WhiteCoat

Defensive Medicine #1

Kevin, MD (a.k.a the “CliffsNotes of the Medical Blogosphere”) hit the big time with his prime time appearance on CBS News for a piece on defensive medicine. Congratulations, Kevin. Nice work!

The story is troubling, though. The beginning of the segment features a doctor that, using his retrospectoscope, comes to the conclusion that his daughter with abdominal pain that “kept getting worse and worse” only needed a $1400 ultrasound to diagnose what ended up being a “harmless ovarian cyst.” The $8500 CT scan of the abdomen and pelvis that the ED physician ordered, in that physician’s opinion, was unnecessary “defensive medicine.” To be fair, we weren’t given a complete history, but I think this guy is way off base.

A history, a pelvic examination, and an ultrasound – these are the only things Dr. Retrospectoscope would have needed to diagnose the cause of his daughter’s abdominal pain … after the fact. He advocated doing an ultrasound first and then doing a CT scan if the ultrasound is negative. That way most patients can leave with a $10,000 diagnostic imaging bill instead of a $8500 bill. Ooops, forgot the radiologist’s charges. Make the bill $13,000.

Obviously Dr. Retrospectoscope hasn’t set foot in an ED in a while. There are a heck of a lot of other causes of abdominal pain CT scans catch that ultrasounds do not: diverticulitis, colitis, obstruction, free air, kidney stones, tumors, possibly appendicitis, possibly pancreatitis. These are just off the top of my head. I’m sure there are others. I bet that if the ED doc only ordered the ultrasound, found a cyst, and sent “daughter Retrospectoscope” home with pain meds, only to later find that her pain was caused by appendicitis, Dr. Retrospectoscope would have been on the phone to the Law Firm of Dewey, Cheatum, and Howe before the surgical incision on his daughter had even been closed. Then the news segment would have been titled “Cowboy ED physicians who gamble with patient’s lives.”

If a history, pelvic exam, and ultrasound were all that was needed, why didn’t he take her history over the phone and call in an order for an ultrasound? Was a pelvic exam even necessary? Scalpel made a good point that most of the time pelvic exams don’t affect the outcome of a case.

So instead of presenting a balanced argument of the differential diagnosis of abdominal pain in a young female and the benefits and limitations of each diagnostic modality in the emergency department, the American public was treated to a lopsided story about how Dr. Retrospectoscope, sight unseen, knew more about the cause of his daughter’s pain than the doctor that evaluated her.

Backstabbers like this need a swift kick in the crotch. Especially ones that get on national news and try to make themselves look smart. Even I wouldn’t need an ultrasound to diagnose the cause of that pain.

Ordering a CT of the abdomen on someone with “bad” abdominal pain is proper medical care. Second guessing the doctor that evaluated the patient without a full set of facts is not.

UPDATE

Kevin updated the debate about this issue through a posting at The Blog That Ate Manhattan.

“Dr. Bob,” a neurologist, added a little more history to his daughter’s problem by stating that there was “No fever, a cursory hx and exam by PA, and no pelvic exam.” He stated that in his opinion “today’s ER’s have become CT Triage Centers.”

  1. Does absence of a fever preclude the existence of a life-threatening abdominal condition? I’m not aware of any evidence-based medicine to that effect.
  2. Is a pelvic exam necessary to cinch a diagnosis? See Scalpel’s post above. I still do them, but I agree with Scalpel that my findings often do not affect my treatment plan.
  3. What is a “cursory exam”? I can’t comment on that one without seeing the chart.

If a PA was the only one that saw Dr. Bob’s daughter, then I have a problem with that. The sole fact that a PA provided his daughter’s medical care does not mean the PA came to the wrong conclusions. I know a lot of PAs who are very good clinicians. But issues of experience and billing may come into play.
I stick by my guns with this one.
I have a lot of reservations about a neurologist criticizing an emergency physician’s evaluation of abdominal pain. What would Dr. Bob’s differential diagnosis of lower abdominal pain in a young female be? Neurogenic bladder would not be very high on my list.
This is another example of someone giving opinions that are way outside of their specialty. Just because I pick up a book on Applied Mechanical Engineering doesn’t make me an expert on the topic. You have to practice in any specialty to learn what the books don’t tell you. If Dr. Bob tried to offer testimony in court about evaluation of abdominal pain, he would likely be excluded as a witness. I suppose these statements do make for good viewer stats on the evening news, though.
And as for EDs being a holding area for patients to receive their CT scans, Dr. Bob, I could make that same argument about neurologists. When I call a neurologist for an opinion, often I hardly get the patient’s name out of my mouth before I get the question “what did the CT show?” So how many head CTs have you ordered in the past 12 months? Or do you just go straight to MRIs? People who practice in glass offices ought not throw stones.

12 Responses to “Defensive Medicine #1”

  1. Ten out of Ten says:

    I like the overall message of this report. Defensive medicine IS bad medicine, and patients absolutely should feel empowered to ask questions about the nature of their workup.

    But in the end it’ll be the rare patient asking for a streamlined workup. Not when the deductible has been met at triage. Who gives a crap when someone else is footing the bill? Been paying premiums month after month, let’s get something back for it. That’s what’s going to happen in a third party payer system.

    I have had a couple of uninsured patients who I felt needed CAT scans who asked me if I would not do them because of cost reasons. We went over the risk/benefits and I sent them home. They had good outcomes, but there is absolutely no incentive for me to do this other than I try to do right by people. I am certainly putting myself at risk, like one of my partners says: no one will come back to shake your hand for not ordering a test.

    As for this Dr. Rectospectoscope, I’m sorry but what a complete asshole. Clearly the urine pregnancy test wasn’t indicated, since it was presumably negative, nor was the urinalysis, since she presumably didn’t have a UTI. Oh wait, we don’t look at the results of tests and decide if they were appropriate, we order them based on what we can glean from history and exam. And some of them are going to be negative. Pre- and post-test probabilities, likelihood ratios, receiver-operator curves. It’s what we do, usually subconsciously, everyday for every patient.

    Man that guys makes me angry. You don’t throw your colleagues under the bus. I would never bad mouth other doc in front of a patient even if it was clear that mismanagement had taken place. I certainly wouldn’t do it on national tv when it looks like I’m in the wrong. (Granted, we don’t have all the information here, but based on the one piece of history we have, “worsening pain,” I can tell you that is much more consistant with appendicitis than an ovarian cyst.)

    Ok I’ve had my say and feel better now.

  2. I have to disagree about the pelvic exam. A pelvic exam (at least a bimanual) is essential to the diagnosis of PID. All female patients with abdominal or back related complaints in the emergency room should have at least a bimanual exam. It’s a cheap test and when you know a little bit about what you’re doing, it often will give you the diagnosis. Both PID and a severe cystitis can cause urinary and abdominal symptoms as well as wbcs in the urine. You can tell the difference on a pelvic exam. I can usually differentiate bowel related pain from gyn-related pain on a pelvic exam. Endometriosis, etc. all can be diagnosed from a bimanual exam. The speculum exam isn’t always necesary, but a bimanual can be extremely helpful.

  3. Surfie says:

    One other problem is that defensive medicine has been in ‘practice’ for so long and, as such, a vicious circle has begun.

    Uneducated patients are used to having everything and the kitchen sink thrown at them and done to them for even the most minor complaints. So, now you have these same patients questioning the thoroughness of a workup, tests, and medications (or the lack thereof) when not done, as well as the physician providing the care.

    Think about it in terms of antibiotics. Patients insist on them for viruses and such when they shouldn’t. Why is this? This wasn’t borne in a vacuum. Now try to explain to that very same patient that they don’t need antibiotics (or test/workup/scan/medication) for this condition or that, and they get generally get pissed.

    It’s a mess, all of the way around.

  4. [...] Coat Rants starts what promises to be a series on defensive medicine. He takes the same ground as everyone else, that the ER’s decision was justifiable. He adds a [...]

  5. Nurse K says:

    Law Firm of Dewey, Cheatum, and Howe

    *Snort*

  6. SeaSpray says:

    That’s funny..Law Firm of Dewey, Cheatum and Howe. My uncle gave me a business card with that on there. :)

  7. SeaSpray says:

    I also meant to say that because I have had so many CT’s and other radiologic/nuclear tests that I would be appreciative of a doc taking a more conservative route. Although when I was an ER pt in August, I didn’t think to tell the doc that. He ordered an ultrasound and I guess the truth is that because I was in pain and experiencing nausea…I wouldn’t have contested anyway. Just fix it Doc..please. :)

    It was neat having a face to Kevin MD and interesting to see someone representing the medical blogosphere, which he did well.

  8. Ed Flinn says:

    a swift kick in the crotch

    Asclepius used to conceal a snake in his hand before smiling and offering to shake. I understand it worked well.

  9. David says:

    Where did you come up with the $3000 radiologist charge? I assume you mean the charge for interpreting an ultrasound or CT scan. These charges are set by or based on Medicare rates. Maybe $25-40 for ultrasound and $50-60 for a CT. So your figure is off by a factor of 20-30. Did you make this number up?

  10. Lesley Stevens says:

    Interesting.

    Over a 10 year period I was seen in the same ED for different instances of severe abdominal pain on four occasions.

    1) Diagnosis: none
    2) Diagnosis: appendicitis
    3) Diagnosis: ovarian cyst
    4) Diagnosis: PID

    Ultrasound was performed on all four occasions, I was
    never offered a CT. Is this really the standard, now?

  11. James says:

    The whole argument over whether a test is medically appropriate or not misses the point. Current “cover your ass” medicine and the tests we order is not based on science.

    I order the CT instead of the ultrasound not necessarily because it is more appropriate, but that in the event I was wrong about my diagnosis, I have ordered the test that provides the most information. If an ultrasound reveals my diagnosis accurately 99% of the time but misses a 1% chance of something else (such as appendicitis, or worse, a cancer) will any jury take into account my scientific rationale? What if a condition is only 0.1% likely that would be missed by CT scan? Would a jury then consider this 1/1000 incidence and forgive me for not ordering the CT in that event, even though, of course, CT are available in every medical center throughout this country. What if me being wrong results in the death of a 30 year old mother of 2 who makes 200K per year? I can see the question from greeseball lawyer, “Geez, doc, CT’s are so easily obtained, why not just order one to be safe!”. I would respond, well you see the risks/benefits of ordering a CT and getting a false-positive result that might result in a more invasive test that carries more risk to it then the original problem I was investigating led me forego the CT. To this, greeseball responds, “My client is dead, look at the pictures of her children and dog!!! Look how happy she was in Florida with her husband last year!! Look at my yacht—oh sorry, wrong slide deck”.

    See….the choice of ordering a test has no basis in science many times because a potential jury populated by the masses of asses watching Springer don’t give a damn about science. The test is ordered so that I, as a doctor, can tell a jury that I ordered the best test available and cannot be blamed for missing her problem. Just pay us the money, doc, you can afford it.

  12. [...] on defensive medicine at docblog White Coat Rants [first, second, [...]

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