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Is Bad Medical Care Better Than No Medical Care?

In my past few shifts in the emergency department, I have seen the following patients who were seeking further care after being treated by other providers.

HerpanginaOne was a child who had been seen twice at an urgent care clinic. He had a fever of 103 degrees and wasn’t eating. The first time he went to the urgent care center, he was diagnosed with an ear infection. He was started on amoxicillin and sent home. He returned to the clinic 8 hours later because he still had the fever and still wasn’t eating. When the clinic provider looked in his mouth, he saw a red rash that appeared to be an allergic reaction. He was therefore changed from amoxicillin to Biaxin and started on Benadryl. The parents were concerned that his allergic reaction may get worse, so they left the urgent care clinic and came directly to the emergency department.
When he came to the emergency department, he still had a fever, his ears looked fine, and he had the typical enanthem of herpangina. We stopped the antibiotics, stopped the Benadryl, gave the child some stronger pain medication, and had the parents feed him popsicles and cool liquids.

Extensor Tendon LacerationAnother patient had been in a bar fight several days prior. He had a cut on his knuckle and his knuckle was starting to hurt. He went to another emergency department and saw a provider who washed out the cut, started the patient on amoxicillin, and then put packing in the wound.
When he came to our emergency department, we started IV antibiotics, removed the packing … from the joint … and sent the patient for surgery to clean out the infected joint and to repair the lacerated tendon.

WPW A third patient had been to both an urgent care clinic and an emergency department for evaluation of palpitations. The urgent care clinic diagnosed the patient with anxiety and discharged the patient with a prescription for Xanax. When the Xanax didn’t help and the palpitations were causing worsening shortness of breath, the patient went to an emergency department. There the patient was seen by a provider who performed an EKG and did a drug screen. The patient was told not to drink caffeine and given a refill for Xanax.
When she came to our emergency department, an EKG showed Wolff Parkinson White syndrome. We got a copy of the EKG from the prior hospital and it showed the same thing. Their EKG even said “Ventricular pre-excitation, WPW pattern” on it.

Sigmoid VolvulusFinally was the patient in his 70s who was seen at another emergency department for evaluation of abdominal pain and no bowel movement for a couple of days. He had some lab tests done and the provider performed a rectal exam which showed that he had a lot of soft stool in his colon. So the patient received an enema and was discharged home with a diagnosis of constipation. He was told to take laxatives and eat more fiber.
When he came to our emergency department by ambulance later that evening because he vomited the Milk of Magnesia, his abdomen was swollen and tympanitic. He had low blood pressure, no bowel sounds, and a sigmoid volvulus with an obstruction on x-ray. He also went straight to surgery.

I understand that it is considered bad form to question the care of other practitioners. If another provider’s care is criticized, often the criticisms are met with allegations of elitism and hindsight bias followed by a plethora of anecdotes about how those commenting were able to catch some other provider’s mistakes.
You don’t know which patients, if any, were seen by physicians and which patients, if any, were seen by NPs or PAs or medical students. So step back and look at the bigger picture.

In each of the cases above, a patient required multiple medical visits to diagnose and/or treat a problem that should have been apparent on the initial examination. In at least one of the cases, a patient probably had a worse outcome from the initial treatment rendered. Perhaps some people will disagree with me on one case or another. Fine. Assume I’m right.

Providers who may not be as adept at picking out subtle (or not so subtle) findings on a patient’s physical exam and who may provide less than adequate medical care are more commonly being placed in positions of first contact with patients. 57% of all Italians fear being harmed by physicians and 44% disapprove of their national health care system. In the wake of Obamacare, should patients adopt more of a “caveat emptor” approach toward health care?

Pick whatever definition of “bad” that you want. Is bad medical care better than no medical care at all?

If a problem exists, how do we fix it?

24 comments

  1. “Bad” medical care is worse than no care at all. At least with no care, you know what’s been done: nothing.

    Facilities and practitioners should be graded based on quality of services, and their prices posted like restaurants in the lobby. It should include the price for cash self-pay.
    Which should be posted right next to that quality grade.

    (And such rating shouldn’t be done by JCAHO et al, who couldn’t find their @$$ with both hands, a mirror, and an anatomical chart. Any entity that doesn’t show a bell-curve distribution of ratings is de facto rigged, or they’ve set the ratings bar far too low.)

    Everybody “in the biz” knows not to go to Dr. X, Hospital Y, or Clinic Z, because their practice model is medieval, documented anecdotally time after time. A Lake Woebegone model, where all the facilities and practitioners are above-average, is B.S. No one is perfect. Some persons, or facilities are above average, and some are below average.

    Reimbursement by third parties should accept meeting the baseline of care at 80% as a multiplier of 1.00 for payment. Lower scores would be less than scale, and above average to outstanding would be reimbursed above-scale.
    Thus patients could choose above-average facilities, but they’d hit their benefit caps faster.
    And average facilities would either get compensated commensurately to their quality by people willing to settle for chops and hamburger instead of steak filet, while truly sub-standard facilities would live on far less, or go broke/out of business. Boo hoo.
    And the above-average facilities and practitioners would be compensated commensurate to their skill and diligence in providing care.

    We could also stop handing out admissions to medical/PA/nursing/etc. schools and programs based on EEOC preferences. I can’t count the number of times I’ve seen a new crop of residents or nursing school grad photos that looks like a rainbow coalition. If I’m the guy on the gurney, I could give a flying f*** what color my caregiver is, I just want him or her to have clawed their way to the top of the medical food chain through naked competence and unfailing skill.

    Actual performance and intelligence might, in the interim, be a far better solution to explore for admissions, and compensation based on documented competence wouldn’t go amiss either.

    • I agree with you about pricing transparency, but I’ve stated multiple times that trying to find an objective measurement of “quality” is impossible.
      I think that it’s fine to let market forces take over, but remember that medicine isn’t a free market. Hospitals are forced to provide stabilizing care to everyone, even though the cost of providing that care is often more than the reimbursement. If substandard facilities get paid even less and go out of business (assuming that we have an accurate measurement of “substandard”), then what happens to the patients? They go to other facilities. When those patients overwhelm the other facilities, throughput times decrease, quality suffers, payments decrease, then more facilities close. Lather. Rinse. Repeat.
      I also agree that we should be encouraging the best and brightest to enter into training, but with the overregulation, rising educational costs, and sinking reimbursements, many of the truly smart and innovative candidates are going to use that intelligence to find better and easier ways to earn a buck.

      • Measuring quality perfectly is impossible. But we can come far closer to that achievement in reality than anything that’s out there currently, and we should try. Currently, there’s not even a standard. That prices skyrocket faster than inflation with such wild variances in quality is simply ridiculous, and benefits no one, least of all patients. It’s like an NFL with no scoreboards, and it’s been that way for decades.
        Worse, HopeyDopeyCare’s ultimate goal is to eliminate the idea of keeping score. “Everybody plays, here’s your jersey, who cares if you die? At least you got to play.”

        If substandard facilities get paid even less, they might elect to up their game and improve their quality. (Or cut their expenses and live with what they can make as a B-list shop.) Currently, they have no impetus to do anything except massage their Press-Ganey scores, at the expense of staff, best practices, medical ethics, and common sense, simultaneously. So if we’re going to apply a standard, let’s make it one that works in the best interests of both patient outcomes and the facilities and practitioners involved. That’s how actual modern medicine started: the ruthless application of statistical science to treatments, to weed out the bad and improve the results overall.

        As for the smart and motivated, that ship began to sail in the ’70s-’80s. Not entirely, and I’m still amazed by some of the folks that make it onto the floor – both the great ones and ones that make me shudder. But once again, if we’re going to select people in and out of the club, how about if we do it on a basis that will improve patient outcomes and maximize the entire industry’s investment in the true best and brightest, rather than the passable-and-unwhitest?
        There are great practitioners for every healthcare licensure, in all colors of the rainbow. But I want the selection criteria without fail to be how good they are, not how colorful. Which gets back to #2 above.

  2. I would say it is worse as it gives the patient and their family a course of treatment to follow, leading them to potentially ignore symptoms before re-seeking out appropriate medical care. I was treated for an ankle injury (hadn’t twisted my ankle or any other type of incident) for 2 months before I finally walked into an ED and stated, “I have no risk factors, but my leg is swollen, I think I need to be checked for a DVT.” Turns out I not only had a DVT by that point but 3 large PEs. Thankful for the care I received in the ED.

    My husband works in orthopedics, and I work in rehab. We have a list of facilities and medical providers that are not allowed to touch us or our family members.

  3. Bad is worse than none.

    But (reminder: I have NO credentials here beyond customer/victim/patient/survivor-so-far) I am not sure the whole blame is being accounted-for.

    In this day and age, people ought to be able to monitor their own care and that of people near and dear and ring a bell when something fails the smell test.

    • I agree that the “monitor yourself” approach is one of the ways out of this mess. Purchase your own medications OTC – except antibiotics and narcotics. Take whatever you want. Go into a store and get your own blood tests.
      If you want help, you’re welcome to see a physician. Otherwise, hope nothing too bad happens when Dr. Google gives you wrong advice.

      • Wow! What a bizarre twisting of stuff I did NOT say.

        I’m out.

        (I have tried several times to shut off the emails–this will be a good place to re-route you to the spam sump.)

        Note to others, if you actually read what I said, you will not that there ins not word one about cutting doctors or medical facilities out of the loop.

        I did pay attention to my mother when she taught me some of the things they survived with, but the main part of my message is “Take responsibility for your care. Ask questions and demand sensible answers. Make it make sense.”

        If you take your car in with what you suspect is a flat tire, and the mechanic says “We need to flush the radiator.” I hope you ask the mechanic to “connect” the cure with the ailment.

        Your body is entitled to the same respect for truth.

        • My bad.

          I didn’t intend to attribute those thoughts to you. I assumed that the “monitor yourself” comment meant that you believed the patients should have more autonomy in monitoring and managing their own health care – a point that I firmly believe.

          I think patients *should* be able to purchase most medications over the counter, obtain lab testing that they want, and any radiology testing they want. We need less regulation, not more. Why should patients have to pay a doctor every few months to get a prescription for blood pressure pills?
          Patients should have the ability to interpret the results themselves or follow up with a doctor if they choose to do so. The caveat is that “Dr. Google” doesn’t always provide the right answers with the do-it-yourself approach.

          Tying this back to the post – asking questions about diagnoses and results is also good advice, but often people without the medical knowledge don’t know whether the answers are medically valid, so having a doctor you trust or who can provide you with handouts describing the information is also important. Sometimes tough to tell when your medical provider is blowing smoke or just doesn’t have the knowledge – as in the cases above. How would a non-medical person know how to diagnose herpangina, know that you shouldn’t pack a joint, know that WPW probably needs a cardiology consult, or know that elderly patients with abdominal pain often have bad diagnoses?

          • OK — working assumption: there have been serious misunderstandings here.

            I will ponder them for a bit.

            (Unvoiced in my rant: As your car deserves a trusted mechanic familiar with it foibles and records, so also are you deserving of such care.)

            We deal with a “Family Practice” clinic — have for years. For unscheduled care, that is where we call. If “our” doctor is not available in an interval we think appropriate, we run the list to see who is available and depending on what the complaint is, make a choice.

            As often is the case the only “available” is one particular PA (who ought to be doing hard time), we say “thanks” and head for the Lakesside ER—-eer ED.

            But even then we try to remain in charge.

          • And I do wish that the tests and procedures that are not in general dangerous were more “accessible”, such TSH, A1C, the Lipid panels, and blood chemistry. (I would really like to see the current chemistry because the other day I found, inadvertently, that I had “passed” a pill pretty much unscathed that I am pretty sure was one of the two Klorcon tabs I take every day. I understand rich urine, that it weird.)

            I understand rationing–especially if I am expecting somebody else to pay for it.

        • I’m still not sure who went into the ditch first but I have had a couple of other events lately, so let us assume it is me. And that I am sorry. And that I will go back and read the thread to see if I can see what set me off.

          And let me say: This is funny to me because it has never happened to me (I have had a total of one incident where the ordered test was clearly legal-defense medicine and I ultimate declined it (MRI for a claustrophobe).

          http://www.glasbergen.com/wp-content/gallery/cartoons/toon-1934.gif

  4. Every practitioner had a story about someone else’s miss. But… the first commenter’s plan seem quite viable. (If you can keep the politicians, elected and medical, out of it)

  5. Charlotte Duncan

    I’m with Larry Shelton. My credentials are the same: “(I have NO credentials here beyond customer/victim/patient/survivor-so-far).” I was not surprised by the negative and off-the-charts response. Rule No. 1 is don’t dare breath a word that can be construed as being less than worshipful about the care you have received or the care givers who have given that care.

    • Curiousity overwhelms me:
      What “negative and off-the-chart” responses would those be?

      And how does any of that tie in with “less than worshipful” after-care comments?

      I only work in the field, and the number of patients nightly who say “Thank you” afterwards can generally be counted on one’s thumbs.
      Whereas the F-bomb tally usually requires a hand-clicker to keep track of.

      • I accept that the huge negative must be a problem–both of the medical facilities I frequent are plastered with posters advising me of the felonious nature of a list of things I migh be tempted to do.

        Which is a very sad thing, separate and apart from any of the rest of this.

        Any of the practitioners I frequent should be able to tell you that I express gratitude each and every time I am there, if I am able.

        We seem to have wandered from what ever the original point is or was.

        Suffice to say there is a small number of practioners that I don’t like and don’t visit unless I have to.

        My beefs are with the idiot bureaucracy practices that have barnacled-up the process.

        And chased favored practitioners out of the business.

      • Charlotte Duncan

        Sorry, but I’m still grieving the recent death of a friend who was sent home from the ER (Go home, we don’t admit people with stomach aches!) and then admitted two days later with pancreatitis. She died a painful and horrible death in less than a week. Hours before her death, she was still being taken around for “tests.” My brother died from a medical mistake (no, there was no law suit). I was dismissed and blacklisted by a doctor because I dared to question him and took in medical info from trusted Web sites (Mayo Clinic, NIH) to back up my questions. Time has proven that I was right, he was wrong. I thank my current MD when I see her.

        • I can’t comment on what happened to your friend, but the etiology for abdominal pain can sometimes be quite difficult to diagnose. My condolences for your friend and your brother.
          As for the doctor who dismissed you for questioning him, you’re probably in better care without him. There are bad apples in every profession, so it may have been a mixed blessing.
          One thing I wanted to point out is that many outside influences are actively trying to reduce the amount of testing and treatment in medical care to save money. Medicare is cutting reimbursements for treatments and refusing to pay if a patient retrospectively didn’t meet their criteria for admission (note that Medicare won’t give prior authorization since then it would be required to take a prospective view like the rest of medical practitioners). Insurers refuse to authorize testing that doctors deem necessary. The Choosing Wisely campaign is also putting pressure on doctors not to perform testing and treatment that it deems “unnecessary.” The result is going to be more misdiagnosis and delays in diagnosis.

          • Charlotte Duncan

            Thank you for your response. Again, I apologize for my rant. I know there are far too many regulations, but I can’t make sense of what I see these days.

            I’m fortunate that I’m healthy. I’ve been in the local hospital only once and was overtreated (for a side effect from a drug — everything was ignored or misdiagnosed). The hospitalist never made eye contact with me.

            I see people being overtreated and undertreated, overtested and undertested. Sometimes it feels like care is handed out at random.

            I want to participate in my care, but most of my friends (medicare age) don’t know — and don’t want to know — what is going on. Therefore, I also feel for the caregivers.

            As I said, I can’t make sense of things, medical or otherwise. The more I try to learn, the less it makes sense.

  6. I think the elephant in the room is the growing emphasis on performance metrics, especially speed. My bosses want more patients per hour, less time to dispo, higher patient satisfaction (which is strongly and inversely related to the length of stay.) The way the “rock stars” at my current shop, including the director and his number two, accomplish this via shitty exams and patchy work-ups. This works great for the 90% of patients that are going to get better on their own. Maybe even for an additional 8% where the obvious diagnosis is correct. The 2% who are poorly served and end up sicker aren’t enough to alter the statistics in a significant way.

  7. Yikes.
    That’ll work until one of those 2-percenters dies (or nearly so), and they or the next-of-kin sues the practice group, which will wipe out several years of corner-cutting, possibly end somebody’s career, and make a nice splash in the news, to say nothing of what it’s going to do to the patient(s). As I’m sure you well know.

    Maybe ask TPTB at your next meeting if it wouldn’t be easier to just install a drive-thru window. Or perhaps just rent a hall, have the patients come up onstage, and lay on hands on them and pluck the cancers out of their bodies as they shuffle by. I understand it’s quite a lucrative approach, and no shortage of folks lining up to go.

    Speed isn’t a performance metric in healthcare except for morons. Getting it right is the performance metric. As long as one has an error rate of zero, they should go as fast as they can.

    Same for patient satisfaction. Polling the clueless for a rating on things they don’t even understand is as blatantly ridiculous as handing them a tray of instruments and letting them take out their own appendix.
    (Somebody needs to do a PSA on expected wait times, featuring Dustin Hoffman as RainMan Patient:
    “Raymond, how long does it take to cook an egg?”
    “About a minute.”
    “And how long does it take to work up and diagnose an ED patient?”
    “About a minute.”)
    Anybody who worships at the altar of Press-Ganey is too stupid to listen to on any other subject under the sun. And if anybody, management or patient, thinks anyone’s going to provide Beverly Hills Spa service when they’re expected to deliver care going by on roller skates, they’re frankly too stupid to live, and the kind thing would be to hold a pillow over their faces until they stop squirming. The only pity is it’s unethical, and the authorities frown on it.
    If I ever find the first person who started the idea and ran with it rather than strangling it in its metaphorical crib, I’m going to do everything possible to chop down his entire family tree. Just like TV sitcoms, they should be shot before a live audience.

    The only place speed is a performance metric is at the racetrack.
    Unless your bosses and/or facility are willing to accept 60-70% crash-and-burn casualties from your group’s care, just like happens at the Indy 500, in which case there’ll be an opening soon where you and your colleagues used to work.

    That’s the other elephant in the room.
    The more administupid morons listen to bogus “patient satisfaction” surveys and metrics, the harder they crack the whip, the worse care gets, the lower actual patient satisfaction will be when every hospital becomes the VA, 24/7/365.

    What doctor anywhere (not counting witch doctors) ever sat bolt upright and said “I’ve got it! I’ll just skip the part where I use my knowledge, training, skill, and experience, and just whisk them in and out with shoddy half-@$$ed care! They’ll be out the door in record time, and be much happier! Through-put will skyrocket too! Everybody wins! What could possibly go wrong?”

    • I’m just going to start making your comments into posts.
      You are way more interesting and entertaining than I could ever be.

  8. That’s usually what I do with them.

    But it only looks that way because you and my fellow commenters keep feeding me the easy lay-ups.

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