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Emergency Room Medicine: Model for Excellence or Excess?

Posted Aug 02 2009 12:00am

The concept of medical excess is very difficult for ordinary patients to grasp. The medical community has worked hard for decades teaching them that more medicine meant better medical care. The public has learned these lessons well. Physicians who sent their patients for various diagnostic tests or specialty consultations were regarded as conscientious and thorough. Patients approved of doctors who prescribed antibiotics regularly for colds and other viruses believing that something beneficial was being done for them.

We can’t expect a patient to know if a CAT scan a physician orders is medically necessary. From a patient’s perspective, a test is medically necessary if the doctor orders it. However, physicians, with professional training and experience, know whether medical testing is urgent or optional. Isn’t that our jobs?

Of course, the practice of medicine often resides in the murky gray area where there is no single correct answer. In these instances, there can be several rational medical options available. Often, different medical studies examining a clinical question reach opposite conclusions. Sometimes, the medical issue at hand hasn’t been scientifically studied so there is no authoritative medical evidence to rely on. In these examples, differing medical recommendations are to be expected.

The bulk of excessive medical care I witness is not within the nebulous medical arena described above. These unneeded medical tests and treatments are black and white, not gray. It occurs every day in every doctor’s office, including mine. The most dramatic example of it, however, is the care rendered in our emergency rooms. The volume and expense of care given there routinely is absolutely astonishing. It is wasting a fortune of money and exposing patients to the risks and anxieties of extensive testing, even for minor medical conditions. Whenever one of my patients sees me in the office to review a recent ER visit, I try to disguise my amazement, as I look through all the lab results, x-ray reports, CAT scan interpretations and EKG tracings – often performed for some innocent complaint that has already resolved on its own. While this patient may believe that this medical pile on was great care, it wasn’t.

A serious risk of this buckshot-style medicine is that any one of the ultrasounds, CAT scans or other tests will detect an irrelevant and innocent abnormality that drags the patient to a brand new avenue of medical adventure . These new ‘abnormalities’, found by accident, create anxiety, cost money and mean more medical testing. This vicious circle is no merry-go-round carnival ride.

Why do ER physicians practice this way? Are they dumb? Hardly. In general, they are extremely capable and well trained. They perform well under pressure that can rival the tension found in any operating room. They make decisions routinely that determine whether a patient survives or succumbs. They have all of the necessary tools to practice judicious and conservative medicine, but they don’t.

They claim that the ER is a different medical universe, unlike primary doctors’ offices. They argue that they can’t miss serious diagnoses like heart attacks, strokes and blood clots to the lungs, all of which can be fatal. They need to test extensively because they have only one visit with the patient to get it right. Additionally, they point out that some of their patients may not follow up afterward with their primary physicians, even though they are advised to do so. Understandably, these physicians fear lawsuits against them if a patient they saw deteriorates after discharge. This latter reality motivates them to test patients aggressively.

I reject these arguments. In fact, the same ones could be applied to patients I see every day in my office. ER physicians should practice the same style of medicine that we all were taught to do during our medical training. Take a thorough history, perform an examination and then make appropriate recommendations. As a gastroenterologist, I see patients with chest burning in my office several times a week. The medical history allows me to determine if the chest discomfort is innocent or suspicious. In most cases, these patients don’t need a stat cardiac work up. Yet, if this same patient were seen in an ER…

Physicians, being members of the human species, are not perfect. It is not our task to test for every conceivable diagnosis in one visit. If an ER physician, or any doctor, thinks his patient’s abdominal discomfort is from constipation, then treat it accordingly and arrange for proper follow-up in the office. Don’t start a scan attack just because you can’t exclude appendicitis with 100% certainty. When we shoot for perfection, we are target our own profession.

I don’t think that the ER needs a different playbook. It just needs to play differently.
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