People accuse doctors of not doing enough, or doing too much

Medicine is never an easy field. People accuse doctors of not doing enough, or doing too much.

There are no easy answers. We’re caught between doing what’s best, without putting the patient through too much, and doing what’s needed to protect ourselves from legal action.

Let’s take Mrs. Summer. She’s a nice 78 year-old lady I saw in the office last week.

Earlier this month she hurt her back. So she saw her internist, who correctly diagnosed her with a muscle strain. He gave her a muscle relaxant and Tylenol #3.

A few hours after she took the medications she became confused and sleepy. Her family called Dr. Internist, who said to stop them immediately.

She was absolutely fine the next morning, but her daughter is a nurse at the hospital, and wanted me to have a look at her for the episode. So she called Mary, and they came in last week.

The odds are that all she had was confusion due to Tylenol #3. So do nothing. It’s most likely and least expensive.

But maybe she had a TIA. If I don’t correctly diagnose that, and she has a big stroke, than they could sue me. So let’s order a brain MRI, head & neck MRA, and echocardiogram. That’s a few thousand dollars in tests.

Or maybe she had a seizure, and needs to be started on seizure medications. So lets order an EEG, too. Another $500.

Perhaps it was a metabolic event, with her blood sugar getting too low. So I’ll order some labs. That’ll be another $500-$1000 depending on how much I order.

This is the dilemma your doctor faces each day, many times over. None of us come to work saying “Oh boy! I can’t wait to drive up the cost of health care today!” But we’re faced with finding an (at times) impossible balance.

We don’t get a 2nd chance, either. If we guess wrong we run the risk of getting sued. Another doctor is always willing to make a living as an expert witness and testify that we are incompetent.

And yet, with this sword of Damocles hanging over our heads, I and thousands of other doctors do this every day. And try to do the best we can, within the limits of human fallibility.

Doctor Grumpy is a neurologist who blogs at Doctor Grumpy in the House.

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  • Anonymous

    This reminds me of the DeNiro speech in the movie “Men of Honor”

    “The Navy Diver is not a fighting man, he is a salvage expert. If it is lost underwater, he finds it. If it’s sunk, he brings it up. If it’s in the way, he moves it. If he’s lucky, he will die young, 200 feet beneath the waves, for that is the closest he’ll ever get to being a hero. Hell, I don’t know why anybody’d want to be a Navy diver.”

  • http://twitter.com/davisliumd davisliumd

    That is why you are a doctor.  The nurse is asking someone, who is better trained and an expert, for advice on a loved one.  Who else better would she trust here, but a neurologist?

    Any person can ask if a MRI, work-up for seizure, or other testing is necessary.  In fact, patients ask for more testing for simple things like ankle sprains or migraine headaches.
    http://davisliumd.blogspot.com/2011/07/are-patients-becoming-day-traders.html

    Yet, someone needs to make the call on what is necessary and what is not.

    That is why if the American health care system is to be sustainable, it will require doctors to lead the change.


    Davis Liu, MD

  • Anonymous

       Dr. Grumpy’s “testing” dilemma, with the events and forces
    precipitating it, speaks volumes to two big-time contributors to the cost of
    care:  defensive medicine and the self referral—or, more accurately, referral from a non
    physician.  All physicians were taught in
    medical school that testing should be ordered only for confirming a condition
    or diagnosis— that the physician’s
    clinical history and exam has already led him to be reasonably certain
    exists!  The ability to perform a
    proper history and physical exam, and to process the findings through an extensive
    pathological and physiological knowledge base obtained through years of medical
    school education, is what enables a physician to be highly accurate in arriving
    at the proper diagnosis—and to only need expensive ancillary testing, for
    confirming the diagnosis, in a limited and select number of instances. This
    should be the primary reason for paying high fees in order to be evaluated by a
    physician.  Unfortunately, cultural and
    societal forces today have empowered consumers to demand the practice of
    defensive medicine.  Indeed,  reality suggests that today we have consumers, nursing staff—and hospital
    & nursing home administrations—all able to demand defensive medicine from
    the physician.

         A separate and
    unintended pearl of information contained in Dr. Grumpy’s anecdote was that the
    chain of events was set in motion by a nurse from his hospital.  It is extremely unlikely that, if the individual
    asking him to see this patient under such circumstances, had not been a
    nurse—but rather a primary care MD—that any such request of him would have been made.  After all, the patient being referred had already recieved, from an internist, a perfectly likely diagnosis under the circumstances.  Nurses are an invaluable and integral part of
    the health care team, but they are not interchangeable with physicians—the
    content and volume of their scientific medical formal educations are simply too
    disparate from those of physicians.

       This should give our health care system’s cost-management
    gurus pause for concern, given that the numbers of individuals granted permission
    for ordering pricey drugs and pricey high-tech imaging—but having only nursing
    degrees—are snowballing annually.  —Alan D. Cato MD, F.A.A.F.P. (past) and
    author of The Medical Profession Is Dead
    and the Doctor Is “Critically ill!” (Oct., 2010)

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