Comments on: Choosing Wisely – Good Medical Practice or Prelude to Rationing?

By: Podcast #15: Choosing Wisely | The Skeptics Guide to Emergency Medicine

Podcast #15: Choosing Wisely | The Skeptics Guide to Emergency Medicine — Sun, 16 Dec 2012 22:20:38 +0000

[...] White Coat’s Call Room [...]

By: chadpdx

chadpdx — Thu, 06 Dec 2012 19:06:38 +0000

a bit late for comment I know but I think a response should be made to the statement by the author to let free market principles dictate use. Free market conditions do not exist in medicine. There are no knowledgable transactions being made unless the patient is also a physician. Ultimately the decision IS up to the patient but with the guidance of an expert in medical matters. That guidance should be given with only the patient’s benefit in mind not the physician’s.

By: Nurse K

Nurse K — Sun, 16 Sep 2012 16:59:50 +0000

Indcidentally, she was very happy with the ODT Zofran and lack of lab draws.

By: Nurse K

Nurse K — Sun, 16 Sep 2012 16:58:53 +0000

1. The patient in question said she would refuse any lab tests that were ordered because she didn’t like needles.

2. After talking to her, it turns out she had no BM x 5 days. Her pain was mid-abdomen down into the lower abdomen, worse with movement, not worse with palpation, and she personally felt as if it was constipation, but wasn’t sure.

3. Her blood pressure and pulse were normal.

4. After ODT Zofran, she was able to tolerate water and some bites of applesauce. She never vomited in the ER.

5. Now what do you think? Huge workup with CT?

By: Matt

Matt — Sun, 16 Sep 2012 01:59:13 +0000

Inevitable? Statements like that are nonsense.

By: WhiteCoat

WhiteCoat — Sat, 15 Sep 2012 20:14:37 +0000

So you think workup of patients post gastric bypass and abdominal pain is “necessary” testing in Nurse K’s contest.
Another physician didn’t think so and discharged the patient home without any testing.
Who’s right?
And if you’re the patient on whom something is missed, how do you feel if a doctor missed the diagnosis because the testing to find the disease was labeled “unnecessary”?

Also, a head CT in a patient with a migraine headache may be intended to rule out an emergent brain bleed – even if that bleed has little chance of being present.
Necessary or unnecessary? After all, it was performed to rule out something urgent or emergent …
See my point?

But you’re right that many other outside influences affect whether tests are ordered.
Can you say “Press Ganey”?

By: jennyct

jennyct — Fri, 14 Sep 2012 12:15:07 +0000

Note that of the cost of $750 billion wasted, only 17% is from overuse of testing. The rest is as follows: excess administrative costs ($190 billion); inflated prices ($105 billion); prevention failures ($55 billion), and fraud ($75 billion). Why are we not hearing about the other factors?

The physician needs to educate the patient on which tests are necessary, and what the risks are. Restrict too much and some will lose their lives. With 30% of diagnoses being incorrect (Sloan et al, 1993), can you blame some individuals?

If the patient wants to pay for it, it should be an option. Think about it. A month goes by with no resolution. You tell him to give it two more months. Now the patient starts getting depressed and needs to go to a psychiatrist. Where’s the savings there?

Anecdotally, I needed two HIDA scans for a diagnosis of acalculus gallbladder disease. After resisting the second test for years, I finally gave in. But you don’t want to know what I went through in the meantime.

COMMON SENSE should prevail.

By: Dr Killpatient

Dr Killpatient — Wed, 12 Sep 2012 21:27:09 +0000

From the ER standpoint, “unnecessary” is easy to define – that with little or no usefulness in the emergency setting – ie something not done to rule out something urgent or emergent. Er docs are terrible with ordering so much shit – because is it too easy for us to do it! (and patient’s and PMD’s demand it)

By: DensityDuck

DensityDuck — Tue, 11 Sep 2012 23:42:10 +0000

“What’s the problem with taking suggestions on what tests could be avoided to save time/money”

The problem is that when you don’t do a test and you miss a condition and a patient dies, “I was following the Choosing Wisely guidelines published by the ABIM Foundation” isn’t going to save you from the inevitable malpratice lawsuit.

By: Mary

Mary — Tue, 11 Sep 2012 17:09:39 +0000

I am sure it is much more complicated than this, but the bottom line is, we, as a nation, cannot afford to do everything medical, for everybody. Some difficult choices must be made, or the national debt will continue to spiral out of control. The question is, who gets screwed? I am guessing it will be the poor and undereducated, who often don’t vote, and cannot afford a lobbyist.