Thursday, July 21, 2011

Balancing act

Medicine is never an easy field. People accuse doctors of not doing enough, or doing too much.

There are no easy answers. We're caught between doing what's best, without putting the patient through too much, and doing what's needed to protect ourselves from legal action.

Let's take Mrs. Summer. She's a nice 78 year-old lady I saw in the office last week.

Earlier this month she hurt her back. So she saw her internist, who correctly diagnosed her with a muscle strain. He gave her a muscle relaxant and Tylenol #3.

A few hours after she took the medications she became confused and sleepy. Her family called Dr. Internist, who said to stop them immediately.

She was absolutely fine the next morning, but her daughter is a nurse at the hospital, and wanted me to have a look at her for the episode. So she called Mary, and they came in last week.

The odds are that all she had was confusion due to Tylenol #3. So do nothing. It's most likely and least expensive.

BUT maybe she had a TIA. If I don't correctly diagnose that, and she has a big stroke, than they could sue me. So let's order a brain MRI, head & neck MRA, and echocardiogram. That's a few thousand dollars in tests.

Or maybe she had a seizure, and needs to be started on seizure medications. So lets order an EEG, too. Another $500.

Perhaps it was a metabolic event, with her blood sugar getting too low. So I'll order some labs. That'll be another $500-$1000 depending on how much I order.

This is the dilemma your doctor faces each day, many times over. None of us come to work saying "Oh boy! I can't wait to drive up the cost of health care today!" But we're faced with finding an (at times) impossible balance.

We don't get a 2nd chance, either. If we guess wrong we run the risk of getting sued. Another doctor is always willing to make a living as an expert witness and testify that we are incompetent.

And yet, with this sword of Damocles hanging over our heads, I and thousands of other doctors do this every day. And try to do the best we can, within the limits of human fallibility.


Mrs A said...

yeah we are all human ibee, except those who have cotards!

Old MD Girl said...

It's not just defensive medicine, it's that prices are unbelievably inflated to cover the cost of caring for the uninsured.

Why does a metabolic panel cost $1000? It's not like this is new technology. Or an MRI -- $5000 EACH?

But yes I see your point. Now imagine this times 1000000 for every admission to the hospital of a little old lady with some minor confusion. I had a patient once who was hallucinating because of a recent change in her Parkinson's meds, and we still had to do the whole change in mental status workup.

Anonymous said...

And that's considering that she is not the mom of two daughter's who barely talk to each other but both take her to separate Neurologists for the same episode without consulting each other or taking Mrs. Summer's word that the other daughter just did that last week. Yep, that happened to me. Of course a little dementia on Mrs. Summer played a part in my experience! Therefore the same multi-thousand dollar work up was done twice and insurance/Medicare paid once and the patient paid once...UGH! Nice, huh!


wv: plaqua, could have been noted on all those MRI's!

Packer said...

78 years old, nearly at full life expectancy. Only influencing factor of note--medication with known side effects--fine the next morning. Observe for an additional 24 to 48 hours and move on. Hey no one lives forever, we need to start looking at that part of the equation. Ok, now with that said I am retreating to my bunker. Fire away.

Anonymous said...

So when the doc stuffed a tongue depressor in my face and looked inside he didn't see everything he needed to?

Anonymous said...

No flames here, Packer. You have a good point.

Dr. Grumpy, we who are nurses salute you. It really is the sword of Damocles. I would have a very difficult time making those decisions.

Anonymous said...

Decisions, decisions...

I guess Mr Parcker do not have elder parents...

Oh grandpa you got a stroke, but you'll be 76 in two months! It's time to move on... to (cough cough) coffin...
So relax and enjoy your pneumonia from aspiration

on the other hand mri for acetominophen its too much

bobbie said...

No flames here, either ~I'll be at your side in that bunker, Packer...
I saw this type of thing all the time in the ICU, and I always thought I'd hate to be the one who had to make those decisions.
Rock on, Dr. G. 'Tis a puzzlement.

A Doc 2 Be said...

"We don't get a 2nd chance, either. If we guess wrong we run the risk of getting sued. "

Worse, the patient dies.

My elderly father has been seen so often since his "event" in late January, Mayo is naming a wing after him. :P He grumbles that the urologist is doing too much, the nephrologist is just trying to get more money from his insurance company and that he is just some research guinea pig for them.

It was fabulous to tell him docs have far better things to do than research on a non-consenting patient and that instead, they are doing the least they can while making solid choices to keep him alive.

I thoroughly confused him, he shut up and smiled.

Oh, and those docs that he sees? According to US N&WR, Mayo is #1 in the specialties for which he has docs.

He smiled at that too... geezers :)

Christie Critters said...


Anonymous said...

Here is another side of the coin. I am taking care of my 88 year old dad. His personality type means that he will never give me or his doctor a clear idea of his symptoms. Always has been evasive and unable to self diagnose. I can't tell whether he needs to be seen or not. It's always guesswork. Too bad there isn't a care manual for the aged for us laypersons.

Anonymous said...

Have been the Pt in this situation. Docs were pretty confident they had figured what was wrong, but the thought of lawyers had them thinking of a herd of zebras not just horses. Or that there might be a zebra in the herd.
So, off the (now even poorer) pt went for more painful and expensive tests.
And the Docs had Dx'd the presenting problem correctly, but the zebra test uncovered something that would have bothered me into the grave. It was treated early and all is well.
But we would not have known until too late that there was a zebra getting stronger in the middle of the herd w/o those tests.
So, Dr. G, I feel for you and your pt. You are probably right with the medication. The tests are probably going to show nothing that is going to do an elderly pt any good.
But the hospital is going to get some blood $, the daughters are going to think they are "doing their best" for mom and the malpractice lawyers are going w/o a case. Only Dr. Ibee is going to lose sleep.
And you haven't slept since you were a resident and handling carousels of slides.

OldSquid said...

It is a fine line you walk. How many MRI's need to be run for one treatable dx to show up. What about wait and see even though that isn't the society that we live in?

Packer said...

OK, the truth, my father fell doing something no 81 year old should be doing, Subdural Hematoma, prevented usual medication-stroked heavily 5 days later, paralyzed mid line, head to toe. Lasted 6.5 years during which time I was with him most often. I did not like what I saw and realized that perhaps there are things worse than dying, especially if you have lived life full out. At age 87 there were plans to do surgery for metastic melanoma. I knew to say when , when it was when. The thing that still sticks in my head were the times he asked me to smother him with his pillow. I felt empty but relieved when it was over.I do not advocate my views, but I do not apologize for them.

Anonymous said...

So what do you do in those situations?

Or if the patients that say, "I have good insurance so just run the tests!"

Dr. Goggle says, "I need A, B, and C!

I have great respect for doctors that refer out when they don't know the answers.

Most of my family uses the same PCP and have been since 1992. I trust him with my life, and that of those I love. He made a judgement call on one of my family members (said person is 35) in April and ordered a STAT, WET READ, CT because his "SPIDY SENSE" kicked in. That test, SAVED HIS LIFE!

So, again I ask, what is a doctor to do in a "sue crazy society?"

Any Medical Professional, please chime in on this one?

ronstew said...

Looking at my 73-year-old dad, I know that 73 ain't old. I'm pretty sure that he'll not be old at 78 either. But his mom was very old at 68.

People, even highly skilled medical professionals, have a poor track record at predicting the future.

Tough spot to be in.

terri c said...

Excellent post Dr Grumpy!

To the person who talked about inflation "to pay for the uninsured," just be aware that because of the varieties of contracting and billing in medicine it is very difficult to tell what ANYTHING "costs" anymore. And that the uninsured get huge bills for things they receive, sometimes more than what insurance companies pay for the same treatment. There are plenty of uninsured/underinsured who do everything they can to pay. Uninsured does not equal lazy in this world.

terri c said...

At least, Dr Grumpy, you have brains and a heart and when you are dealing with a sane person/family I know you can discuss the possibilities and involve the person/family in the decision making. Still it is a HUGE stress.

Anonymous said...

As an aside, "WET READ" (anonymous 11:45) is a request that disappeared in the 60's and, at more remote sites, in the 70's. It meant reading the x-ray film as it was pulled dripping wet, from the fixer tank. By then, most imaging clinics had automatic processors.
And now most of us don't even have film. Pretty well all on computers, especially the CT.

You also get physicians asking for "flat plate abdomen" Well, the only curved plates I've seen are used for knees and shoulders.

Anonymous said...

This is why we need coinsurrance, not copays. When my 89 yo dad's PCP runs a whole lot of expensive tests and I ask my dad why, he says, "I don't know and I don't care. Medicare pays for it." (He's not demented at all.)

If docs could explain to family and pt what they think is the most likely thing going on, but if they want, you can do a bunch of expensive tests for zebras, for which they will owe a % copay, they will most likely say no.

MedStudent said...

I'm with Packer.

Is it feasible to explain the situation and options to the patient and/or family and let them decide?

Anonymous said...

terri c

I agree completely. 6 weeks ago, I broke my leg. Today, I opened the bill for my surgery. My insurance was billed $53,000+ for my hospital stay. Just the stay, not the doctor. Insurance paid about $8000. My portion is zero. If I didn't have insurance my portion would be $53000?! I don't quite know how that works, but it sounds like a mess!
I have no idea what the real cost is. I doubt anyone does.

Anonymous said...

It was as a result of a barrage of tests, some probably not really required, and for a totally unrelated matter, that the Drs discovered my 23 year old daughter had an atrial myxoma that had not caused any symptoms at all - yet.

It was removed and her life saved from an event further down the track!

Anonymous said...

Anon 12:47:

Perhaps, "wet read," is no longer the correct term (however, I hear it used often and recently had my own CT done and WET READ was a choice on the form---revised 2004). If "WET READ" is not the term, then what is it? A STAT READ? Thanks!

The PCP requested it to be read immediately, so the imagining center had to call the radiologist (all scans are read off site) who was doing the reading at that moment and let him know that patient was waiting, per the MD's instructions.

The only choice the family member had was which hospital he wanted to go to. He was permitted to go home and get a few things, only because we had to pass his house to get to the hospital (he was met in the ER by another MD within 45 minutes of getting the results) it was too late for a direct admit or he would have gone directly to the floor.

Sure, the MD could have sent him to the ER for the CT scan, but if his Spidey Sense was wrong, why use up the resources of the ER? But because he was right, a serious and DEADLY crisis was avoided.

Anonymous said...

My comment was just an aside. I agree that some tests require an immediate interpretation. Our choice of wording is either STAT or VERBAL required.
On the PACS and RIS that most places use, the technologist or even receptionist just clicks on the STAT box, and it will move the case up to the top of the radiologist's worklist along with a red flag of some sort.
I agree that off-site centres take the pressure off hospitals, and am not disagreeing with you at all. Just one of those terms that has long outlived its relevance.

Rathskeller said...

This particular case does seem applicable to a little Bayesian analysis. for this type of patient, the odds of everything you noted are probably known: marked confusion after Tylenol #3, risk of TIA, risk of metabolic event, risk of seizure, etc. And many of the answers to differential diagnosis are already known from patient history: no history of seizures, current orientation is perfect, etc. If you had a program assisting you, you could have come up with a "better" number, which you could act on yourself, or present to the patient, e.g, "All the information we have now points to this being 98% likely it was just the medication, which you've stopped. Do you want to pursue more analysis with tests now or wait & see?

I know doctors tend to abhor the idea of computer assistance during diagnosis, yet this case seems like it would have been especially helpful. (I personally couldn't do the Bayesian analysis in my head, and I would doubt nearly anyone who thought they had done it correctly.)

CT tech said...

I know, wouldn't it be nice if, when we found a reasonable explanation for the symptoms, we could just go with that, rather than ruling out every possible cause?

John Woolman said...

It all comes down to "clinical Judgement". Science, experience, mature reflection and intelligence. And blessed is the physician who has it as is her patient.

Officer Cynical said...

So, I've been right all along. I just ignore whatever it is, and eventually it goes away. And if it kills me, I won't be around to bitch (or sue) about it .

Jess said...

Well, the only thing I can say is that most medical professionals do a damn fine job with dealing with modern medicine. I appreciate their work and concerns.

Anonymous said...

I can appreciate the comments from people who found something early or unexpected because of a barrage of tests but sometimes that can backfire. I had a discussion with a neuroradiologist recently who had an unnecessary CT head ordered and an incidental aneurysm was found. Because it was found, it was clipped and she suffered a major complication during the procedure. And from the standpoint of worrying about lawsuits it was actually the doctor who ordered the initial CT head without a good indication who got sued (successfully).

Sometimes ordering things just to cover your a** doesn't work either.

C said...

the older the patient, the more likely you will find something else wrong if you do more tests...boyfriend's grandmother, however, lived to be 111, so for her, 78 was young...I agree with Packer that "after a certain point" less should be done, but God help us if the "point" is just decided from a chart or an algorythm because everybody really is not equal in the life expectancy area and a lot depends on the individual and his/her overall condition.

Anonymous said...

Anon 3:21:

I understand it was an aside.

Are you saying that WET READ is not the same as STAT?

Not trying to cause an argument, just looking to be informed.


Rathskeller said...

> God help us if the "point" is just decided from a chart or an
> algorythm because everybody really is not equal in the life expectancy area and a lot depends on
> the individual and his/her overall condition.

I think you've missed something important about the status quo. On the one hand, you have the physician's judgment and experience combined with whatever information they're aware of. Not good, but better than roots & berries or whatever they used in the 19th century. On the other hand, you have for-profit companies that DO use algorithms and charts to decide what procedures and medicines to pay for, on top of additional flim-flammery.

You're talking in a general, fear of the future sense when you speak of avoiding charts and algorithms, but you're ignoring the reality that this is happening right now, sometimes explicitly against physician's strongly-felt opinions. I presume that older patients suffer the most in these type of situations, although I do not know for certain.

I vividly remember my physician a few years ago talking about a potential medicine, then stopping herself, checking my insurance, then continuing the discussion. If that medicine had not been on the formulary, her judgment would have been effectively overruled. Who benefits from that? Me? I don't think so...

Anonymous said...


I think the fear around a program is two-fold. First, who dictates what goes into the program? Risks and algorithms are not determined by a single study alone. Guidelines for heart failure, for example, are set up by a panel of experts who analyze the studies out there, determine which ones are good designs with solid results, and make a conclusion based on them. Second, doctors don't want to be replaced, or feel like a program is overriding their own decision. How much power is given to the program?
As for the rest of your first comment and your second comment, you sound like an intelligent individual and a responsible patient. Some patients unfortunately are not. Some would have no idea what to do if they were told "You have a 98% probability of being OK. Do you still want tests anyway?"

Rathskeller said...

> Some patients unfortunately are not [ responsible ]. Some would have no idea what to do if
> they were told "You have a 98% probability of being OK. Do you still want tests anyway?"

Indeed, one of the most harrowing and frustrating posts Grumpy has put up here concerned the wife of a stroke victim who pathetically couldn't decide what to do within the typical 3-hour window for giving tPA, despite ample time to decide. Her husband almost certainly had a worse outcome because he married a ninny. And I personally am not sure how I'd react if a doctor said we're 98% sure you didn't have a stroke, mind if we don't do a MRI?

The two points I'm making are just this: first, you could design interactive programs for different specialties that requested all the information you had, it could suggest both diagnoses AND the cheapest/lowest harm ways of making the differential diagnosis more accurate. That is, it would tell you what to test next or what to clarify in terms of patient history. It could avoid some of the agita, and narrow in on some issues in a rapid way. This would supplement the doctor's skill, and could never replace it.

Second, insurance companies are doing a much cruder version of these programmed diagnoses now, maximizing their profit. they frequently override doctors on treatment options, and doctors have to regularly fight with them just to give the standard of care.

cliffintokyo said...

You are so professional, I sometimes wonder if you are too good to be a doctor!

WV: backc

That's me, Back-you-up - Cliff

Anonymous said...

I just don't get why doctors have to be sued all the time. they are human and some things they just cannot possibly recognize. i get why you'd sue the doctor who left his car keys in your belly but other than that.. maybe grandpa's time has just come after he lived 90 fulfilling years.

Anonymous said...

There was a time when your doctor KNEW you and you knew him. It was possible to have complete faith in him and his judgment because a person could confidently "bet the farm" knowing he had their best interests at heart. I had a doctor (he is dead now) and we went through everything together. He delivered my sons, fixed their broken bones, sutured their cuts, and treated their ear infections. He saved my oldest son's life. One time he slept down the hall, even though he only lived four blocks from the hospital, because he wanted to BE there just in case I needed him. If he had told me to go home and spin around three times under the full moon I would have done so because I knew I could trust him. Was he infallible? Absolutely not. Was he ever sued? Absolutely not. He was a beloved member of the community. Alas, those days appear to be gone and do not even get me started on those f***ing insurance companies.

Anonymous said...

According to the lawyers, there is no such thing as defensive medicine. If you just provide the standard of care, you'll be fine!

mcb05 said...

I feel your pain. As a veterinarian, where our clients actually have to PAY the bill, and our patients cant even talk, its always a struggle. If you do to little and they don't get better quick enough, then you are a terrible doctor, if you start running tests to try to figure out what the heck is wrong then you get accused of doing things just to pad the bill and make money...

Suzanne said...

I'm in Canada and I chose medical transcription because I really respect our healthcare system and its professionals. I'm convinced that two things need to happen: People need to be educated early on about the tendency to deify doctors and start treating them as human beings; people need to have healthcare as a subject taught in high school, at least, in both Can/US.

I think many would be shocked to discover just how similar the two systems are. People would grow up with a sense of responsibility for their own healthcare and could handle a pop quiz about different levels of care with ease.

Better informed general public could mean doctors wouldn't be pressured, we'd save money and build respect for the very systems that need the money to save us.

(Oops! Don't mean to go on so. It's 117 F with humidity where I am.)

Anonymous said...

Despite having a life expectancy of at least 95 myself, I am in favour of palliative care only for all those over 75. (Joins Packer in the bunker).

Vicky said...

"I had a discussion with a neuroradiologist recently who had an unnecessary CT head ordered and an incidental aneurysm was found. Because it was found, it was clipped and she suffered a major complication during the procedure. And from the standpoint of worrying about lawsuits it was actually the doctor who ordered the initial CT head without a good indication who got sued (successfully)."

So an informed person, a neuroradiologist, is informed about an aneurism and the possibility of treatment -- clipping it in surgery. She has to choose whether she wants to leave it there or clip it and decides to clip it. Being an informed person, she understands there are risks involved in every procedure, but she chose *inspite* of them.

And then she has her procedure, chosen by herself, and complications happen. And she sues -- *successfully* -- a doctor that first ordered the exam that found the aneurism??? WTF? Did the exam implant the aneurism there as per doctor's requests?

That's just so sick and twisted.

Chris said...

Tort Reform. Thats all I gotta say.

mikraas said...

I wonder what would happen if there were laws that made it illegal to pay doctor's for their testimony.

Or they get paid what the jury gets paid for their time.

Frantic Pharmacist said...

I hear ya, Dr. Grumpy. I hear ya.

Anonymous said...

Move to Canada, dude. We don't sue much at all and we're all insured. Oddly enough, doctors stick together like glue here so no worries there. Sure, you may not become filthy rich but you can have both a comfortable life and peace of mind!

Anonymous said...

The problem with chronological age is, it's quite relative. For example, a 78 year old person might not be "old". Yet, their 62 year old friend might be quite "old" because they're suffering from more of the collection of end of life symptoms.

I guess the way I look at it, is the person's overall health. If they're 78 years old and have no other diagnoses (not uncommon!) Why shouldn't we treat them?

But if they have CHF, HTN, DM, and Renal Failure, then we should start looking at scaling back the heroic measures. Most of the time, getting to that sort of stage means you were quite non-compliant with your treatment.

Bottom line - take care of yourselves or pay the price. *Hides in the bunker*

Anonymous said...

To anonymous about "WET READ" Yes, wet read and stat are the same thing. I'm just pointing out that that expression is old hat. Films are no longer read when they are wet and dripping with fixer or rinse. It took a few minutes to get from exposed film to readable image.
Some techs would crank up the temp so the films would process faster. Once it was fixed, you could look at it and see what was there. It still needed to be rinsed and dried, but the film could be read when it was LITERALLY (correct use of the word) wet.
In fact, seldom are images even recorded on film now. Most places have gone to computer recorded images, that are ready if not instantly, within 5 seconds of instant.
So, no dripping fixer. That stuff stunk, but it was the developer tht stained the clothes. (And probably the lungs)

Anonymous said...

I'm a zebra and had the opposite experience...had every test known to humankind over 5 years and was told repeatedly what the test said wasn't really the problem...I guess because they weren't sure what to do with what they were seeing? Weird. Now I finally had surgery for said problem, and am healthy for the first time in years.


Diane said...

The cost of stuff is amazing. But it varies so much - here in Houston area, MRIs vary from $380 (incl. your CD of it) up to over $4,000. I recently had labs done, over $1,000 at the hospital, with over $300 disallowed by insurance as 'excessive'...called the local medical clinic - total there for all the labs - $155. I'm tired of supporting those that don't pay.

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