient-centered medicine, rely on your exam skills where indicated, and really dig beyond chasing numbers to solve problems. This will ensure medicine retains its value, cost-effectiveness and not a commodity to be outsourced.
I recently edited an inpatient history and physical report produced using our hospital’s state-of-the-art voice recognition software before it uploaded to our multimillion dollar EMR. Instead of transcribing the attending physician’s name as dictated, it inserted the name, “Dr. Computer” in its place. Ironic isn’t it?
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