DB’s Med Rants slurs EP’s

A doctor I used to think had it together shows himself to be yet another ED basher, and a rather arrogant one to boot.

In a blog post today Dr. Centor unloads egregious tripe on me and my colleagues:

The second major concern is over use of technology in the emergency department.  Ask any practicing physician about testing in the ED.  Patients have too many imaging studies.  I think we all understand why those studies are done, but a significant percentage are clearly unnecessary.

Now clearly, ER physicians have a high exposure to malpractice claims.  When in doubt, they image.  The emergency department is often overwhelmed with patients, so technology trumps the history and physical examination.  We need a multispecialty panel to develop reasonable standards for technology use in the ED.

In case you missed it I’ll rephrase: there are too many imaging tests in the ED because EP’s are too lazy or stupid to do a history and a physical exam, so we just CT everybody.  Additionally, EM isn’t an actual specialty, so other specialties need to meet and tell them what to do.

The contempt he (and apparently his friends) hold the ED in is inexplicable though sadly common.  I’d like to have him explain the patronizing ‘I think we all know why these studies are done’ that’s not doublespeak for ‘they aren’t as smart as we internists are’.

First the monetary rebuttal to this load: as of 2006, ED care was 3.5% of the total healthcare budget.  Squeeze out all the negative imaging studies and it’d be less, but getting a margin out of 3.5% to make a dent in total healthcare expenditures would be difficult to say the least.

EP’s image patients after a history, a physical examination, and in order to rule out life threats while still focusing on the most likely diagnosis.  The statement “when in doubt, they image” is both dismissively arrogant and ill informed.  Are there a large number of scans done in EDs?  Yes.  I’ve called Dr. Centor on this bias hobby horse of his before, but he doesn’t want to hear it.

 

As for needing ‘multispecialty panels to develop reasonable standards for imaging in the ED’, he’s ignoring two very important things.  First, EM is an actual specialty with its own standards and unique fund of knowledge, since 1979.  From ACEP:

In 1979 emergency medicine was recognized as the 23rd medical specialty, a major milestone for ACEP and its members. The American Board of Emergency Medicine, the independent certifying body for the specialty, was also established and the first certification exam was given in 1980.

Second, EP’s do the studies they do because they have a higher diagnostic yield in the shortest amount of time.  A urologist would prefer an IVP for that hematuria and flank pain, but the CT will pick up the renal artery dissection a lot better than the IVP ever will.  EM is past needing specialists telling us their worms’-eye-view imaging recommendations, thanks just the same. 

 

Dr. Centor’s proposals about the ED are unwarranted from an economic perspective and unfounded from the medical.  Let’s hope nobody offers him that Health Czar post, and that if there is such a person they focus on actual problems and not peeves. 


Comments

  1. Perhaps the Rantologist would like to address his colleagues and the “on-call” advice services that: 1. commonly believe that the ER is an office extention (“just go to the ER”) and 2. invariable suggest testing, x-rays, and CTs for almost every problem. My comments from several years ago to another of the Rantologists, specifically:

    Finally, I practice on the tip of the emergent healthcare spear, some aspects of my practice are defensive in terms of thwarting future litigations; but also defensive because of the need to block the offenses of my fellow healthcare colleagues. My clinical agenda are many times set by the defensive agendas of my clinical colleagues, and many times completely beyond any backfield maneuverings.

    Perhaps if they understood the “emergeny” in “Emergency Medicine” they wouldn’t frontload patient–expectations with their fears and defensive practices—we could help them with a single–specialty panel develop reasonable expectations and utilizations of the ER and “ER technologies.” Of course that would be asking the Rantologist to look in the mirror… Perhaps more primary care would be helpful, since we have neither the training nor disposition, not to mention time, to provide the services that are being shucked by many and forced upon a single specialty.
    Truly an enlightening observation by the Rantologist: testing might be done in lieu of time spent with the patient. Gosh, I wonder if the surgical specialties have heard of this…

  2. So what does DB suggest? The whole point of the emergency room is just that — aside from the folks who are just clogging the triage desks with runny noses and splinters, people are there because they’re really sick. I spent a day in our ER after intermittent side pain became constant and severe, very early on a weekend morning. And yes, I had an ultrasound and a CT scan, because the doctors figured it was important to know whether I was having appendicitis, ectopic pregnancy, or a kidney stone. The courses of treatment are somewhat different.
    Rather than assuming all ER docs are attempting to cover their asses with unnecessary testing, why not realize that in most cases, doctors are acting in the best interest of their patients. They are using the available technology to quickly and accurately diagnose & treat illness.

  3. TheNewGuy says:

    Well shoooot… I shur do ‘preciate ole’ Doc Centor helpin’ us poor ER docs out. ‘specially wit me gettin’ mah board certification outta a craker jack box ‘n all…

  4. I’m not a doc, and not in your industry at all. However, in my industry (computer programming), we refer to people who post things like that as “dickheads”

  5. Please read what I said carefully. I do understand the overuse of imaging studies in the emergency department. I also truly believe that we could decrease the number of such studies without compromising health care. I have discussed this with hospitalists all over the country. I have discussed this with radiologists.

    I am not attacking ER physicians. I am attacking the system which sends too many patients to the ER. I am attacking a malpractice system which puts ER physicians at greater risk.

    I was careful in my rant, and do not plan to apologize for my statements. We all need to work to save health care costs. The emergency department should not be immune.

  6. “Emergency Medicine is being second best at everything, and second guessed by everyone.”
    We may not be cardiologists, but we are pretty handy at interpreting EKG’s.
    Of course, the cardiologist will complain that we did a CTA coronary when they would have preferred a stress echo
    We may not be surgeons, but we can but in a chest tube with the best of them.
    Of course the surgeon will be the first to be critical of the size of the incision.
    We can treat a patient for sepsis but the ID specialist will question our choice of antibiotics
    We can treat diabetic ketoacidosis, but the endocrinologist will consider our treatment of simple hyperglycemia as crude.

    There is not much out there where EPs are not capable of getting a patient out of trouble, but we are not, definitive care in anything in particular except for running codes, whether they are medical or trauma. It is very easy for other specialists to review a narrow spectrum of medicine and point out the faults, but that ignores the great body of work we do in other areas. I have had ortho residents complain about me tapping an ankle. Of course, these same docs will turn to me with an EKG in hand, because they have no clue as to what they are looking at.

    I also agree that internal medicine can easily complain, but they have to deliberately ignore the fact that when their patients show up to their office, they know them, where we do not. They also have the option of firing patients when we do not. They can also punt to the Emergency Department when they start to get out of their comfort zone. We cannot call the cavalry. We are the cavalry. I cannot count the number of times that a patient showed up at my doorstep because their primary care either told them to come to the EC for something they could have and should have given taken care of themselves, or because their primary stopped answering their calls/ went on vacation/ didn’t give them good instructions, and they showed up to the ED out of frustration. We end up taking up the slack whenever a primary care doc can’t get their sh*t together.

    Naturally, these patients are poor historians, can’t recall their meds, and unlike primary docs, we do not have an established history. We have to make decisions based upon incomplete or frankly inaccurate information, so we end up doing more imaging and lab testing than we would like, and then finally, once we have done our sleuthing, and figured out what the Hell is going on, the specialist comes along and looks down their noses at us for unnecessary testing based upon what is *now* a known diagnosis. It’s easy to look back and see where energy and resources were wasted, but it’s very hard to look forward at a vague complaint by a poor historian with an ambivalent exam and know intrinsically what is going on.

  7. I have discussed this with hospitalists all over the country. I have discussed this with radiologists.

    What about EM specialists?

  8. “Dan” is right…

    I have been doing EM just long enough that I don’t pay a lot of attention to what others think we should be doing in the ED. However, I encourage all the specialist to spend a weekend working in the ED and then let me know what I should do different.

  9. Agreed, Doc Russia. DB is focusing on the wrong reasons we image. He says we image because we don’t do an adequate history and physical; but I’d argue that more often we have absolutely no history to go on: charts aren’t available, patients have no idea what their medical history is, what pills they’re on, or why they were admitted to the hospital last week, or whether their cath was normal or not (or if they got stents put in!).

    Patients show up to the EMERGENCY DEPARTMENT, and gosh, we work them up for EMERGENCIES. Are most of our CTA’s negative for PE? Yeah, they are. What are we supposed to do about it when the patient is persistently tachy, and we don’t know what the outpatient doctor does–that they forget their beta block frequently and/or have anxiety.

  10. Dr. Centor,
    I did read it carefully (I moved my lips and everything). I got it right, and you need to look inward a bit more.

    Now try reading my post again, and explain your egregious and unwarranted contempt for Emergency Physicians. And while you’re at it I’d also like to know why you’re willing to talk about us but not to us.

  11. “In case you missed it I’ll rephrase: there are too many imaging tests in the ED because EP’s are too lazy or stupid to do a history and a physical exam, so we just CT everybody. Additionally, EM isn’t an actual specialty, so other specialties need to meet and tell them what to do.”

    Grunt Doc.

    I didn’t see “lazy” or “stupid” in DB’s rant. He said in his post and in the comment above that it was the system, not anything inherently stupid or lazy about ER docs, that drives unnecessary imaging. Why can’t you (and your commenters) take those words at face value? And does DB really have contempt for Emergency Physicians? Either you know him personally very well or there is some psychological projection going on here.

  12. Please refrain from ad hominem attacks. I do not have contempt. I do think that the pressures that emergency physicians face can lead to shortcuts. Many primary care physicians do the same thing for the same reasons.

    I know emergency physicians who have great judgment. I know others who just order tests.

  13. Goatwhacker says:

    I think DB has a point, and the ED Docs here are taking this way too personally. Most of my experience is with small to medium hospitals so possibly it won’t apply to larger centers, but I don’t think there is any question needless imaging studies are frequently performed. When I worked in the ED I ordered studies that were probably unnecessary and so did every other doctor I worked with.

    The reason isn’t because EM physicians are stupid or lazy. It usually boils down to fear of litigation, attempts to meet patient expectations, or the ED physician being overwhelmed and having to use the CT/X-ray as a form of triage.

    The solutions would be tort reform, changing patient expectations, and/or more ED physicians. Since I don’t see any of those improving in the foreseeable future, it’s not a likely spot to cut costs any time soon. In that sense DB’s article is putting the cart before the horse.

  14. Patrick Baroco says:

    Wow, Grunt Doc, paranoid much? Clearly you disagree with Dr. Centor, but he certainly was not attacking you personally. Your rather shocking personal attacks in return seem a bit childish. If you read Dr. Centor’s posts in general, you’ll see he is equally critical of those within his own specialty who practice carelessly, and is _always_ critical of the system that encourages–indeed, often requires–wasteful testing.

    It seems you were looking for a fight and determined to find one, even if it requires reading personal attacks into statements that contain no such thing.

  15. “Needless” tests are always those ordered by someone else, and it presumes you’re smarter and have better clinical skills than the person ordering the test (and never before the test is resulted). Complaining about needless testing in another specialty without walking in their shoes in the current practice environment is unwarranted, and frankly arrogant.

    As for the rest, I’ve been over it, and have nothing to add.

  16. Patrick Baroco says:

    GruntDoc,

    So I presume you do not believe internists, surgeons, ob/gyn, family practice, nor any other specialty have ever ordered tests needlessly? I cannot see but how that makes you either a naif or a hypocrite. If you truly believe they do not order any “needless” tests then you are a fool. I see it in my own specialty all the time. If you do believe so, you are a hypocrite for launching a personal attack on somebody who suggests there could be improvements in efficiency in your specialty–especially when that same person consistently calls for improvements in his _own_ specialty.

    Or perhaps you will say you do believe other specialties test needlessly, but do not point it out. But that smacks of cowardice, and seems unlikely, for surely you know such discussions can be had in a professional and polite manner. To wit, see Dr. Centor’s post, which was completely devoid of ad hominum attacks.

    It is my impression that Dr. Centor considers himself a _physician_ first, and sees specialties second. Improvements in one specialty benefit us all–and benefit our patients most of all. We should all strive for that. But first you need to let go of that impulse to attack when somebody suggests things are not perfect in your workplace. Unless they are indeed perfect, in which case I am most envious. My specialty has a long way to go–and I myself even further.

  17. Dr. Baroco,
    Dr. Centor didn’t call out all specialties in his post, he specifically called out EM, and only EM. This was a focused attack on me and my colleagues in EM, one which he’s engaged in before.

    I’ve never said either that I am perfect or that there’s no need to improve; indeed, I will be the first to point it out. However, when Dr. Centor goes well out of his way to insult EM specifically and pointedly I’m going to call him, or anyone else, on it.

    (Your second paragraph indicates you didn’t read my last comment very well, so I don’t understand your position).

  18. Patrick Baroco says:

    GruntDoc,
    It was a blog post. I doubt it was intended to be a comprehensive review of various specialties’ use/overuse of testing and imaging. He did use the ED as his example. Where I guess we disagree is that you read criticism as being an insult. There is no insult in his post–the best you have to offer is you believe he was using “doublespeak.” I believe you are overly sensitive.

    As for your parenthetical, I read your comment very well. You stated:

    “Needless” tests are always those ordered by someone else, and it presumes you’re smarter and have better clinical skills than the person ordering the test (and never before the test is resulted). Complaining about needless testing in another specialty without walking in their shoes in the current practice environment is unwarranted, and frankly arrogant.

    By your own comment, you make it clear that it is unacceptable to call somebody else’s testing “needless.” I think you are wrong. I believe that we can have a discussion on improving cost efficiencies–where I suggest that ED physicians, like all others–order some tests that are not strictly necessary, and that I can do so without being arrogant. You clearly disagree, and believe that only ED physicians can criticize ED physicians. I suspect you are a hypocrite, but at best you are childish.

  19. Aah, you were doing fine until you threw in the childish at the end (and the coward in the prior post), so I’ll assume you don’t think before you type. You get the benefit of the doubt.

    Again, Dr. Centor didn’t say ‘for example’, he very clearly slighted the professional competence of Emergency Physicians solely and directly. If you want to criticize us, fine, but be prepared to back it up with facts; demeaning comments about me and my colleagues H&P skills don’t ingratiate you to the audience you’re criticizing, even if you mean it constructively.

    The second part of his post about EP’s nails the intent of the first: we need outside supervision. That speaks volumes to his mindset in the first paragraph. Want a collegial discussion? Fine: treat me like a colleague and not someone run-amok with the CT scanner.

  20. Quick! Name Alert!

    (Man, for a minute I came over here loaded for bear, only to find your “EP” means something different than “Electrophysiologist.” But hey, we do lots of tests, too.)

    So, just to keep the arrogant theme going, I call first dibs on the term “EP.”

  21. Patrick Baroco says:

    You flatter yourself, GruntDoc. I _do_ think before I type. But I can understand why you wish to think I do not.

  22. Patrick Baroco says:

    To reiterate, I simply think you are being overly sensitive, and that you are unwise when you explicitly preclude the possibility of an adult discussion on this matter. So I guess I am just spitting in the wind, and will leave you alone…

  23. Utter nonsense: “It is my impression that Dr. Centor considers himself a _physician_ first, and sees specialties second.” That mindset hasn’t existed since the specialists became dominate over the generalists—what, 40 years ago. Reimbursement hasn’t followed that notion for about as long. Is there wasteful testing in medicine? Emphatically yes! Is there needless imaging tests? Again, emphatically yes! Does Emergency Medicine participate in this overuse? Of course it does, but the practice is universal, chosing a specialty for focused attention speaks to Centor’s bias, and not the causes or remedies.

    Part of being in a specialty is recognizing the autonomy of that specialty, and the autonomy of the other specialties. Emergency Medicine was formed as a conjoined board in 1978 and obtained primary board status in 1988. Centor’s notions of “multispecialty panel to develop reasonable standards” (for “ER physicians” to follow) are anachronistic by twenty years. Centor’s conclusory statements were facial insulting and would not have been leveled at any other specialty. Clearly he sees two classes of physicians: “practicing physicians” who see the problem,” and “ER physicians” that create the problem.

    The use of the perjorative, “ER Physicians,” only accentuates Centor bias against a specialty defined by a room and not a discipline. Of course, I may be wrong—I’ll ask my colleague the “OR Physician”…

  24. Didn’t Dr. Centor make it clear he felt it was the environment and culture in which Emergency Physicians practice (too little time to spend with patients, increased liability) rather than some inherent quality of Emergency Physicians that drives excessive testing? Aren’t you putting words in his mouth?

  25. Patrick Baroco says:

    See, I think when people start ranting that “ER physician” is a blatant insult, something has gone off a cliff. I think it says more about habits dying hard than anything else. Yes, yes, I know that it is now the “Emergency Department” and not the “Emergency _Room_”, but hell, it’s been the “ER” for a long time. Any really, what the hell does “internal” medicine mean? Should I be insulted that it doesn’t account for all the “external” work I do? I mean, some days its just one rash after another!

    As for developing standards, we all have standards imposed on us. JCAHO for one. CMS for another. Surely you do not view EP’s (and I agree with the above comment–I’ve only heard that abbreviation applied to electrophysiologists, but hey, I’ll go with it) as entirely self-regulating? If so, yours would be the only such specialty!

    Lastly, if you wish to talk about subtle slights, I’ll point out it is _Dr._ Centor, as you well know from your first sentence. The rest of your paranoid rant omits that.

    Am I in the wrong place? Is this a place for Emergency Physicians to rant about how mistreated they are? If so, then I’m just being rude by crashing the party. But if this is supposed to be more broad-based, then I’m really just still trying to figure out what pissed everybody off so much. Dr. Centor could have said the exact same things about internal medicine, and my response would have been, “Damn straight. Too many people ordering [insert excessive test here] just to cover their ass. No data to support it, and meanwhile my uninsured patient down the hall can’t get the meds he needs.” It’s not a problem in Emergency Medicine, it’s a problem in MEDICINE.

    Lastly, about that crack about nobody being a physician first. You proclaim you are not, and I certainly believe you. But I definitely think of myself that way, and I guess that is why I am so confused about why y’all have run so far with this fight. Aren’t we on the same team? Though Dr. Centor’s wording may have offended, there was nothing patently insulting in anything he said (unless you believe all ED’s to be the model of cost-effectiveness) and it just seems y’all are itching to fight. But why? Has self-esteem become a big problem amongst EP’s?

  26. i don’t know who is right or wrong, but wow, it sure seems like the er guy’s are touchy on the subject. btw i agree with dr wes, ep stands for electrophysiologist in these parts.

    i didn’t find it accusatory in particular. there is debate in nejm and wachter’s world about the utility of the physical exam in today’s world, and this debate may stem as much from differences in the ages of the participants as anything.

    certainly the terms needless and overuse can be subjective and reflect the differences in the nature of the medical practices of the debaters. if someone says they did not mean to be offensive, why not take them at their word until proven otherwise?

    i also find it curious why the er doc russia says they are the cavalry and don’t call for help. certainly er docs call for help just as much as anyone else does. so i can understand the cavalry part in some sense, i think that is an exaggeration.

    imo, it is also probably not fair to say primary care docs don’t have experience making the initial diagnoses from vague or nonspecific symptoms. they probably do it as much as the er docs. whether they do it better or more or less efficiently i will leave to others to discuss.

  27. If you won’t take DB’s words at face value then you have to try and read his mind. How reliable is that?

    BTW, in the past I’ve used the term “ER doc” with great admiration and respect. What would be a better term?

  28. Permit me to go in a little further on the cavalry comment;
    True. We do ask for input from specialists. This is usually done because, as I also stated, we are not definitive care in many circumstances. We also do it in order to facilitate continuity of care. If I have any concerns about follow-up I will call the other specialist in order to communicate my findings, and my concerns.
    What I mean is that when a patient comes into the ED with, say, an arrhythmia, we do not (although there are exceptions), as a rule go “huh! would ya look at that… let’s call an electrophysiologist.” While there are some EM docs who act like glorified traffic cops directing which specialist to send the patient to, we otherwise do our best to diagnose and treat the arrhythmia first, *then* we call the EP or cardiologist with what we saw, what we did, and how we think it would be best for the patient to follow up with the specialist.
    Was I perhaps being a bit bombastic? Yes, perhaps.

  29. As an ambulance driver, I do not really have a dog in this fight. If anything, I am critical of much of what emergency physicians do. But here is my way of looking at the way people are interpreting what Dr. Centor wrote:

    The second major concern is over use of technology in the emergency department. Ask any practicing physician about testing in the ED. Patients have too many imaging studies.

    This seems to encourage everyone to gang up on emergency physicians.

    Why is any practicing physician qualified to judge the number of imaging studies used by any one specialty?

    If you were to state that any practicing physician knows what the problem is with any other specialty, I would expect that many in that specialty would feel offended. And I do not think that it would be unjustified.

    I think we all understand why those studies are done, but a significant percentage are clearly unnecessary.

    I think that some are reading the first part of this sentence without taking the second part into consideration. The first part of this sentence appears to me to be saying that there are legitimate reasons for imaging. The wording I think we all understand why is often used by someone to belittle what someone else does. Such as I think we all understand why those dirty rotten nogoodnicks do . . . . Following the call for any practicing physician to judge emergency physicians, jumping to negative conclusions does not seem surprising, or paranoid, or overly sensitive.

    Now clearly, ER physicians have a high exposure to malpractice claims. When in doubt, they image.

    Isn’t that the purpose of the imaging? If a thorough assessment, short of imaging, does not provide the information you want to feel comfortable in treating a patient, don’t you move to something that may help you find that comfort level?

    The emergency department is often overwhelmed with patients, so technology trumps the history and physical examination.

    There is one emergency physician I know who has a reputation for scanning everything. Ice cream headache? Maybe he needs a CT. :-)

    I feel comfortable criticizing his use of imaging, but he also does a very thorough history and physical before ordering anything.

    Suggesting that emergency physicians abandon history and physical examination, because they are overwhelmed is not an argument that I think can be supported. Quite the opposite. If things are especially busy, the history and physical are the quickest, most productive way to find out what is going on. Creating a line of patients, waiting for imaging, is only going to slow down disposition. If the emergency department is functioning at capacity, there is a chance that radiology is, too. Imaging a higher percentage of patients, because the ED is busy, will only slow things down. The patients who really need to be imaged will be more likely to have delays. I think emergency medicine specialists understand this.

    We need a multispecialty panel to develop reasonable standards for technology use in the ED.

    If you do not see the insult in this, perhaps look at it this way (and feel free to substitute whatever you want for technology use – antibiotic use, anesthetic use, . . . ):

    We need a multispecialty panel to develop reasonable standards for technology use in the ICU.

    We need a multispecialty panel to develop reasonable standards for technology use in the OR.

    We need a multispecialty panel to develop reasonable standards for technology use in the cath lab.

    Then in the comments, the defense is this:

    Please read what I said carefully. I do understand the overuse of imaging studies in the emergency department. I also truly believe that we could decrease the number of such studies without compromising health care. I have discussed this with hospitalists all over the country. I have discussed this with radiologists.

    Now go back to the multispecialty panel comment and, since Dr. Centor seemed comfortable listing the people to be consulted on use of imaging in the ED as not including emergency medicine specialists, rephrase the multispecialty panel to read any specialty except emergency medicine. Maybe I read too much into this, but if you want to know why this has touched a nerve, I think this has a lot to do with it.

    We need a multispecialty panel, excluding internal medicine, to develop reasonable standards for technology use in the ICU.

    We need a multispecialty panel, excluding surgeons or excluding anesthesiologists, to develop reasonable standards for technology use in the OR.

    We need a multispecialty panel, excluding electrophysiologists, to develop reasonable standards for technology use in the cath lab.

    If things need to be changed, and I don’t think that there is disagreement about that, start with a panel of emergency physicians.

    Dr. Baroco compares a multispecialty panel with JCAHO. As if that is a good thing? JCAHO is the antithesis of quality. Yes, everybody does put up with outside regulation. That does not mean that the way to bring about improvement is to bring in outside regulation as the first step.

    If you want to change imaging in the ED, ask the emergency medicine specialists to do it.

    If you want to have a significant effect on waste in medicine, do not limit yourself to overuse in the ED. There are many problems in medicine. Choosing just one example of overuse is a good way to make that specialty feel they are being picked on.

    If you wish to prevent change, picking on one specialty is a good way to divert attention from the problem and focus it on politics.

    I think that all of this demonstrates that.

  30. TheNewGuy says:

    Those who think Grunt is being paranoid should perhaps ask themselves why the article raised the hackles of every EM physician in this discussion, including myself and Doc Russia.

    If you’re trying to push physicians to change their practice, and you’re pissing off 100% of your intended audience, you’re doing it wrong.

  31. As some nurse who has seen thousands of ER/ED etc etc patients, I think it would be a swell idea for the ER/ED/EP etc etc etc medical directors/administration themselves to question some of the scans ordered sometimes. There are some really goofy practice patterns that I’ve seen, such as one doc that MRIs knee sprains and another who, seemingly at random, might image everyone’s chest for aortic dissection (maybe 5 scans for that in one day and then none for a month). Usually he images everyone for aortic dissection when there is a med student with him, but I digress.

    You don’t need a bunch of internists to question it, but somebody should be. It seems, again, as a casual observer and from what I’ve heard, that our administration does no such thing. It’s different to say “hey did you really need to image that one guy” vs “why are you MRI-ing all/most of your knee sprains?”

    It seems too that the emergency residency-trained physicians have a method to determine who does and does not need a scan based on some sort of learned criteria that seems to be rather consistently followed vs. a more random approach from some of the non-emergency residency docs at my work.

  32. how is three individuals 100% of the intended audience?

  33. You know, I like his idea of having multi-specialty groups police each other.

    I want to be on the one that evaluates internists who don’t follow their own JNC 7 guidelines for severe asymptomatic hypertension and instead just panic when they see the numbers and send that pt. to the ED.

    Or the one for surgeons who dismiss altered mental status and belly pain and order a contrast CT. Then rush the pt to the OR 6 hours later when they see the pneumatosis intestinalis on CT.

    Or the one for the OB/Gyn docs who told me to transfuse 2 units of PRBC’s for the lady that was bleeding heavily and hypotensive post hysterectomy and then told me to send her home for follow-up tomorrow (apparently in their autopsy clinic).

    Or the one for the FP guys who prescribe Zantac to the pt with unstable angina, then I see that same pt a week later with an STEMI.

    We see everyone’s screw-ups in the ED, don’t forget that. I am willing and able to start casting stones at everyone else.

    We do police our own in the ED. DB, how about you mind your own beeswax? Or come up with a better solution? Trust me, we often talk about saving on the healthcare dollar. Clean your own house first.

  34. AnonPatient says:

    I think it’s humorous that the history and physical exams are claimed to be insufficient.

    I suffered from a severe Crohn’s Disease flare last year that ultimately ended in needing surgery.

    In the time frame between establishing that I needed surgery and the actual surgery, I was not ill enough to stay admitted in the hospital nor was I well by any means. As a result, I ended up in the ER a good number of times due to severe pain which only could be helped by IV pain medication (believe me that this was not someone over reacting to pain as I was told by both ER nurses and doctors that it was obvious I really needed help and if my pain medications at home weren’t helping, it was probably a good idea that I be evaluated in case that was the day that something further did go wrong).

    After establishing that I didn’t have a fever and sending test to check against infection (and the one time I did, I had micro-abscesses and was immediately scanned and admitted), I was always given a physical exam. Most of the time these two things combined with medication to treated my pain and nausea were enough to determine that it was safe for me to go home and talk to my gastroenterologist the next day. I only was imaged in the ER before my Crohn’s disease was diagnosed and the other time when I was going to admitted anyway because of the initial symptoms of infection and the ER wanted to check how severe things were in case I was a more dire case than I appeared.

    What I had going for me though was that I could give a clear and concise history of my Crohn’s disease and also provide a full list of medications and information about treatment during previous ER visits. There was a time or two when I was asked, “Do you want a CT?” and I was able to give an intelligent answer that include information about the last time I was scanned and reasonable answers to questions about my history of pain and my worsening condition. I understand that this is not the typical situation and that many people can’t provide detailed medical information but still expect a doctor to be able to fix them. Once when I was admitted directly by my gastroenterologist and not through the ER, I had prepared a list of medications and dosage information and the internal medicine resident who evaluated me was practically drooling when he saw the list and that he was going to have to waste time slowly getting this information out of me.

    Overall, I’d say that the gastroenterology department was a lot more interested in over-imaging me than the ER. But every doctor I saw (in the ER or not), gave me a thorough abdominal exam (great to have lots of doctors poke you in the area giving you extreme pain) and a good general once over for anything else that could be problematic. While some of the ER docs I met were better than others — and one or two might have been not very good at all in the bedside manner dept. — I did always leave knowing that nothing had dangerously changed and sure in the knowledge that there was no need to be admitted to the hospital on that occasion.

  35. Specialists want these work-ups. See Emergency Physicians–When in doubt, they image

  36. ToLazyToThinkOfOne says:

    White Coat had a very interesting(and believable) blog entry this week related to this. He documented the number of unnecessary tests he ordered(mostly radiologic) that were for extremly unlikely and not needed per his clinical judgement. The only one that has been questioned is the Head CT in the minor head trauma guy with a HA a few days later who also takes Coumadin. Most would probably image that guy. Otherwise they were all lame and he knew it at the time.
    So that’s an Emergency Physician(our local ER docs call themselves ER docs by the way) saying he images too much.

    And as a FP I will freely admit I order unnecessary tests. At least half the x-rays I do are done more for patient concern than mine. And it’s done for reasons similar to what Doctor Centor outlined: patient expectation, the less than 0.1% chance. And for reasons outlined by some of the ER docs above: exceptionally poor historians(just because they are in my office doesn’t mean they are my long-term patient and if the cardiologist sent me zippo related to their recent cath then I don’t know anything about it, and heck the EMR data dumps are unreadable anyway), and inability of patient to allow a decent physical exam for whatever reason.

    SO yes you do unnecessary testing. And you know it. So do we. So does every specialty. Maybe he should have painted with a broader brush. But the basic point remains.

  37. Sometimes it pays to listen to the patient/parent who pushes for that xray or CT. The ER doc said he would order a CT for my daughter after a bad skateboarding accident with LOC just to calm my “mom nerves” after I made a stink that he was just going to release her. CT showed a brain bleed. (Lean a little closer and I’ll show you my “mom nerves”)
    It might not be fair to compare a military ER with a civilian one but I could be here all night giving examples of MAJOR things that they’ve missed on my family. Ruptured appendix and a broken neck to name a couple… Generic Motrin is cheaper than Xrays and lab work!

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