Shotgun medicine: An arrow is often better

During my internal medicine rotation, the medical students had the opportunity to attend intern morning report, an interactive teaching session where attending physicians walk the interns through a patient’s story, starting from the moment they hit the door of the emergency room to the final stages of diagnosis and treatment.

After discussing the patient’s symptoms, complaints and past medical history, the attendings always ask the group to think carefully about the evidence they needed — what images and data they may consider collecting –  to support or refute different diseases listed on the differential (a list of conditions that may be responsible for the patient’s illness). Finding a diagnosis is not always an easy task.

Sometimes, it is a work in progress.

One of the most salient lessons I learned from these sessions was the importance of clinical discretion and sequential testing. Medical resources are not infinite, nor are they free or even cheap. Every test run or scan ordered is often accompanied by a hefty price tag. As such, we are encouraged to use clinical evidence to guide decision making. When it comes to pinpointing a diagnosis, we are supposed to order tests to specifically confirm a clinical suspicion, based on the patient’s history and exam findings, in addition to our knowledge of statistical probabilities. We also order tests to collect data that would help us rule out an etiology that would alter the patient’s treatment. It is inappropriate to “shotgun” medical tests just because we are unsure of what’s going on.

Intern morning report was the first time I heard the term “shotgun”used in real life. The first time I heard the term used was on the series premiere of Grey’s Anatomy. In this particular episode, a young girl comes to the hospital with seizures of an unknown origin. As Dr. Burke, the attending surgeon assesses the situation, he instructs Dr. Bailey, his resident, to “shotgun” the patient, who in turn instructs all the interns on the team to run a full battery of tests.

Burke: “So I heard we got a wet fish on dry land?”

Bailey: “Absolutely, Dr. Burke.”

Burke: “Dr. Bailey, I’m gonna shotgun her.”

Bailey: “That means every test in the book, CT, CBC, chem. seven, tox screen, Cristina, you’re on labs, George, patient workups, Meredith, get Katie for a CT, she’s your responsibility now.”

The attendings at UVA urge us not to employ the “shotgun method, “where a physician blindly orders every possible test upfront. Rifling through extraneous data collected without rhyme or reason is not only wasteful, but also can lead to diagnostic confusion and cause the patient more harm than good.

Interestingly, the “shotgun” method is not just a plot device utilized by the creative team at Grey’s Anatomy for dramatic effect. I recently read an article in the New England Journal of Medicine comparing the use of the “shotgun” method to sequential testing.

The article explained that that the art of diagnosis is “… difficult because of its myriad presentations and its overlap with many other clinical syndromes. Sometimes the diagnosis can be made only when all other possibilities have been eliminated. But often some diagnoses are more likely than others. Following a straight line based on the use of all the clinical data — including the findings on physical examination — and the use of probabilistic reasoning may lead to the diagnosis more rapidly and more efficiently than performing multiple tests to exclude a wide variety of diagnoses. In medicine, perhaps, as in hunting, an arrow is often a better weapon than a shotgun.”

Given the current health care climate, I think our patients may thank the upcoming generation of physicians if we sharpen our clinical skills and all try to be a little more like Katniss in the clinic!

Jennifer Adaeze Anyaegbunam is a medical student who blogs at her self-titled site, Jennifer Adaeze AnyaegbunamShe can be reached on Twitter @JenniferAdaeze.  This article originally appeared in The American Resident Project.

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  • http://hautuconsulting.com/ Shane Irving

    Good article… Also reviewing tests/studies completed at other facilities before ordering new tests is a good thing. It may take a little extra time but saving a second CT or other expensive tests is worth it… Although you may have to convince Hospital Administrators of that…

  • medicontheedge

    Never heard the term “shot gun testing”, we use the term “million dollar work-up”… and it is a very common approach in ours and many ED’s. Test them till you find something. And, many “clinical pathways” are just automatically followed, with-out any discretionary fine tuning, as an example, canceling the ECG on the “septic” pathway for a otherwise healthy 14 year old with a raging paronychia. Or doing an ECG on every elderly person who has a simple mechanical fall. Or the admitting Doc upstairs who orders a new battery of tests before even seeing the patient. Oh, the waste and inconvenience for the patient, but Ka Ching for the hospital!

  • Gaspere (Gus) Geraci

    Shotgun, Million Dollar workup, whatever you call it, it’s dictated by the circumstances. Inpatient – getting to a diagnosis quickly in a DRG world is good, bad in a per-diem or fee for service world. (Defining bad in financial terms.) What’s best for the patient should be the defining concept, but that’s not factored into reimbursement, yet. We’re moving there – and Value-Based payment, where we theoretically take into account cost AND what’s best for the patient should override. What we’ve not addressed are the zebras that we get sued for. A deliberative approach to low back pain gets you sued for not getting the MRI day one when the cause of the pain was metastases influences practice.

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