Wednesday, May 21, 2008

It is easier to order a test that it is to talk to a patient!

(Medical/legal standard of care) In medical school I was taught that if a pateint can talk, 90% of the time they will be able to tell you what is wrong with them. The problem is that this is not true in the medical/legal sense. I hate that so many unnecessary tests are ordered as part of the CYA mentality that exists in medicine, but it has become so pervasive that know ordering the defensive tests are preferable to actually examining and talking to the pateint. A great example of this is the pateint in the ER with a headache. You don't know if it is a bad headache and they just didn't want to go to a walk in clinic where they may have to pay or if it is a horrible migrane. You see headache on the triage form and go straight to ordering a CT. There is no stopping and asking about when it started or how it progressed. The diagnosis is simple, 99% of the time you can get it right by talking and examining the patient. If you miss the asymptomatic glioma though, you get sued so off the pateint goes to CT. You then make sure that there is follow up for the pateint after their negative ct just in case they get something years down the road and try to sue you.

This is the new "Medical/legal Standard" that is taught to our residents and medical students. The actual standard of medical care doesn't matter.

Oh, what got me going on this was seeing 11 head cts in the ER while doing a consult. the ER attending was explaining to the residents that it takes 5 seconds to order a ct and 4 years to make it though a frivoulous lawsuit.


SeaSpray said...

Understandable Throckmorton... but disturbing because of the excessive and unnecessary radiation.

I just recently joked that I have had so many CTs since 2000 that I could be out in the backyard glowing with the fireflies. ;)

I now realize that 2 of the ABD CTs were not necessary. I was the squirrelly patient who thought something was wrong. This is where I do wish docs would take as stand but then we're all between a rock and a hard place because we aren't God and just don't know these things.

It seems everyone loses in this. The patients are potentially compromised. The docs are harmed if they go with what they really believe vs doing the CYA routine. Medical costs skyrocket -these tests are so expensive.

WhiteCoat from WhiteCoat Rants (excellent blog)wrote a post a while back in which he discussed his guilt for assuming this lady "just" had a headache. I don't recall exactly now but based on certain circumstances he concluded he would send her home with a certain med and I think it was nonnarcotic. Again...not sure.

Anyway...she returned under someone else's watch and a head CT was done and she had an incurable brain tumor. He felt so awful about it and wanted to go to her room to say he was sorry but he thought it was better to stay away. (Again...I'm a bit fuzzy on the facts but that is the gist of it)

THAT is a sad commentary on how things are! You WANT to do the right thing but your hands are tied because of potential legal ramifications.

I hate that you docs have to think that way...but..that is the way it is. It all seems like such a waste of energy and concern that could be better used on patient care instead of doctor defense.

I have to get going but will come back to this.

I know I write long comments most of the time but do question whether I should. You know just delete if you want to.

Bare with me for a minute because I am going somewhere with what I am about to say.

I adore my urodoc and as far as I am concerned the sun rises and sets on him. SERIOUSLY! I have mentioned him here in other posts.

It's just that I was so sick and he has done a lot of work on me.He has always been so compassionate and I know has gone out of his way in helping me. I trust him implicitly and am grateful for his skill and dedication to my case. And even though he specializes in urology...he as always treated me as a whole person. Because of those things and his take charge, I'm on top of it attitude, I always felt/feel that I am safe and in good hands with him. I am so grateful he ended up being my urodoc over the 1st one I had, who was nice and I am sure skilled but I know that new urodoc and office was the best place for me.

All of that is the tip of the iceberg for what I could say and I have conveyed these thought/feelings to him and his office in various ways.

YET...even though he has to know how highly I regard him...he has on a few occasions gotten a little squirrelly over some things and then he makes a point to correct it to make sure that I know he didn't mean it that way or whatever.

I can see when he does it and it isn't anything bad. I just feel for him because I know that comes from not wanting something to come back at him in the wrong way. It bothers me to think the he would think that I would ever cause him a problem. I would CRAZY GLUE my mouth shut before I would ever say anything negative about him...even if I had something negative to say...which I don't.

Then doctor should ever let his guard down in practice or on the blogs because don't know if that one comment can be misconstrued into something else.

I just wish things were more simple and people can just be themselves and we can all do what we need/want to do without looking over our shoulders in fear of what "might" happen.

I know I got off track just a bit. :) I will come back to comment on research and maybe a bit more on my cTs if ok.

SeaSpray said...
This comment has been removed by the author.
SeaSpray said...

I have to say that I don't think our ED docs routinely ordered CTs for migraine patients. I know for a fact that patients were put in a darkened area and after doctor saw them they were then given an IV and later discharged. Now maybe because a smaller hospital and maybe because some of them were regular migraners ...I don't know. But by the standard you mention..they would still be at risk of a law suit.

Some blogging ED docs have been talking about ordering too many CTs putting patients at risk and so they could be sued for not ordering the test and sued for ordering because of excessive radiation.

Ignorance is bliss. I have had 8, yes EIGHT CTs since 2000. 7 ABD CTs and 1 head CT.

I thought I might have endometriosis and so mentioned it to my OBGYN but he wanted me to see a gastro doc 1st. That doc ordered a CT -everything normal. But then my PCP mentioned that I had a nodule in one of my lower lungs and that with today's tests even the most incidental things are picked up and they have to tell us. he said if I ever had pneumonia or bronchitis that could cause it. Yes I did as a teenager. I never smoked. But it scared me and so he called the radiologist and neither of them were concerned. But the following year I was still concerned and requested a follow-up CT. It was still there but nothing had changed. And ...get this...the tech told me that for something like this I would have to get it checked every year! But my PCP didn't think it was necessary and I really had forgotten about it until i started thinking about CTs again. But I really don't think about them either unless I read something in a blog.

So... I definitely shouldn't have had the 2nd CT.

The 3rd Abd CT was in May 2004 when I had the big kidney stone.

The 4th CT was 2 weeks later after having the stent out, I ended up with 3 more little stones. (Hindsight being 20-20, couldn't that urologist have figured I had more stones and just take me to the OR for a procedure? I presented with the classic symptoms for a kidney stone. "I" didn't know it then but I sure do now.)Which would have less risk at this point -the OR procedure or the CT? And I did end up in the OR because he said my ureter is more narrow than most people and I couldn't pass these tiny stones and he stented me again.

The 5th CT was January 1, 2006 with 2 big disgusting drinks. I DEFINITELY needed that CT! Sepsis, hydronephrosis and pyelonephritis. That is when I my current urologist took over and I truly thank God for him. Knowing what I know now, I believe he was definitely the doc to work on my case.

My 6th abd CT was Feb. 06 because I had an excruciating left kidney spasm when it was my r kidney that was stented. It was normal. Now i know that just because I have a ureteral stent in me is enough of a reason to cause kidney spasms in either kidney. Again...hindsight 20-20.

Then the 7th ABD CT was a 3mm cut all the way down with contrast in NOv 06. I didn't need this one either and had been cleared by my doc based on Renal scans, etc. but "I" was afraid something was wrong and sure enough it came back with normal results.

The head CT was in the summer 2004 and yes, I did present to the ED with a headache and high BP. That whole thing could've been avoided if I just had I-buprofen at work that day.

So knowing what I know...i am thinking I need to be proactive with my health care in the future in that if the doctor mentions CT I should update him/her on my hx.

Speaking as a patient...I WANT my doctor to do what HE REALLY thinks is necessary - no more and no less. not worry about my feelings but tell it like it is. If I am over reacting..say so. If I am wrong and not concerned enough..say so. And I REALLY DON'T want any of them to order a CYA test that could do me more harm than good.

Maybe if patients knew the risk of radiation exposure they wouldn't be so quick to get on that table. And then...sometimes...there just isn't any other choice. I get that.

But amidst all that...I also had IVPs, KUBs and OR procedures. HA! Maybe I DON'T have to worry about birth control! I'm just sayin. ;)

But here is what I think about it all. It was what it was and it is what it is. I give it to God and joke that I can glow with the fireflies.

Chrysalis Angel said...

How true. I'm glad to see you've been writing again. I'll have to check in when I get the chance.