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.
“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.”
- 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.
- 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.
- 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.