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Tag Archives: Defensive Medicine

Dr. WhiteCoat Goes to Washington

Sorry about the sparse posting lately – have been away in Washington at an ACEP conference Just so Matt and others don’t think that all I’m all talk and no action, I’ll let you in on some things that I did at the conference. I attended some excellent lectures about leadership. Colonel Thomas Kolditz gave a great talk about leadership in extreme circumstances. He described his interviews with many soldiers, Iraqi prisoners, sports team captains and their teammates, and various other people in leadership positions to determine what makes a good leader. Why do people follow some leaders and not others? Commitment is important. If a leader doesn’t believe in a mission, neither will the rest of the team. Effective leaders work with the team – they get down in the trenches and don’t sit on the sidelines barking orders and cheerleading. Trust is also important. If team members are worried about whether their leader might throw them under the bus, they will second-guess the leader’s intentions. The biggest factor in being an effective leader is competence. Col. Kolditz described his interview with a group of soldiers in an elite army unit. Almost all of them hated their commander. They thought he was a jerk. But every one of them said that when the rubber met the road he knew what he was doing and that there was no one else they would rather have leading them in their missions. I listened to Dr. Melissa Givens, a Lieutenant Colonel in the US Army, describe how difficult it was to manage the shootings at Fort Hood and all of the unexpected difficulties they had in trying to save the wounded soldiers. Ever wonder what it’s like to watch one of your co-workers die right in front of you? She told us how she was in the same room where the shootings took place only two days prior to when the shootings occurred. Very informative and very emotional. I watched a room full of physicians throw up their hands in frustration when a California physician showed how his group and other groups in the state are having difficulty staying solvent because California does not allow medical groups to bill patients fair prices for the care that they provide. Insurers lowball payment to the physicians and the California government made it illegal for the physicians to bill the patients for the remainder of the payments. Many physicians are considering whether or not to leave the state. California patients may soon be getting what they – or their insurers – pay for. There were other lectures about how health care reform fell short and some possible options for the future. One of the most informative lectures I attended was given by a former Congressional aide and current consultant who described his impressions about how legislators come to decisions and what does and does not influence a legislator’s decision-making. Personalized letters to legislators really do make a difference. And I went to legislators’ offices. The legislators weren’t in town when I went to visit, so I was lucky enough to get appointments with some of their staff. I discussed ideas for health reform and medical malpractice reform with one legislator’s assistant. He took my name and said that he was going to have another assistant get in touch with me to get some more ideas and input. I spent 45 minutes talking with one legislator’s assistant who is the go-to person for health care policy. I didn’t try to sell anything to him, I asked him if he had any questions that I could answer ...

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Shotgun Testing

Part of a resident’s job is to learn the ropes in preparing for independent practice. While you’re a resident, you get the benefit of having someone looking over your shoulder to critique you as you determine how you are going to manage patients. I frequently tell residents that different attending physicians practice medicine in different ways. Some practice defensive medicine more than others, some prescribe antibiotics more than others and some work harder than others. The resident’s job is to figure out whose practice they are going to emulate when they begin practicing on their own. That being said, I usually practice conservatively. I don’t tend to shotgun a lot of cases. When residents present cases to me, I make them give me a differential diagnosis and justify why they order the tests that they order. If they can’t justify why they’re doing the tests, then I won’t approve the tests. A resident rotating on the first day in our emergency department presented a case to me and his comments made me think. A woman in her 40’s came in complaining of tender lymph nodes to her neck for the previous 36 hours. That was it. She had pain in her neck when she turned her head to one side and thought she had cancer. The resident ordered a CBC, comprehensive metabolic panel, cardiac enzymes, coags, chest x-ray, urinalysis, influenza swab, and strep test. He wanted to know whether I wanted to do a soft tissue x-ray of the neck or a CT scan of the neck. “So what do you think is causing the swollen glands?” “Maybe strep, maybe cancer.” “Why the cardiac enzymes and coags?” “If it is cancer and she needs surgery, the surgeons require a baseline.” “Any other symptoms besides the swollen glands?” “Nope.” “Why the urinalysis?” “I figured they could do that while they’re getting the pregnancy test.” “Why the pregnancy test?” “She’s going to need x-rays, right?” “We can’t do an abdominal shield?” “Sure.” “Is a $200 flu swab going to be worthwhile?” “It could cause the swollen glands.” “In a patient with no fever, no cough, no pharyngitis, and the incidence of influenza sporadic according to the CDC?” “Didn’t think of that.” He was obviously getting annoyed. “Fine. What do you want me to order?” “Anything else on the physical exam?” “Not really. No nodes anywhere else. No signs of infection.” “Let’s go look.” I’m typing this case up on the fly and was going to finish describing the interaction, but then I thought that maybe you all would like to take a crack at guessing what was causing the bilateral tender lymphadenopathy in the patient’s neck. I’ll give you a couple of hints, since the diagnosis was rather obvious on examination and therefore I can’t tell you what the exam showed. First, the resident didn’t perform a good physical examination and didn’t take a good history. Both of those would have led to the correct diagnosis. Remember, the nodes were bilateral and the diagnosis was obvious. What do you think? I’ll post the answer in the comments in a couple of days. UPDATE APRIL 29, 2010 The answer is posted in the comments section. The point of the post was not to belittle the resident, but was more to make a statement about how another resident felt that residency training was lacking. Another resident in our program lamented that most of their didactic teaching doesn’t involve close physical examination or a thorough history any more. She felt that the overwhelming teaching points during the residency program were to perform procedures and to ...

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Healthcare Update — 04-01-2010

Tort reform lessens the risk of medical malpractice, “but it doesn’t change the capriciousness of the legal system … and it hasn’t changed the nature of the risk.” “If there is ANY DELAY AT ALL in the diagnosis of a condition, then they label it as ‘malpractice.'” This Newsweek article explains very succinctly why defensive medicine is real – despite what the American Association for Justice’s mouthpieces would tell you. Ooops. One lawyer in the comment section says defensive medicine is a myth. Oh well. There goes my theory. It’s not really patient “dumping” — I helped her get out of the car. Florida surgeon cuts wrong duct during gallbladder surgery, then brings patient to another hospital in his own car and drops her off at the emergency department, telling her to inform the staff that she was discharged from the first hospital two days prior. Funny … his hospital notes showed that the patient was feeling better and that he was discharging the patient home. Moron. Michael Jackson’s heart was still beating when he got to the emergency department. Joe Jackson, Michael Jackson’s father alleges a “cover up” in Jacko’s death. Yeah. The agonal heart rhythm must prove it. Sorry, but I just could never write about celebrities for a living. The Wisconsin State medical malpractice fund was running a surplus. Then Governor Jim Doyle raided the fund for $200 million to cover some of the state deficits. Now, payments to patients have the fund running at a net negative for the past two years. This year it is $109 million in the hole. Governor’s response: The fund could afford to give up the money – it had a surplus. Next source of state revenues: Children’s piggybanks and the spaces between old ladies’ couch cushions. Total emergency department visits dropped by 1.3% in 2009. Meanwhile, emergency department visits by Medicaid recipients increased by 6%. When few physicians accept your insurance, where are you supposed to go for treatment of your medical problems? Should psychotherapists Google their clients? What about Facebook friending? Personally, I think the whole Facebook thing between physicians and patients really crosses the line for a professional relationship. Will patients start disclosing their protected health information on your Facebook wall? Will physicians be hesitant to deny inappropriate requests for prescriptions or requests for medical care out of the office because they don’t want to offend their Facebook “friends”? I stay off of Facebook for just this reason. Don’t have your heart attack in Nova Scotia on Sunday night or during Monday afternoon. This Nova Scotia emergency department will be closed — due to physician shortages. Now that health care is all shored up, we can start fixing this country’s legal system. Enter SinglePayerLegal.org. According to the site … half of poor Americans suffer from at least one serious legal problem each year, but 75% of those people have no access to legal care … thousands of innocent working Americans are wrongfully convicted of crimes every year – in part due to negligent or poorly trained lawyers … and the average profit per partner at the most successful law firms was more than $750,000 per year. I really think we should pass a law about this whole legal mess. Hat tip to Throckmorton. Philippine physicians take a mass leave of absence from Philippine General Hospital to “to strongly protest the lack of a democratic process” in selecting hospital director. Hospital staff elected one person for the hospital director and the hospital chose someone else. Now administrators can do the appendectomies. Houston’s mayor may have priced some retired city ...

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On Nursing Home Transfers and Liability Reform

Several times in the past few days we have gotten ambulance runs from the nursing homes in the middle of the night to evaluate elderly nursing home patients for “unresponsiveness”. When the “unresponsive” patients arrive, they are at their baseline mental status and, after the obligatory workup to rule out the bad causes of “unresponsiveness,” nothing is wrong with them. Is “unresponsive state – rule out REM sleep” a legitimate discharge diagnosis? Then, last night we got an 82 year old COPD patient by ambulance from a nursing home who was having “severe shortness of breath” and “hypoxia”. Her oxygen saturation was in the 70s in the nursing home (normal is in the 90s) and she was “dusky,” prompting the ambulance call. When she arrived by ambulance, with her usual oxygen settings on the nasal cannula, her saturation was a respectable 92% – an acceptable value for a COPD patient. Was her shortness of breath and hypoxia due to some acute underlying medical disaster? Fortunately, I like to talk to the EMTs when they bring in the patients. In this case, the patient’s nurse told them that the patient took off her oxygen to go outside and smoke a cigarette in the cold. She enjoyed the first cigarette so much that she had a second – while her oxygen canister waited longingly for her inside the nursing home. She may have gone for a third and turned into a smokesicle, but her nurse noted the lonely oxygen canister in the hall and investigated, finding the patient standing out in the cold. Now of course none of this was written in the transfer papers and we had to call the nursing home to verify the story. The patient’s nurse had left for the evening and the nurse that was there had no idea about the patient, so we had to call the previous nurse on her cell phone at 11:30 at night. She didn’t answer her cell, so we had to call her house. Oh, and don’t forget the obligatory emergency department testing just so that we can prove that the patient really is at her baseline before sending her back – just in case she wakes up dead the next morning. All this because granny wanted a couple drags from a Marlboro. Kind of ridiculous, huh? Although I get frustrated by what some people perceive as “bullshit nursing home transfers,” I also find myself bowing to the same pressures that nursing homes have when I see the patients in the emergency department. How often does any emergency physician look at a frail elderly nursing home patient who complained of shortness of breath and not order any testing? I’ve done minimal workups on some patients (including Granny Marlboro above) and have had people tell me that I am lugging a couple of coconuts around in my scrub bottoms for not doing a million dollar workup on all the nursing home patients … and even for sending the patients back to the nursing home when they come in with vague complaints. If a patient complains of shortness of breath in the nursing home and the nurses don’t send the patient for evaluation, the nurse and the nursing home will be investigated by all the clipboard brigades and would likely be sued if the patient suffered a bad outcome. Similarly, if I don’t do a thorough emergency department workup on a nursing home patient with a vague complaint of shortness of breath or weakness or fleeting chest pain and the patient has a bad outcome after their emergency department visit, all the people ...

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When Will We Learn?

Hey, its ERP from ER stories doing a guest rant post. OK, I have blogged about this before, but nearly every shift, I have cases which emphasize the need to repeat myself. When the hell with doctors learn to stop obsessing about hypertension?  I don’t mean to say that we should not treat it – of course we should. I am talking about blaming every symptom a patient is having on it.  I am talking about aggressive lowering of the BP in the acute setting.  It is just stupid. If I had a nickle for every time a patient’s headache or dizziness is attributed to hypertension I would be a millionaire.  The sad truth is that it almost never is!  The BP is a REACTION to the symptoms not the cause.  This is obviously true in people who are chronically hypertensive – it took years for them to develop it so why do we think we need it lowered in 5 minutes?  Of course their pressure will go up to 200 when they have pain.  And guess what, lowering it fast will probably make new problems – like syncope and rebound hypertension caused by crappy old drugs like Clonidine. This is different than when a young person has hypertensive encephalopathy or when someone has a big head bleed (where you want to lower the pressure only a small amount) or an aortic dissection.  They people do need IV treatment but almost no one else does! I just had a patient who was admitted to three days in England (where he was visiting I assume)  for “hypertensive emergency” because he was having a room spinning sensation and a systolic pressure of over 200.  Guess what, they lowered his pressure and gave him new drugs to go home with but he still had dizziness! Why? He had obvious benign positional vertigo!  I gave him antivert (an antihistamine that works well for it) and it went away!   And as a bonus, his pressure came down on its own! So, patients do not check your BP when you feel pain or dizziness (unless you are on the verge of passing out – in which case you are looking to see if your BP is LOW), check it when you feel normal and have been chilling out for 10-15 minutes.  Do that over several weeks and show the numbers to your doctors and let him or her decide treatment. Doctors, do not attribute every headache, vertiginous episode, or other discomfort referable to the head to hypertension.  Do not agressively lower it in the ER or your office and then discharge the patient.  Do not give someone labatelol because the have a nose bleed.  Do not fail to examine someone and miss benign positional vertigo.  Don’t just treat the number to make yourself feel better!  Treat hypertension for the long term!

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