Anyone bored enough to help?

[LadyWolverine]

While his example was geared specifically towards residents, it's an excellent summary of what is so frustrating about MS1 curriculums. They often spend so much time on the zebras that they often bias their students towards the zebras as well...and then they find that they know very little about the "bread and butter" problems that they encounter in clinical practice.

Oh man. This is SO true. I think we like the zebras because many of them are treatable/hopeful/intellectually satisfying. We shy away from the horses because they tend to be chronic/everything-else-has-been-ruled out type diagnoses.

I can probably think of a bunch of rare causes of chest pain, but I'm not yet comfortable with the diagnostic workup and management of ACS. We spent significant time learning all these exotic infectious diseases when we should have been focusing on pneumonia, HIV, and hospital-acquired infections. I remember studying all of those glomerular diseases, and I don't think we spent enough time on diabetic and hypertensive nephropathy. I can give you the entire differential for a patient with a liver mass, but I freak out when I have to help manage a cirrhotic patient.

There's a reason why the rare cases tend to be the most interesting.

---

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[OncoCaP]

<sigh>

One of the moderators in the anesthesia forum is JetPropPilot - who, despite being very colorful and having several unique posting idiosyncracies, truly seems like a great attending that has a lot to teach. In one thread in that forum, he wrote:



While his example was geared specifically towards residents, it's an excellent summary of what is so frustrating about MS1 curriculums. They often spend so much time on the zebras that they often bias their students towards the zebras as well...and then they find that they know very little about the "bread and butter" problems that they encounter in clinical practice.

And, if you think about it, relentlessly chasing down zebras is kind of selfish. Patients want answers - no matter how you try, explaining to them why they need 7 different lab tests to rule out 7 fairly rare conditions is not going to help. It's worse with something like HTN where there often aren't any overt symptoms - "I feel fine. I don't feel sick. So why is he wasting so much time doing so many stupid and expensive tests? Screw him, he's an idiot and doesn't know what the hell he's doing. I'm leaving." While, in a minor way, you're doing all those lab tests for them, it doesn't really help them - it's more likely a huge turn-off, and may drive them away from the healthcare system altogether.



Yeah, it will. <sigh>

No kidding. I'm still trying to figure out why if something is extremely rare it is more likely to show up on STEP 1 (or any sort of medical exam) than if it's the kind of thing you are actually going to see during your lifetime.

I had an argument with one of the libertarians around here (MiamiMed or something like that) and he suggested we should do away with the power of medical boards and just let the free market efficiently take care of the problems. At first I thought he was nuts, but now I'm not so sure. My current take is that a medical license should be available to anyone who can pass the board exam and present documented hands-on training (apprenticeship) by licensed physicians. If we went this route, medical schools would actually need to compete to provide training and we would see schools that would be more efficient and effective. Who knows, the medical field might even change as businessmen innovate.

Tired, here's a picture of a handheld U/S. Not quite there yet, but ...

I think it's pretty funny that it's on a site that has an alternative medicine kind of name to it.

 

[OncoCaP]

Oh man. This is SO true. I think we like the zebras because many of them are treatable/hopeful/intellectually satisfying. We shy away from the horses because they tend to be chronic/everything-else-has-been-ruled out type diagnoses.

I can probably think of a bunch of rare causes of chest pain, but I'm not yet comfortable with the diagnostic workup and management of ACS. We spent significant time learning all these exotic infectious diseases when we should have been focusing on pneumonia, HIV, and hospital-acquired infections. I remember studying all of those glomerular diseases, and I don't think we spent enough time on diabetic and hypertensive nephropathy. I can give you the entire differential for a patient with a liver mass, but I freak out when I have to help manage a cirrhotic patient.

There's a reason why the rare cases tend to be the most interesting.

I remember when I did my first neuro exam on an 80 yo woman. I had her pegged with so many neurological deficits and dorsal column lesions that the PC physician who I was following around had to work hard not to burst out laughing. She was really nice and told me, Onco, I don't know what they are teaching you, but this woman is healthy and normal. Keep learning normal. Until you know what normal looks and feels like, don't try to diagnose anything abnormal. Apparently as you get older, it's acceptable to lose a certain amount of position sense and experience other decreases in neurological function. Well, now I know that. I wish they would teach us more practical stuff like this. It's coming in clinical rotations, I hope.

 

[mjl1717]

we were told that whenever we have an african american patient, we should test for anemia.

1) Im not absolutely buying this! (but I would consider sickle cell or if there is a bleed){a rectal is important here] HTN+ End organ damage= RX.. Consider metabolic syndrome also.... And even pheo!

2)The OP asked a d--- good, question. We do not often get good academic qs..

3) Im going to sit back since in so many words (there are alot of cooks in the kitchen)

 

[mjl1717]

I remember when I did my first neuro exam on an 80 yo woman. I had her pegged with so many neurological deficits and dorsal column lesions that the PC physician who I was following around had to work hard not to burst out laughing. She was really nice and told me, Onco, I don't know what they are teaching you, but this woman is healthy and normal. Keep learning normal. Until you know what normal looks and feels like, don't try to diagnose anything abnormal. Apparently as you get older, it's acceptable to lose a certain amount of position sense and experience other decreases in neurological function. Well, now I know that. I wish they would teach us more practical stuff like this. It's coming in clinical rotations, I hope.

$$



Boy this takes guts!!

 

[mjl1717]

Umm, he HAS disease, i.e. long-standing hypertension -- his fundi are messed up, and he has an S4 gallop indicating LV stiffness, and increased QRS amplitude, indicating LVH (the other epocrates differentials you have can be ruled out just by the information you've provided). I don't think the appropriate initial treatment is diet + exercise, though that is definitely going to be part of it -- that would be more appropriate for anything pre-Stage I hypertension. This dude has Stage I, but he's teetering on Stage II, so we have to get his BP down by meds. In addition to the things people have recommended, I would do a fasting glucose test (and you'll need 2 to confirm DM), CBC (why not), CMP. I'm not sure what else the EKG said (there could be contraindications to stress tests!) or whether a stress test would be necessary- he doesn't have any chest pain. You might get an echo to look at the valves and check out his hemodynamics. And yes, you can diagnose hypertension in this case, it just takes two separate readings. I'd start him on HCTZ 25mg (always first line for African Americans unless they have diabetes), and/or depending on diabetic status, an ace inhibitor. Depending on his liver, I would definitely add a statin +/- niacin (raises HDL, lowers LDL). I would also consider Vytorin instead, which is a statin + ezetimibe, although the ezetimibe wouldn't really raise HDL so much as lowering LDL.

Yeah, and what the hell? The most important question to ask your hypertensive patient is about erectile dysfunction?!?! How about questions relating to signs and symptoms that will KILL the person?! This dude's a walking time-bomb for a stroke and/or heart failure w/ flash pulmonary edema, etc. etc. - I wouldn't be too concerned about ED right now.

Im about practicing smart medicine also:

I hear that if the CRP is greater then 2 (new info I found out) regardless of the cholesterol and LDL it is prudent to start a statin eg.-[rovastatin]

 

[45408]

See, this is why I'm still a 3rd year. I'm not certain at what point an echo is deemed necessary. When there's an S4? An S3? When the heart becomes a certain size on CXR? When there are signs of left heart failure? When the patient has bilateral pitting edema to mid-thigh? I'm sure there are multiple indications and some clinicians' thresholds are different than others.

To be honest I vaguely remember the original question. I could stop being lazy and go look at it again, I guess.

If there were signs of failure - an S3, pitting edema, JVD, dyspnea on exertion, orthopnea, etc - then I think an echo is indicated. I had a patient come in with very, very undiagnosed heart failure (hadn't seen a doctor in decades), and it was definitely worthwhile. Her EF wasn't terrible, but it was definitely in the heart failure range.

 

[45408]

Just auscultate the abdomen and back near the kidneys for bruits. Cost $0.

Value in calculating ejection fraction: 0. That's only going to tell you about renal artery stenosis, not heart failure. Edema, an S3, JVD, DOE, PND, orthopnea, etc., are all much more indicative of heart failure. Sure, I also think the physical exam is underrated, and in the peds cards clinic I'm in this month, there have been more than a few patients whose pediatricians shouldn't have referred. It was an obvious physiologic murmur.

 

[45408]

Im about practicing smart medicine also:

I hear that if the CRP is greater then 2 (new info I found out) regardless of the cholesterol and LDL it is prudent to start a statin eg.-[rovastatin]

It's also pricey, and the NNT is quite high. Furthermore, the PI on the case has a patent on a lab test to check CRPs. Surprise, surprise. Furthermore, they also found during that study that the patients on the statin were more likely to get diabetes.

1) Im not absolutely buying this! (but I would consider sickle cell or if there is a bleed){a rectal is important here] HTN+ End organ damage= RX.. Consider metabolic syndrome also.... And even pheo!

2)The OP asked a d--- good, question. We do not often get good academic qs..

3) Im going to sit back since in so many words (there are alot of cooks in the kitchen)

A pheo? Don't stop there, check for a VIPoma too.

Only if they have other corroborating symptoms, like fluctuating blood pressure, diarrhea, flushing, etc. Doing a 24-hour urine collection for metanephrines is kind of a pain in the butt for a patient, not to mention it probably has to be sent out and costs a good chunk of change.

 

[smq123]

We get to have some patient exposure our first couple of years. It's not every day, but usually every other week. It's not unusual to get to spend more than an hour with some patients, asking for a detailed history, doing all kinds of physical exam procedures. Sometimes I would sit in and listen to a dietitian or a nephrologist come by and do their thing. We had lots of time. I know this will change, but we actually were able to spend many hours with patients on a regular basis.

We also had a lot of "patient exposure" during the first 2 years, very similar to what you describe here. Sadly, it was a bit of a shock to me how much that changes during 3rd year. You simply don't have time to spend an hour with each patient, because you are worried about checking labs, getting hospital records, being on time for rounds/morning report/noon conference, actually working...enjoy the time you get to spend with your patients now.

Not to mention that, when you hit third year, you're suddenly faced with taking care of patients that are either severely demented, sedated, or intubated/trached and unable to talk.

I know that they admonish you in MS1 not to "practice veterinary medicine," but they seem to buy the delusion that you'll spend your clinical years taking care of totally alert, awake, and oriented people who have no difficulty talking or writing.

HAH!

 

[USArmyDoc]

Well I frequent the forums alot as a quest, read multiple topics, and yall are a bunch of smart people
but anyways, Its my first semester in medical school at USUHS and one of my instructors approached me with this case study and told me to complete it by Monday and turn it in during class.
Its another case study, and its rediculous because we didn't even scratch the surface of any of the complexities covered in these "studies."
So I'll just tell you the questions, my anwsers, and we'll see how badly I fail

To begin with, my patient is African American, 47, and comes to the clinic with a concern for high blood pressure. During my initial exam, his BP in both arms = 156/94, and during my two follow up examinations his BP is still 150+/90+. During my physical assessment, everything is WDL - exception: vundi with vasoconstriction, s4 gallop, increased QRS voltage on ECG, high LDL low HDL, all other blood tests WDL.
What tests do you order, what do you do now, and would you make a Dx or DDx.

Skimming through my books and going through my epocrates software, I concluded the following:
Since the fundoscopy revealed vasoconstriction, I could assume it could be correlated to HTN and that the overall condition if left unchecked could lead to eye damage. The S4 gallop could indicate left ventricular ischemia, and the high voltage QRS could indicate LVH. In epocrates, it advises that high QRS voltage DDx=HTN AS AR coarctation MR.
As far as tests, would it be necessary to order : Glucose finger stick, stress test, another ECG, and CBC?
I would diagnose HTN, I don't think its too presumptious since during all 3 visits BP = abnormal, so as far as "what would you do now" is it safe to just provide education, indicate changes in lifestyle as far as diet and exercise?
this whole study isn't vital, its not graded, but I feel I should go the extra yard and ask for help thanks guys

S4 LVH secondary to HTN....young to have aortic stenosis
-LVH is supported by high voltage QRS

Maybe get a lipid panel? Consider starting a statin? How high are his LDL's, HDL's, etc

From what I see....no need for stress test as the pt has no complaints of CP.

Any murmurs?
Coarctation would be change in BP's between each arms
Aortic Regurg: no signs or sx's....

Drug Therapy: Hydrochlorothiazide or CCB

Non-Drug Therapy: lifestyle changes

 

[anon-y-mouse]

Oncocap, there's just not enough time and resources and it's unrealistic to use these as screening tests for everyone who walks in the door with HTN (except for a good physical exam, of course). That extra 0.001% of diagnostic accuracy becomes hard to justify in practice when you think in terms of time, cost, etc. Your best bet in most cases is to treat the most likely cause, and if there is no response in a decent amount of time, then zero in on the other "hooved mammals."

Amen. I agree with the rest of your post as well (and your treatment plan, naturally), but I think this is the most important point here. One of my mentors told me that one of the things that separates medical school graduates from webMD is the knowledge of patterns, how things present, and what's more likely -- you're not going to suspect pel ebstein fever for everyone who comes in with a fever, but you have to be able to put things together and have that on the back of your mind if you see constitutional symptoms, find a node, etc. You have to consider pretest probabilities (they did teach you about that Onco?), cost of tests, the way diseases present, and the fact that you have to be ridiculously familiar with how certain things present, how to manage the horses, and how to keep on the lookout for the zebras.

Incidentally, as for echos, I'm wondering how hard it is to even do them? I've used a sono on several non-medicine rotations (well, I used it on medicine to place IJ lines) and I would think it would be fairly easy to learn how to use / interpret echos... thereby saving $500 or whatever the cost of an echo is. How hard is this? Are there any electives out there?

 

[45408]

Incidentally, as for echos, I'm wondering how hard it is to even do them? I've used a sono on several non-medicine rotations (well, I used it on medicine to place IJ lines) and I would think it would be fairly easy to learn how to use / interpret echos... thereby saving $500 or whatever the cost of an echo is. How hard is this? Are there any electives out there?

Liability, dude. If you do an echo, and you miss something important that you weren't even looking for, you could easily get sued. Echos aren't easy to do, and they're even harder to read.

It's a lot more than $500. The cardiologist can charge $1500 just to read it. I imagine it's another $500-1000 to do one, and if you have to sedate the patient (children), that could be another $500.

 

[OncoCaP]

Liability, dude. If you do an echo, and you miss something important that you weren't even looking for, you could easily get sued. Echos aren't easy to do, and they're even harder to read.

It's a lot more than $500. The cardiologist can charge $1500 just to read it. I imagine it's another $500-1000 to do one, and if you have to sedate the patient (children), that could be another $500.

What is he going to miss? We are already accepting the fact that an echo is not indicated and that we don't have time to check for RAS and pheos in the usual case. He's already going above and beyond standard of care. If he used an ultrasound to make sure the kidneys had what appeared to be reasonable arterial flow and that the heart wasn't > 50% of the chest width and the valves were grossly intact, why would they sue him if he explained to the patient that this was not a full echo or imaging study (just doing some extra screening beyond what is normally done). If he's going to get sued, it's for the RAS or whatever that was missed and they'll try to show that it should be have been checked for (based on expert testimony). Checking for the more unusual conditions should reduce the liability actually because it shows extra effort to provide higher quality patient care. Just carefully document that a full echo or U/S study is not indicated (and why), but that some very limited screening tests are being done as an effort to go above and beyond what is required by standard of care (just don't expect to be able to bill for it). As long as you document it and explain it to the patient, chances are very good that any lawsuit will be dismissed (that's what happened in the cases I have seen). Being a physician means you are going to get sued. Might as well as accept that now. The only thing we control is what we get sued for. If it's practicing good medicine, then it's just a cost of doing business in this field and the cases will be dismissed more often. We shouldn't let the threat of lawsuits prevent us from providing the best care possible.

The more difficult issue in my mind is that using the U/S or Echo is going to be stepping on some very big money-making toes (cardiology, imaging, etc.). Because it threatens to take money and/or work away from someone who is generating revenue, it probably won't be allowed (that's my guess anyway).

 

[smq123]

Incidentally, as for echos, I'm wondering how hard it is to even do them? I've used a sono on several non-medicine rotations (well, I used it on medicine to place IJ lines) and I would think it would be fairly easy to learn how to use / interpret echos... thereby saving $500 or whatever the cost of an echo is. How hard is this? Are there any electives out there?

If you're truly interested in learning how to interpret echos, take a cardiology elective, and beg one of the cards fellows to teach you.

Sono is easy when done in extremely limited situations, or when it is being used to find something relatively obvious - for instance, helping to place an IJ, or determining fetal positioning.

Anything more complicated (and certainly, anything that could result in a huge lawsuit if you interpreted the sono incorrectly) requires further training. For instance, in OB, while all OB/gyns can do basic U/S for fetal positioning and basic transvaginal U/S, they require a specific rotation to teach them how to do BPP and how to determine AFI. MFMs get even further training to help them identify fetal abnormalities, etc.

What is he going to miss?

If he used an ultrasound to make sure the kidneys had what appeared to be reasonable arterial flow and that the heart wasn't > 50% of the chest width and the valves were grossly intact, why would they sue him if he explained to the patient that this was not a full echo or imaging study (just doing some extra screening beyond what is normally done).

Checking for the more unusual conditions should reduce the liability actually because it shows extra effort to provide higher quality patient care. Just carefully document that a full echo or U/S study is not indicated (and why), but that some very limited screening tests are being done as an effort to go above and beyond what is required by standard of care (just don't expect to be able to bill for it)..

- In this case, he shouldn't even be doing an echo anyway. Even if you don't bill for it (which the hospital is going to freaking HATE), it's a waste of the patient's time. Considering how much time it actually DOES take for the patient to get off of work, get to the hospital, etc., that's not fair to the patient.

- You can't half-ass an echo. Either you do it, to identify a problem, or you don't. But you don't run an ultrasound probe over a person's chest "just to see."

- Going "above and beyond the standard of care" is a fuzzy term that people like to throw around to justify getting further, unnecessary tests. What do you need an echo for? In this case, no good reason. Running a ultrasound probe over someone's heart, when you really have NO CLEAR IDEA of what you're actually LOOKING for, is an even less justifiable reason. Leave the ultrasound machine in the closet, and send the patient home.

The more difficult issue in my mind is that using the U/S or Echo is going to be stepping on some very big money-making toes (cardiology, imaging, etc.). Because it threatens to take money and/or work away from someone who is generating revenue, it probably won't be allowed (that's my guess anyway).

Actually, that's NOT the reason, usually. (Well, not the full reason, anyway.)

You send the patient to get an echo done by someone who can actually DO something about the results. Even if you have the echo officially read by a radiologist, what are you going to do about the patient's severely calcified aortic valves? Or the patient's mitral valves that are covered in vegetations? As a general internist (or as an IM resident), not much. Might as well send the patient to have an echo done by someone who can also take real steps to fix the issue.

We shouldn't let the threat of lawsuits prevent us from providing the best care possible.

...

To be honest, it generally doesn't....but then you have to wonder what defines "the best care possible." I don't think it means "order every single test that may tell you something useful." I think it means to get the patient a good diagnosis, without unduly inconveniencing the patient any further, or racking up their insurance bills if you don't have to.

 

[45408]

Checking for the more unusual conditions should reduce the liability actually because it shows extra effort to provide higher quality patient care.

But it won't reduce your liability. It increases it, because you don't have adequate training to perform and interpret one of these studies. Even if you've done hundreds or thousands, it doesn't matter. The surgeons never order an x-ray or CT and then opt not to have it read by the radiologist, even if they've already taken the patient to the OR.

In addition, if you do an ultrasound and don't notice a tiny finding, the ultrasound is saved for posterity (and the courtroom), where everyone can notice what you missed. That's why our radiology reports for trauma patients include tons of "incidentals" like degenerative joint disease, lipomas, fibrocystic changes, etc. If you auscultate for a bruit and don't hear one, it's not going to be digitally analyzed in front of the jury to find it. If you say and document that the lungs were clear, they were clear. If you do a chest x-ray and say there's no pneumothorax, they'll just pull up the image and second-guess you.

Being a physician means you are going to get sued. Might as well as accept that now. The only thing we control is what we get sued for. If it's practicing good medicine, then it's just a cost of doing business in this field and the cases will be dismissed more often. We shouldn't let the threat of lawsuits prevent us from providing the best care possible.

You're giving up the ghost just a bit too early. It's very likely yes, but you should control your exposure, and a good way to do that is to avoid doing tests that you're not qualified to perform.

 

[OncoCaP]

- In this case, he shouldn't even be doing an echo anyway. Even if you don't bill for it (which the hospital is going to freaking HATE), it's a waste of the patient's time. Considering how much time it actually DOES take for the patient to get off of work, get to the hospital, etc., that's not fair to the patient.

Yes, agreed. It's not necessary here. The main thing I personally would be interested in is whether the patient has RAS. Seems like it should be possible to check that with U/S, but I don't know how difficult it is to do that with all the other vasculature that hangs around in the general vicinity.

- You can't half-ass an echo. Either you do it, to identify a problem, or you don't. But you don't run an ultrasound probe over a person's chest "just to see."

I predict we'll have handheld U/S devices that we use as commonly as fever thermometers within 10 years. We'll be able to look at the heart, liver, kidney, and anything else not completely blocked by bone or gas.

Medicine as we know it today is too expensive and inefficient (a dinosaur, and a cruel expensive one at that). We use 7 highly paid professionals where a high school student with the right tool and protocol could do the job more effectively, cheaply (maybe 1/1000th of the cost), and faster with orders of magnitude better outcomes. The arcane way of doing things we have inherited (sending someone to a specialist for a routine echo that costs ~$1000 or whatever) is going to change, perhaps slowly or quickly, but we can't afford to continue this much longer. Medicine today is like electronics before vacuum tubes ... a crude art that serves mostly to enrich a select group of individuals at the expense of our country's health and wealth. Governments and companies are struggling financially and will put increasing pressure on the medical establishment. With improved technology and reduced reimbursement, computers will run most of the analysis (if systolic pressure > 130 and age > 30 then if race = AA ...). As physicians, we will look over the analysis to make sure it makes sense and, for garden variety HTN, we probably won't even see the patient anymore. They might take their BP at a pharmacy and the pharmacist will ask them a few questions before handing them their medications after screening them for everything under the sun that we couldn't do even if we had an NIH research grant. Everything will be preprogrammed and the mind-numbing paperwork and rote turning the crank will be taken over by $7/hr medical assistants and be more effective, more thorough, and customized for that patient (perhaps even based to some extent on their genotype), widely available, and much cheaper. What Wal-Mart did to bring $4 generics is going to happen for routine medical conditions, I just don't know when exactly.

I know, I know, I'm describing an ATM to bank tellers who are frightened and at the same time scoffing at the idea that a machine could safely dispense cash to accountholders. Don't worry; just as the ATM didn't cost thousands of jobs (that were not replaced by jobs for ATM service personnel, etc.), neither will the automation of medicine cost physicians their jobs (except for those physicians who refuse to change).

Now back to today and reality and your point, yes, we'll do it the expensive thorough way when we must (worrisome murmur, etc.) and only perform very limited diagnostics on the typical HTN patient who walks through the door and wish them luck; if they don't get better or don't like their medicine they can make another appointment. The patient is very poorly served by this process.

- Going "above and beyond the standard of care" is a fuzzy term that people like to throw around to justify getting further, unnecessary tests. What do you need an echo for? In this case, no good reason. Running a ultrasound probe over someone's heart, when you really have NO CLEAR IDEA of what you're actually LOOKING for, is an even less justifiable reason. Leave the ultrasound machine in the closet, and send the patient home.

When someone you care about suffers significant morbidity or perhaps mortality and this incident ruins the lives of several other people you care about because someone was "too busy" or "thought it was unnecessary given the odds" to run a $25 test that required nothing more than checking a checkbox, you'll change your tune. The fact is that we have a broken system and you have no imagination beyond it because it's beating the tar out of you. You sound like a bitter, miserable soul. Hopefully once medicine gets out of the stone age from a business and technological standpoint, it might even be a more pleasant place for physicians to work.

Actually, that's NOT the reason, usually. (Well, not the full reason, anyway.)

You send the patient to get an echo done by someone who can actually DO something about the results. Even if you have the echo officially read by a radiologist, what are you going to do about the patient's severely calcified aortic valves? Or the patient's mitral valves that are covered in vegetations? As a general internist (or as an IM resident), not much. Might as well send the patient to have an echo done by someone who can also take real steps to fix the issue.

...

To be honest, it generally doesn't....but then you have to wonder what defines "the best care possible." I don't think it means "order every single test that may tell you something useful." I think it means to get the patient a good diagnosis, without unduly inconveniencing the patient any further, or racking up their insurance bills if you don't have to.

We got a little off track with the echo. I agree it's not needed. I would like some kind of cheap way of checking the renal artery by ultrasound. I haven't messed with this yet, so I can't really comment too much. However, I suspect we will be able to do this someday.

Again, you are trapped in a sort of mentality that is bringing the U.S. to its knees. It's one thing to accept and deal with a broken system, but another to try and justify it. Before you were born, engineers had fleets of draftsmen who drew (designed) everything by hand. It didn't matter what it was, a house, an airplane, a telephone, ultrasound imaging system, etc. someone drew it with pencil and paper. If you decided the gadget needed to be wider or whatever, the draftsman would need to redraw the thing. Needless to say, the associated calculations would need to be redone also, as they were done in paper and pencil. The end result? Things were massively overdesigned and feature poor. Cost was high and profits were often low. Now one engineer with a computer can do the work that used to take 200 people and generate 100x the profit (and provide the item at a tiny fraction of the previous cost). This engineer might be a mom who is working from her home where she takes care of two kids and works flextime between all the other things she loves to do. The big automakers only partially embraced these kinds of transitions, which is why they are going bankrupt at the moment. Similarly, medicine is bankrupting this country with the "we need a $1000+ test or we can't do it at all" mentality. Or the patient doesn't want to be troubled by more tests when what they are really mad about is that they had to wait 1 hour past their appointment time and now you are sending them to a lab which they could have gone to before your appointment if someone had taken a minute to talk to the patient about what they were coming in for.

I accept the reality of what you are talking about and will play the game by doing most if not all the things you are talking about. However, I won't try to justify a system that is not serving the patient or those who are paying for it (while physicians are often caught in the middle). Whenever I have the opportunity and discretion to do so, I'll run additional inexpensive tests to help rule out conditions that would change my diagnosis and mean potential harm to the patient. I care about my patients enough to "bother" them with tests that enable me to provide the most accurate diagnosis and treatment. This can only be done with sufficient information about the patient's state of health and related conditions. In certain patient populations the prevalence of renal artery stenosis is on the order of 30% (patients who have undergone or are being referred for diagnostic cardiac catheterization ... obviously much sicker than our patient).

My reply above goes way beyond anything this thread was intended to accomplish, but hopefully it gives you some insight as to where I'm coming from. I'm not interested in running tests because I'm bored enough to answer this thread. I genuinely care about the health of my patients and will do what I can to optimize my diagnosis and care with respect to outcome, cost, efficiency and other considerations.

In case you are feeling a little offended about my critique of medical practice, take a look a this little gem I snagged from the pre-allo forum (with another medical gem as well):

http://ca.youtube.com/watch?v=gCMzjJjuxQI
http://www.youtube.com/watch?v=UyhvHB62ph8&NR=1

Yes, that's right folks. Doctors not only had their favorite cigarettes, but medical students actually smoked them in class not that long ago. We have smart hard-working people but sometimes there are major opportunities for improvement that we simply cannot ignore.

 

[OncoCaP]

But it won't reduce your liability. It increases it, because you don't have adequate training to perform and interpret one of these studies. Even if you've done hundreds or thousands, it doesn't matter. The surgeons never order an x-ray or CT and then opt not to have it read by the radiologist, even if they've already taken the patient to the OR.

In addition, if you do an ultrasound and don't notice a tiny finding, the ultrasound is saved for posterity (and the courtroom), where everyone can notice what you missed. That's why our radiology reports for trauma patients include tons of "incidentals" like degenerative joint disease, lipomas, fibrocystic changes, etc. If you auscultate for a bruit and don't hear one, it's not going to be digitally analyzed in front of the jury to find it. If you say and document that the lungs were clear, they were clear. If you do a chest x-ray and say there's no pneumothorax, they'll just pull up the image and second-guess you.


You're giving up the ghost just a bit too early. It's very likely yes, but you should control your exposure, and a good way to do that is to avoid doing tests that you're not qualified to perform.

See my note above. Yes, it's the way we do it, but it's not a good way. Show me a physician who was sued because s/he read an X-ray that he didn't need to read because it wasn't indicated but the physician wanted to be more thorough under the circumstances. Show me someone who did more than they had to and was sued for that reason specifically (i.e., not because they electrocuted a patient while operating a machine they were not trained to operate). If physicians get sued for this, it's a freak random occurrence ... the old lady who held the hot coffee in her lap and then sued the restaurant for burns when it spilled. The only reason we do things this way is because it serves the financial interest of the hospital and others. If insurance companies and the government no longer paid for these techs to read those X-rays, CT's or whatever, physicians would read them because they would have no choice. It's economics plain and simple. I'm not suggesting that physicians do something that they aren't trained to do. If you need to do something as part of your job (to do it well) and it requires training, then let's get the training. If it's a division of labor thing where it's cheaper, faster, and more accurate to have someone besides the primary physician do it, I'm fine with that also.

I guess I would like you to show me some evidence that it actually does increase the liability. I'm certainly open to learning more about how this works.

 

[smq123]

The main thing I personally would be interested in is whether the patient has RAS. Seems like it should be possible to check that with U/S, but I don't know how difficult it is to do that with all the other vasculature that hangs around in the general vicinity.

As a radiologist, not very difficult. As an internist, very difficult.

You're vastly overestimating the amount of ultrasound training you receive. Unless you really do a LOT of ultrasounds (i.e. will be going into emergency medicine or OB/gyn), you will have very, very limited understanding of how to read ultrasounds, and an even more limited understanding of how to perform them.

Even in those specialties, you have just a basic understanding of ultrasound. For instance, in OB, most of what you need ultrasound for is to assess size (i.e. size of ovaries and thickness of endometrial stripe) and position. Plus, the anatomy of the pelvis isn't THAT complicated.

To use U/S for complicated vascular structures or the heart (i.e. to assess size AND movement AND flow), you should get a trained radiology tech to do it.

Now back to today and reality and your point, yes, we'll do it the expensive thorough way when we must (worrisome murmur, etc.) and only perform very limited diagnostics on the typical HTN patient who walks through the door and wish them luck; if they don't get better or don't like their medicine they can make another appointment. The patient is very poorly served by this process.

I honestly feel like you think that zebras are everywhere, and we're doing our patients a disservice by not suspecting more zebras.

You treat common things commonly. 99% of the time, you will be right.

How else do you suggest we do it? Order expensive and unusual tests for all the patients that walk through the door? Suspect all patients of having a bizarre disease that is only found in the dusty pages of an old pathophysiology textbook?

This is NOT House (thank God). Zebras are rare. Shotgunning tests, in the hopes that you will stumble upon something is serving your patients equally as poorly.

When someone you care about suffers significant morbidity or perhaps mortality and this incident ruins the lives of several other people you care about because someone was "too busy" or "thought it was unnecessary given the odds" to run a $25 test that required nothing more than checking a checkbox, you'll change your tune. The fact is that we have a broken system and you have no imagination beyond it because it's beating the tar out of you. You sound like a bitter, miserable soul. Hopefully once medicine gets out of the stone age from a business and technological standpoint, it might even be a more pleasant place for physicians to work.

If I "sound like a bitter, miserable soul," you sound like an overly naive MS2 whose lack of actual clinical experience is not enough of an impediment to prevent you from rudely insulting other users over issues that you have NO EXPERIENCE WITH.

<deep breath>

Okay, having gotten that out of my system....if a test cost $25 dollars, did no harm to the patient, and could be done without excessive inconvenience, I'd order it. Why not? It'll help me sleep at night.

But do you know how much an ultrasound costs? First of all, do you know how much an ultrasound machine costs? A basic, bare-bones ultrasound used to run FASTs [Focused Abdominal Sonograms of Trauma] is $10,000. TEN THOUSAND DOLLARS. The better ultrasounds used for fetal monitoring, echocardiograms, TEEs, etc. can run from $30,000 to $150,000. Seriously. These machines are EXPENSIVE. Is it any wonder that your average IM office doesn't have one? You can't just whip one out and scan your patient whenever you feel like it, because it's just too expensive to have such a machine lying around.

Now, since EVERYTHING in the hospital is marked up (for instance, a basic CBC costs the patient $12-15....seriously!), can you imagine how much more it costs the patient to get an ultrasound?

Furthermore, do you know how irresponsible your suggestion is? "I don't really have any formal training in ultrasound....and I'm the most senior person here, so no one is here to teach me....but I'll just scan your heart anyway, just to satisfy my own curiosity! I don't really have a clue of what I'm looking at, since I'm not a cardiology fellow, but whatever, right? And, just to be safe, I'll have to refer you to a cardiologist, just so you can get ANOTHER ultrasound done!" Why on earth would you want to do that?

This is another thing that med schools don't teach. They spend hours teaching "cultural sensitivity," and not enough on how much tests cost. So MS1s and MS2s learn about all these high-tech tests that are available, without any understanding of how much these tests actually cost. And when they start MS3, they'll suggest these tests, and get laughed at because it's ridiculous to think of someone ordering a $500 test on the off chance that you might stumble upon an extremely rare disease.

 

[Long Dong]

Dude you guys are way over mentally masterbating on this one. That's why I hate internal medicine just treat the guy get his BP done follow the JNC whatever guidelines if that doesn't work then work it up for something else. Lipids hi, OP didn't say how hi, diet and exercise that doesn't work then statin or whatever combination you want. Eternal medicine suck arse.

 

[Scaredshizzles]

I hope that the S4 gallop doesn't indicate LV
You don't need to start him on any meds for his HTN now - ACEI, thiazide diuretic, or otherwise. Diet and exercise are usually the first line treatments. If he smokes, he should stop, and if he's "fluffy" (as my internal med resident used to say), he should lose weight.

LOL, clearly EBM is lost on you. I suppose JNC7 and ALLHAT also mean nothing to you.

You don't just advise diet and exercise and lifestyle modifications to a patient who presents to you with stage 2 hypertension and signs of end organ damage (LVH, retinopathy (stage 1 retinopathy), etc.) You start them on a medication right away, maybe 2. And no metoprolol and lasix are not first line anti-hypertensives. Metoprolol controls rate better than it does hypertension---it alone would not likely control stage 2 htn. Unless patient has underlying CAD or really has HF (which he does not because HF is a clinical diagnosis and he does not have it----s4=LVH, not necessarily diastolic dysfn---and besides beta blockers are questionable in terms of efficacy in non-systolic heart failure), don't bother starting him on metoprolol---he will just feel lousy from bradycardia and still have high bp eating away at his vasculature. And lasix most definitely is not first line for hypertension----lasix has really not been shown to improve mortality in any long term outcomes, including in patients with CHF. Lasix is only for symptom control, and this patient does not have peripheral edema/ascites/dyspnea, etc.

 

[smq123]

You don't just advise diet and exercise and lifestyle modifications to a patient who presents to you with stage 2 hypertension and signs of end organ damage (LVH, retinopathy (stage 1 retinopathy), etc.) You start them on a medication right away, maybe 2. And no metoprolol and lasix are not first line anti-hypertensives. Metoprolol controls rate better than it does hypertension---it alone would not likely control stage 2 htn. Unless patient has underlying CAD or really has HF (which he does not because HF is a clinical diagnosis and he does not have it----s4=LVH, not necessarily diastolic dysfn---and besides beta blockers are questionable in terms of efficacy in non-systolic heart failure), don't bother starting him on metoprolol---he will just feel lousy from bradycardia and still have high bp eating away at his vasculature. And lasix most definitely is not first line for hypertension----lasix has really not been shown to improve mortality in any long term outcomes, including in patients with CHF. Lasix is only for symptom control, and this patient does not have peripheral edema/ascites/dyspnea, etc.

- Later in the thread, I realized my mistake and admitted that he needs to be on meds. Guess you didn't read the whole thread, though.

- He does NOT have Stage 2 HTN. LOL, I suppose JNC7 and ALLHAT also mean nothing to you.

His BP readings have all been in the 150s/90s. That's Stage 1, according to JNC VII.

- For someone with basic high blood pressure, I don't see anything wrong with metoprolol to start with (unless he's really brady for some reason) or lasix (unless his electrolytes are way out of whack).

If you'd like to show the article that talks about why furosemide is a terrible choice for your average, run of the mill, essential HTN, I'm sure we'd all welcome it. Otherwise....

 

[Scaredshizzles]

- Later in the thread, I realized my mistake and admitted that he needs to be on meds. Guess you didn't read the whole thread, though.

- He does NOT have Stage 2 HTN. LOL, I suppose JNC7 and ALLHAT also mean nothing to you.

His BP readings have all been in the 150s/90s. That's Stage 1, according to JNC VII.

- For someone with basic high blood pressure, I don't see anything wrong with metoprolol to start with (unless he's really brady for some reason) or lasix (unless his electrolytes are way out of whack).

If you'd like to show the article that talks about why furosemide is a terrible choice for your average, run of the mill, essential HTN, I'm sure we'd all welcome it. Otherwise....

Perhaps technically true, but I'm thinking as a clinician...A patient has measurements of 150s/90s all the time and nothing lower, I'll assume at times his bp is going to be crossing 160/100. Moreover, the patient has end organ damage (meaning either he has poor follow up and has had htn for a couple of decades or that his bp at times has been around 180/100 over recent years), and the bp is just going to keep going up as he ages.

As far as lasix being a terrible choice, it is in the sense that other anti-htn drugs have been shown to decrease long term sequelae like CVA. Lasix really only lower bp in patients who are fluid overloaded. They might have some short term efficacy in run of the mill hypertension, but the patient is just going to drink more fluids when he gets dehydrate from the stuff. Clearly the benefits of thiazide go beyond their diuretic properties (considering their diuretic properties start to disappear over time---nephron becomes unresponsive)---they likely have some vasodilatory effects and appear to for some reason be particularly good at reducing stroke risk.

 

[Scaredshizzles]

That being said there are some small studies out there on low dose lasix (lower doses than would successfully tx htn) as potentially having long term nephro-sparing effects, and of course the role of using combination lasix-thiazide (usually metolazone) Vs. just lasix in CHF remains to be elucidated.

 

[smq123]

Perhaps technically true, but I'm thinking as a clinician...A patient has measurements of 150s/90s all the time and nothing lower, I'll assume at times his bp is going to be crossing 160/100. Moreover, the patient has end organ damage (meaning either he has poor follow up and has had htn for a couple of decades or that his bp at times has been around 180/100 over recent years), and the bp is just going to keep going up as he ages.

- Even though you have no proof, you're going to "assume that his bp is going to be crossing 160/100," and then treat him as if he has the higher dose?

I'd actually argue the opposite, and say that a bit of residual "white coat HTN" is artificially boosting his BP. But if you're that skeptical, why not have him buy a cheap home BP cuff, and measure it daily at home? Then, when he comes back in a few weeks, you can reassess, and then tweak his meds then.

- He does NOT have "end organ damage." Yeah, he has had HTN for a few years, and he has vasoconstriction that is visible in his retinas. That's not "end organ damage."

"End organ damage" are things like changes in the optic disc, flame-shaped retinal hemorrhages, and signs of neovascularization. He doesn't have that yet.

As far as lasix being a terrible choice, it is in the sense that other anti-htn drugs have been shown to decrease long term sequelae like CVA. Lasix really only lower bp in patients who are fluid overloaded. They might have some short term efficacy in run of the mill hypertension, but the patient is just going to drink more fluids when he gets dehydrate from the stuff. Clearly the benefits of thiazide go beyond their diuretic properties (considering their diuretic properties start to disappear over time---nephron becomes unresponsive)---they likely have some vasodilatory effects and appear to for some reason be particularly good at reducing stroke risk.

You can't accuse me of being ignorant of EBM, and then not cite articles for your generalizations, and just saying that they "make sense." If you have articles, I'd like to read them.

 

[Scaredshizzles]

- Even though you have no proof, you're going to "assume that his bp is going to be crossing 160/100," and then treat him as if he has the higher dose?

I'd actually argue the opposite, and say that a bit of residual "white coat HTN" is artificially boosting his BP. But if you're that skeptical, why not have him buy a cheap home BP cuff, and measure it daily at home? Then, when he comes back in a few weeks, you can reassess, and then tweak his meds then.

- He does NOT have "end organ damage." Yeah, he has had HTN for a few years, and he has vasoconstriction that is visible in his retinas. That's not "end organ damage."

"End organ damage" are things like changes in the optic disc, flame-shaped retinal hemorrhages, and signs of neovascularization. He doesn't have that yet.



You can't accuse me of being ignorant of EBM, and then not cite articles for your generalizations, and just saying that they "make sense." If you have articles, I'd like to read them.

I think you're just arguing because you don't like to be wrong, which is fine. But LVH doesn't develop overnight, you should know that. And stage 1 retinopathy (arteriolar constriction) is commonly cited as early retinal end organ damage in HTN.

As far as looking up these studies, I haven't looked at any of them recently, so I can't help you. Harrison's and pocket medicine are good sources in these sense that they directly reference the quality studies out there. If you have either, just look in their sections on HTN, you will find most of the studies I'm talking about referened. I'd imagine uptodate as well if you're in the hospital.

 

[Scaredshizzles]

As far as stage 1 vs. stage 2, it really makes no difference if the patient is at the high end of stage 1 or the low end of stage 2....They are nice at standardizing guidelines, but obviously you have to use your judgment. I'm not an EBM fundamenetalist. For example I think TIMI scores, CHADS2 scores, Wells criteria, PORT scores, etc. etc. are all cr@p. They are there to facillitate "medicolegally safe" discharge criteria, and add absolutely nothing as far as clinical judgment is concerned.

 

[OncoCaP]

As a radiologist, not very difficult. As an internist, very difficult.

You're vastly overestimating the amount of ultrasound training you receive. Unless you really do a LOT of ultrasounds (i.e. will be going into emergency medicine or OB/gyn), you will have very, very limited understanding of how to read ultrasounds, and an even more limited understanding of how to perform them.

Even in those specialties, you have just a basic understanding of ultrasound. For instance, in OB, most of what you need ultrasound for is to assess size (i.e. size of ovaries and thickness of endometrial stripe) and position. Plus, the anatomy of the pelvis isn't THAT complicated.

To use U/S for complicated vascular structures or the heart (i.e. to assess size AND movement AND flow), you should get a trained radiology tech to do it.

I'm not vastly overestimating anything. You seem to be ignorant of what is technically possible. However, what you say above about the training with respect to ultrasounds today is informative and makes a lot of sense.

I honestly feel like you think that zebras are everywhere, and we're doing our patients a disservice by not suspecting more zebras.

You treat common things commonly. 99% of the time, you will be right.

Well, if your definition of a "zebra" is something that less than 1% of a huge population that numbers in the millions has, then heck yeah, zebras are everywhere. According to CURRENT Medical Dx & Tx, Chapter 22. Kidney Disease Suzanne Watnick, MD, Gail Morrison, MD (2008), "Approximately 5% of Americans with hypertension suffer from renal artery stenosis. It occurs most commonly in those over 45 years of age with a history of atherosclerotic disease. Other risk factors include renal insufficiency, diabetes mellitus, tobacco use, and hypertension. ... Laboratory values can show elevated BUN and serum creatinine levels in the setting of significant renal ischemia."

Do you have any idea how many Americans suffer from RAS if it's ~5% of the people who suffer from hypertension? It's more than 3 million. If you have had 20 HTN patients, there is a good chance you had one even if you didn't know it. If that's your definition of a "zebra" then you too should be worrying about them. Even if it's not 5%, it really doesn't matter if the percentage is 1% or 5%. The point is that we can and should identify high-risk groups and consider RAS in the DDx because it is there and it needs to be considered instead of letting those individuals bounce around and possibly slip through the cracks because you're too busy to do a thorough PE, ask a few questions, check a few boxes, ....

Are you going to tell me that get a BUN and serum creatinine is too much trouble on a patient in the high risk groups for RAS?

While correct diagnosis and treatment 99% of time sounds extremely good, it really is completely unacceptable if an easy/cheap test takes you to 99.9%+. Think about it his way, Let's say 1% of the babies born at your hospital had a hearing defect that, if found and treated, results in the child being able to hear well enough to communicate in later life (go to a "regular" school, order at a restaurant, etc.) but if not diagnosed would lead to almost complete impairment in hearing. Or worse, if 1% of the babies born at your hospital had heart defect that would result in premature death within a few years if undetected ... would you skip those test because in 99% of the population the defect isn't there (treat common things commonly)? You would if we couldn't afford to do the test or did not have time and there was no inexpensive alternative. However, that's not the case here with the 47 yo AA male in the OP's question.

http://www.medscape.com/viewarticle/421425_4
(South Med J 94(11):1058-1064, 2001. © 2001 Southern Medical Assn)

"...certain clinical characteristics stood out as highly prevalent in the population with RVHT. These included high-grade retinopathy, abdominal or flank bruits, the presence of peripheral vascular disease, absence of family history of hypertension, and recent onset of hypertension, especially after age 50. Laboratory findings that were more common in the population with RVHT included hypokalemia, metabolic alkalosis, and an elevated blood urea nitrogen level (>20 mg/dL)."

"The frequency of RVHT in patients with high-grade (grade III or IV) retinopathy has been further investigated. Of 123 patients identified with high-grade retinopathy, 93 had renal angiography, and renovascular disease was detected in 31% of these patients.[32] Thus, severe retinopathy seems to identify a patient population at higher risk."

We can reason through this. You don't need to be an MS3 to figure this out. I would expect an MS1 to be able to remember that RAS should be in the differential for HTN, seriously consider running some simple labs and doing a careful physical exam. It's really not that hard.

It doesn't appear that U/S is the way to go unless you pick up something abnormal in your screening tests or have a high risk patient (>=65 yo with new onset htn, worsening BP despite meds, patient is or was referred for cath diagnostics, etc.). U/S for RAS does have a lot of false positives if you get outside the high-risk populations and requires a skilled operator as you discussed above. However, there other tests we can do very reasonably to screen for RAS, which is a concern and will become more of an issue as our patient population ages.

How else do you suggest we do it? Order expensive and unusual tests for all the patients that walk through the door? Suspect all patients of having a bizarre disease that is only found in the dusty pages of an old pathophysiology textbook?

This is NOT House (thank God). Zebras are rare. Shotgunning tests, in the hopes that you will stumble upon something is serving your patients equally as poorly.

See above. BUN and/or creatinine is expensive and unusual? Please.

If I "sound like a bitter, miserable soul," you sound like an overly naive MS2 whose lack of actual clinical experience is not enough of an impediment to prevent you from rudely insulting other users over issues that you have NO EXPERIENCE WITH.
<deep breath>

Okay, having gotten that out of my system....if a test cost $25 dollars, did no harm to the patient, and could be done without excessive inconvenience, I'd order it. Why not? It'll help me sleep at night.

But do you know how much an ultrasound costs? First of all, do you know how much an ultrasound machine costs? A basic, bare-bones ultrasound used to run FASTs [Focused Abdominal Sonograms of Trauma] is $10,000. TEN THOUSAND DOLLARS. The better ultrasounds used for fetal monitoring, echocardiograms, TEEs, etc. can run from $30,000 to $150,000. Seriously. These machines are EXPENSIVE. Is it any wonder that your average IM office doesn't have one? You can't just whip one out and scan your patient whenever you feel like it, because it's just too expensive to have such a machine lying around.

Now, since EVERYTHING in the hospital is marked up (for instance, a basic CBC costs the patient $12-15....seriously!), can you imagine how much more it costs the patient to get an ultrasound?

Furthermore, do you know how irresponsible your suggestion is? "I don't really have any formal training in ultrasound....and I'm the most senior person here, so no one is here to teach me....but I'll just scan your heart anyway, just to satisfy my own curiosity! I don't really have a clue of what I'm looking at, since I'm not a cardiology fellow, but whatever, right? And, just to be safe, I'll have to refer you to a cardiologist, just so you can get ANOTHER ultrasound done!" Why on earth would you want to do that?

This is another thing that med schools don't teach. They spend hours teaching "cultural sensitivity," and not enough on how much tests cost. So MS1s and MS2s learn about all these high-tech tests that are available, without any understanding of how much these tests actually cost. And when they start MS3, they'll suggest these tests, and get laughed at because it's ridiculous to think of someone ordering a $500 test on the off chance that you might stumble upon an extremely rare disease.

It doesn't look like whatever it is that's bothering you is out of your system yet. Did your attendings abuse you early in your medical career? Did kids pick on you early in life? Really, you still sound like a very miserable person. In fact, it's worse than I suspected. Can you honestly say you are happy person, enjoying yourself? Clearly not. Not only are you miserable, you are a joy-sucker, bringing a dark cloud with you to every reply. You turn every discussion into an argument because you can't control your emotions. It's pretty sad. Lighten up. Life is too short to live that way. It's not something I'm trying to get off my chest. I'm just stating the obvious. If I sound like an MS2 who hasn't done rotations yet ... surprise .. I am an MS2 who hasn't done rotations yet! It's nothing to be ashamed of. I'm actually proud of it. The stuff we are talking about here isn't rocket science. We could teach this to a group of middle school students. It really is pretty simple. It's well documented. Becoming an MS3 isn't going to change that. There are many details, but it's not complicated once you lay it all out and quit losing your temper because you're overly sensitive and blow things out of proportion. You make all kinds of rude remarks in virtually every message to me and then scream bloody murder when I say something critical of you. Relax. It's going to be ok. The medical sky is not going to fall if an internist does an ultrasound. And, as you very carefully explained, we shouldn't do the U/S in this case. As I explained above (based on experts who are well beyond an MS3 in terms of their understanding of the matter), there are some screening tests that we can do for RAS that are reasonable in cost and by no means "unusual."

 

[smq123]

I think you're just arguing because you don't like to be wrong, which is fine.

To be honest, your attitude irritated me more than anything else. Laughingly saying that the "JNC VII guidelines" don't mean anything to me, when you got them incorrect as well, and then going on to insultingly claim that "EBM" didn't mean anything to me....and then not providing the articles that would back up your claims.

You know, and I know, that that kind of crap doesn't work when you're in the clinic or on rotations. If you say to your team, "Lasix is a bad choice for hypertension because of x, y, and z," you better have something to back it up. Otherwise, they're going to assume that you created that on the spur of the moment, and they're going to assume that you're full of BS.

But LVH doesn't develop overnight, you should know that.

Thank you, Captain Condescending.

And stage 1 retinopathy (arteriolar constriction) is commonly cited as early retinal end organ damage in HTN.

As far as stage 1 vs. stage 2, it really makes no difference if the patient is at the high end of stage 1 or the low end of stage 2....They are nice at standardizing guidelines, but obviously you have to use your judgment.

First off, the guy has GRADE 1 (not stage 1) retinopathy.

It's a sign that yes, he's had hypertension for a long time. It is NOT a sign that he's teetering on the verge of a hypertensive crisis, though. And, therefore, it's not a sign that you need to aggressively treat his HTN right now.

You're right - you DO need to use your judgement. And, in this case, I think it's bad judgement to jump on his HTN and treat him as if he's Stage 2 right away. For starters, you don't know for certain what his pressures run at home - I don't agree that it's fair to assume that they run higher at home. White coat HTN is a real phenomenon.

Therefore, I'm not going to start him on TWO anti-hypertensives right away. What would be the point? It makes it harder for you to see how he tolerates individual drugs, and you run the risk of dropping his pressures too fast. He's been living at a higher blood pressure for several years now, and so plummeting him down to 110/80 right away is just going to make him feel like crap.

If he's on the border between Stage 1 and Stage 2, I'd start out with one drug, and see how he does. Adjust if necessary, and tweak gradually. That one drug honestly might be enough.

 

[smq123]

Are you going to tell me that get a BUN and serum creatinine is too much trouble on a patient in the high risk groups for RAS?

While I hate to pull your soapbox out from under you, I in fact suggested those very same blood tests waaaay back in post #10.

He probably needs a Chem 7 - check his BUN and creatinine and make sure his kidneys aren't shot. He should also have a fasting glucose test, although it doesn't really show you if he has insulin resistance or not.

A Chem 7 is a relatively cheap test, very easy to get (often times it is drawn right in the office), and tells you a LOT of information. Actually, I might also get a TSH, too. Again, that can easily be drawn in the office.

I'm hardly suggesting that you slap a medication in the patient's hand and hustle him out the door. But I'm also not in favor of sending him to get a renal artery ultrasound, an abdominal CTA, a 24 hour urine collection, etc., unless I have further proof that this is something more unusual (i.e. his medications do not work for him at all, or he reports other, more worrisome symptoms).

See above. BUN and/or creatinine is expensive and unusual? Please.

As I explained above (based on experts who are well beyond an MS3 in terms of their understanding of the matter), there are some screening tests that we can do for RAS that are reasonable in cost and by no means "unusual."

Look, if you had said, "Well, why don't you get a BUN and creatinine just in case?" then sure, that's reasonable. It lets your check for renal function, which you should be checking for anyway! (Well, if you listen to the nephrologists, they'll tell you that creatinine is kind of useless and you should be calculating GFR instead, but that's a tangent.)

But when you suggest that a physician with minimal-to-no training in ultrasound should scan a patient in the office without really having a clear idea of what he is scanning FOR....that's just irresponsible. And very bad medicine.

It doesn't look like whatever it is that's bothering you is out of your system yet. Did your attendings abuse you early in your medical career? Did kids pick on you early in life? Really, you still sound like a very miserable person. In fact, it's worse than I suspected. Can you honestly say you are happy person, enjoying yourself? Clearly not. Not only are you miserable, you are a joy-sucker, bringing a dark cloud with you to every reply. You turn every discussion into an argument because you can't control your emotions. It's pretty sad. Lighten up. Life is too short to live that way.

a) That sounds close to a personal attack, which tends to get the mods on your case. Just to let you know.

b) I AM irritated, because you insist that just randomly scanning patients in the office with an ultrasound was a good idea. And then when someone tries to explain to you that, really, that's unrealistic, then I'm told that that's because I've "bought into a broken system," and that I'm not interested in "looking for improvement." And then you go on about how YOU will practice when you become an attending one day.

It's your patronizing attitude that irked me the most. And your belief that doctors nowadays aren't interested in good patient care. And that's honestly not true. It may seem that way to you, but there are REAL financial barriers to testing for rare and exotic diseases. It's not a fishing expedition. If your patients had unlimited time and unlimited money - sure, knock yourself out. But, in general, that's not realistic and not a good way to think about medicine.

I know it seems like ultrasound would be such an easy non-invasive test. It really isn't - it's expensive, and can be difficult to interpret. But when your posts sound so condescending, as if you've discovered some great screening tests that we're all overlooking....it gets a little annoying, to be honest. (Well, maybe more than a little....)

I'm actually not a miserable person. I'm a little more sad than usual right now (4 patients on our service have died in a short time, and 2 more are teetering), but not really miserable. Or a dark cloud. Opinionated, sure. I DO tend to flare up when I feel like people are being unnecessarily condescending, though.

 

[OncoCaP]

While I hate to pull your soapbox out from under you, I in fact suggested those very same blood tests waaaay back in post #10.

Yes, you did suggest that. I'm not going to suggest you are a Zebra hunter because you did. What you did not however suggest is some of the other stuff related to RAS, and you did not take RAS seriously in the DDx (and sort of scoffed at the DDx top of that). Here is the relevant quote:

"..certain clinical characteristics stood out as highly prevalent in the population with RVHT. These included high-grade retinopathy, abdominal or flank bruits, the presence of peripheral vascular disease, absence of family history of hypertension, and recent onset of hypertension, especially after age 50. Laboratory findings that were more common in the population with RVHT included hypokalemia, metabolic alkalosis, and an elevated blood urea nitrogen level (>20 mg/dL)."

This is sort of nit-picky, however. I'm not really sure how good / sensitive / positive predictive value the abdominal or flank bruit auscultation is for RAS. Clearly it would be very "operator" dependent. The other stuff you would do. I'm not sure how much we can realistically expect an MS3 to get in any attempt at retinopathy grading. I'm pretty sure you would be looking for the above, but I'm not sure whether you would seriously consider RAS or not.

A Chem 7 is a relatively cheap test, very easy to get (often times it is drawn right in the office), and tells you a LOT of information. Actually, I might also get a TSH, too. Again, that can easily be drawn in the office.

I'm hardly suggesting that you slap a medication in the patient's hand and hustle him out the door. But I'm also not in favor of sending him to get a renal artery ultrasound, an abdominal CTA, a 24 hour urine collection, etc., unless I have further proof that this is something more unusual (i.e. his medications do not work for him at all, or he reports other, more worrisome symptoms).

Yes. Agreed. At the same time, I'm thinking RAS ought to be in the DDx and it's not expensive to screen for it.

Look, if you had said, "Well, why don't you get a BUN and creatinine just in case?" then sure, that's reasonable. It lets your check for renal function, which you should be checking for anyway! (Well, if you listen to the nephrologists, they'll tell you that creatinine is kind of useless and you should be calculating GFR instead, but that's a tangent.)

But when you suggest that a physician with minimal-to-no training in ultrasound should scan a patient in the office without really having a clear idea of what he is scanning FOR....that's just irresponsible. And very bad medicine.

Again, it's more than just getting a BUN and creatinine. That's just the part that costs a little money. Looking at the age or asking about the FH of HTN isn't going to cost anything extra (nor will the auscultation). It's screening for RAS. There is more to it than the labs.

a) That sounds close to a personal attack, which tends to get the mods on your case. Just to let you know.

b) I AM irritated, because you insist that just randomly scanning patients in the office with an ultrasound was a good idea. And then when someone tries to explain to you that, really, that's unrealistic, then I'm told that that's because I've "bought into a broken system," and that I'm not interested in "looking for improvement." And then you go on about how YOU will practice when you become an attending one day.

I do think it's a good idea to do ultrasounds on patients, but I never suggested that it should be random. The way I'm proposing it sounds random to you but let me clarify. I suggested that it should be routine given the right equipment and appropriate training. I'm not suggesting that every physician should be trained as an ultrasound tech (or use the equipment with inadequate training). What I was saying is that in our DDx we should consider differentials that are important and affect millions of Americans (like RAS does) and impacts the accuracy of our diagnosis and treatment (essential HTN does not equal RVHT in diagnosis or treatment). You didn't want to even consider it at this point. I'm suggesting that we can consider it in a useful way even at this point. I considered that U/S would be the best way to do this RAS screening but it currently is not the way to do it unless the patient falls into certain high risk groups (but might be some day if the equipment improves and we can get appropriate training to make it worthwhile and/or otherwise practical).

It's your patronizing attitude that irked me the most. And your belief that doctors nowadays aren't interested in good patient care. And that's honestly not true. It may seem that way to you, but there are REAL financial barriers to testing for rare and exotic diseases. It's not a fishing expedition. If your patients had unlimited time and unlimited money - sure, knock yourself out. But, in general, that's not realistic and not a good way to think about medicine.

I don't mean to be patronizing; consider that you might be overly sensitive and misinterpret my attitude or whatever. I really have nothing against you and I'm not trying to make you look bad. You keep talking about RAS like it's a rare or exotic disease when it isn't. It's kindof tough from my end when you pretend that 3 million people or 1 in 20 HTN patients is a small number. There is a realistic way of dealing with this. I may not always know it off the top of my head, but I know there is a good way to manage these patients without ignoring issues that "only" 5% or 1% of HTN patients have.

I know it seems like ultrasound would be such an easy non-invasive test. It really isn't - it's expensive, and can be difficult to interpret. But when your posts sound so condescending, as if you've discovered some great screening tests that we're all overlooking....it gets a little annoying, to be honest. (Well, maybe more than a little....)

I'm actually not a miserable person. I'm a little more sad than usual right now (4 patients on our service have died in a short time, and 2 more are teetering), but not really miserable. Or a dark cloud. Opinionated, sure. I DO tend to flare up when I feel like people are being unnecessarily condescending, though.

My goal is not to be condescending. Sorry to hear about your patients who died. It really doesn't accomplish anything when you flare up. 9 times out of 10 it just makes things worse. Try to be a bit more patient and we'll have more meaningful and fun discussions around here.

 

[Jwax]

I'm actually not a miserable person. I'm a little more sad than usual right now (4 patients on our service have died in a short time, and 2 more are teetering), but not really miserable. Or a dark cloud. Opinionated, sure. I DO tend to flare up when I feel like people are being unnecessarily condescending, though.

FWIW, I've never found your posts to be joysuckers and have rather liked most of your posts since I've noticed them on SDN. Just thought I'd throw that out there.

 

[smq123]

What you did not however suggest is some of the other stuff related to RAS, and you did not take RAS seriously in the DDx (and sort of scoffed at the DDx top of that).

- Should renal artery stenosis be in the DDx? Sure. Do I think that, in this case, I'd spend a lot of time and energy worrying about everything on the DDx? No. Not unless there was something else that triggered warning bells in my head.

- What other tests should you suggest that relate to RAS?

I also mentioned in post #10 that you could listen for bruits although a) they're unusual and somewhat rare, and b) it doesn't always do anything for you anyway.

By the way, listening for bruits is NOT always easy. The cardiologists make it look easy - they can take one of those cheap disposable stethoscopes, gently put it on the person's neck, listen for 5 seconds, and say, "Yep, a bruit, clear as day." I then take my $200 stethoscope, put it on the neck, listen for two MINUTES, and say, "Uh...sure. A bruit. Yeah...a bruit. Clear as....mud."

Again, it's more than just getting a BUN and creatinine. That's just the part that costs a little money. Looking at the age or asking about the FH of HTN isn't going to cost anything extra (nor will the auscultation). It's screening for RAS. There is more to it than the labs.

What I was saying is that in our DDx we should consider differentials that are important and affect millions of Americans (like RAS does) and impacts the accuracy of our diagnosis and treatment (essential HTN does not equal RVHT in diagnosis or treatment). You didn't want to even consider it at this point.

Ok.

The way that they teach it in med school (and again, this is pretty unrealistic) is that the progression is: CC >> History/Physical >> long DDx >> huge variety of labs to narrow down the DDx >> Diagnosis. I think this is more or less how we were taught.

The reality of it is, though, is that it's not a straight-forward progression. It usually goes CC >> History/Physical >> Quick DDx >> More history to narrow down DDx >> Basic labs >> Add to, or subtract from, original DDx >> Pick some kind of treatment plan to relieve patient's symptoms/prevent death >> More labs >> Diagnosis.

You can't just not treat a patient when they first walk into your office. You may not have all the pieces of the puzzle, but you have enough to make an educated guess based on your knowledge of epidemiology. You can't just let a patient with HTN walk into your office, and then walk out without any kind of treatment.

It's not that it's not in my thought process. But unless the screening test picks up something that would set off sirens, I'm not going to necessarily think too deeply about the other things on the DDx. And I'm not going to test or scan for them either, unless there's a good reason for it.

You keep talking about RAS like it's a rare or exotic disease when it isn't. It's kindof tough from my end when you pretend that 3 million people or 1 in 20 HTN patients is a small number.

There is a realistic way of dealing with this. I may not always know it off the top of my head, but I know there is a good way to manage these patients without ignoring issues that "only" 5% or 1% of HTN patients have.

I have honestly yet to see a patient with renal artery stenosis. I have seen probably over 250 patients with HTN that were on treatment regimens that worked, but never one with renal artery stenosis.

Yeah, and the realistic way of dealing with it is to wait for the Chem 7 to come back. That's the only screening tool you need. If it's abnormal, THEN you reassess. But until then....just wait.

My goal is not to be condescending.

Try to be a bit more patient and we'll have more meaningful and fun discussions around here.

I have tried to be patient. I disagreed with your original thought that sexual dysfunction was the "most important" part of the history....but then it got worse when you kept insisting that it was, and then back-pedaled by denying that you had said that it was the "most important."

And you keep insisting that I'm "ignoring" the prevalence of renal artery stenosis. If the BUN comes back sky high, then I'd re-think. Until then....just wait and see if the HCTZ or the lopressor helps the patient's HTN. There's no reason to do a definitive, gold-standard test to diagnose renal artery stenosis RIGHT NOW.

I think the disconnect is, again, the change in thinking about how/when you time diagnostic tests, which ones take priority, etc.

FWIW, I've never found your posts to be joysuckers and have rather liked most of your posts since I've noticed them on SDN. Just thought I'd throw that out there.

Hey, thanks. I've liked your posts too.

 

[45408]

Now, since EVERYTHING in the hospital is marked up (for instance, a basic CBC costs the patient $12-15....seriously!), can you imagine how much more it costs the patient to get an ultrasound?

Seriously? The hospital I just rotated through has price tags on common tests so that interns don't order things excessively. A CBC is $55, and a manual diff is another $45. A chem panel with liver enzymes is $220. A week of CBCs and chem panels = over $2000.

If insurance companies and the government no longer paid for these techs to read those X-rays, CT's or whatever, physicians would read them because they would have no choice. It's economics plain and simple. I'm not suggesting that physicians do something that they aren't trained to do. If you need to do something as part of your job (to do it well) and it requires training, then let's get the training.

Techs read x-rays?? RADIOLOGISTS read x-rays. If you want to "get the training" to do that, you can add a 4-year radiology residency to your desired specialty.

 

[45408]

I'm not vastly overestimating anything. You seem to be ignorant of what is technically possible. However, what you say above about the training with respect to ultrasounds today is informative and makes a lot of sense.

Oh, SNAP, the pot just called the kettle black.

 

[OncoCaP]

Seriously? The hospital I just rotated through has price tags on common tests so that interns don't order things excessively. A CBC is $55, and a manual diff is another $45. A chem panel with liver enzymes is $220. A week of CBCs and chem panels = over $2000.

And your point is? That we shouldn't be screening for RAS?

Techs read x-rays?? RADIOLOGISTS read x-rays. If you want to "get the training" to do that, you can add a 4-year radiology residency to your desired specialty.

You're right. I forgot how wasteful our system was and had a Freudian slip there not realizing that we get the most expensive person to do a job so that we can cash in more. Radiologists do read X-rays. I'm sure the techs could learn to do many of the things that radiologists do (in fact, they do them sometimes) if they were allowed to. If it didn't require a medical license to read X-rays, tech's would be doing it; that I'm certain of. Techs and nurses would be doing a lot of things if a medical license wasn't required (things are certainly moving that way in primary care it seems). For simple X-ray reading, a tech can be trained to do it. Radiologists do bring a lot of value; it just depends on what it is you are looking at or what you are concerned about.

Ultrasound techs already read the images they take. That's more what I was thinking of.

 

[mjl1717]

Guys, Lasix has NEVER been a 1st or 2nd line med for newly diagnosed essential HTN..

{its my favorite med}

 

[OncoCaP]

- Should renal artery stenosis be in the DDx? Sure. Do I think that, in this case, I'd spend a lot of time and energy worrying about everything on the DDx? No. Not unless there was something else that triggered warning bells in my head.

That's really my point. Glad we agree on that.

- What other tests should you suggest that relate to RAS?

I also mentioned in post #10 that you could listen for bruits although a) they're unusual and somewhat rare, and b) it doesn't always do anything for you anyway.

By the way, listening for bruits is NOT always easy. The cardiologists make it look easy - they can take one of those cheap disposable stethoscopes, gently put it on the person's neck, listen for 5 seconds, and say, "Yep, a bruit, clear as day." I then take my $200 stethoscope, put it on the neck, listen for two MINUTES, and say, "Uh...sure. A bruit. Yeah...a bruit. Clear as....mud."

Again, I totally agree. Here's what it said in the article I mentioned earlier on RVHT:

"Abdominal bruits have a prevalence of 6.5% to 31% in the healthy population,[34] and a prevalence of 28% in patients with all-cause hypertension.[35] However, in patients with angiographically proven RAS, the prevalence ranges from 78% to 87%.[33] Two studies have investigated the sensitivity and specificity of finding a systolic-diastolic abdominal bruit in the diagnosis of RAS.[33] Sensitivity ranged from 39% to 63%, with specificity of 90% to 99%. Thus, the presence of a systolic-diastolic bruit is highly suggestive of RAS and should be screened for, while the absence of a bruit does not exclude RAS."

I have only heard a few abdominal bruits (like maybe 2 or 3) and they were pretty obvious; I heard them in young (20ish or younger) thin females in the epigastric area. I guess they were systolic, but certainly not systolic-diastolic and nothing pathological. You might try that and see if you can pick them up that way.

Ok.

The way that they teach it in med school (and again, this is pretty unrealistic) is that the progression is: CC >> History/Physical >> long DDx >> huge variety of labs to narrow down the DDx >> Diagnosis. I think this is more or less how we were taught.

The reality of it is, though, is that it's not a straight-forward progression. It usually goes CC >> History/Physical >> Quick DDx >> More history to narrow down DDx >> Basic labs >> Add to, or subtract from, original DDx >> Pick some kind of treatment plan to relieve patient's symptoms/prevent death >> More labs >> Diagnosis.

That makes sense to me.

You can't just not treat a patient when they first walk into your office. You may not have all the pieces of the puzzle, but you have enough to make an educated guess based on your knowledge of epidemiology. You can't just let a patient with HTN walk into your office, and then walk out without any kind of treatment.

It's not that it's not in my thought process. But unless the screening test picks up something that would set off sirens, I'm not going to necessarily think too deeply about the other things on the DDx. And I'm not going to test or scan for them either, unless there's a good reason for it.

Yes, that makes sense.

I have honestly yet to see a patient with renal artery stenosis. I have seen probably over 250 patients with HTN that were on treatment regimens that worked, but never one with renal artery stenosis.

Yeah, and the realistic way of dealing with it is to wait for the Chem 7 to come back. That's the only screening tool you need. If it's abnormal, THEN you reassess. But until then....just wait.

Given the prevalence of 1-5% (the kind of numbers that get quoted) you should have had between 2 and 13 RAS's. Do you think it's that you mainly had a patient population that was at low risk for RAS or do you think it's possible you had a patient with RAS but didn't know it because you weren't looking for it (there wasn't a lab result screaming "problem" at you)? I did some more reading on this and it does appear that RVHT pts will respond to HTN meds (particularly ACEIs and probably ARBs) but that additional management is indicated to avoid ischemic nephropathy. Did you have any patients that did not respond to the diuretics very well but did better on the ACEIs? Did any of these patients have kidney problems that might be consistent with RAS?

I have tried to be patient. I disagreed with your original thought that sexual dysfunction was the "most important" part of the history....but then it got worse when you kept insisting that it was, and then back-pedaled by denying that you had said that it was the "most important."

And you keep insisting that I'm "ignoring" the prevalence of renal artery stenosis. If the BUN comes back sky high, then I'd re-think. Until then....just wait and see if the HCTZ or the lopressor helps the patient's HTN. There's no reason to do a definitive, gold-standard test to diagnose renal artery stenosis RIGHT NOW.

I think the disconnect is, again, the change in thinking about how/when you time diagnostic tests, which ones take priority, etc.

I appreciate the effort. Let's take a look at the "most important" Hx item again. Again, you are taking my words out of context. You are more interested in proving me wrong than you are in finding out what my intent was. I have no problem admitting when I make an incorrect suggestions or recommendation. The issue here is that you interpreted my statements about ED and the Hx in a way that I did not intend. I did want to emphasize the issue, but I in no way was suggesting that it should displace asking about previous MI's. Really, to suggest that I think the sexual Hx is more important than PMH is disingenuous. You can't think that any medical student would suggest this. You know that's not true. To pursue it in that way has no value. If you go back and look at the sentence you are so fixated on, you will find that it is clearly in a section on medication compliance specifically. Even so, I should have been more clear to avoid any confusion by qualifying the statement. None of this changes what intended or meant to communicate. In my opinion, for this class of medications, getting a baseline sexual hx for the purpose of determining if there already is ED is the most important part of the history related to medication compliance after inquiring about ability to pay. This way, if you see the patient again, you can check to make sure this is not an issue. Now most parts of the Hx don't related to medication compliance of course. It's by no means more important than everything else we have learned about Hx like PMH for MI's or FH of HTN, DM, CAD, etc. I put emphasis on it because it receives no emphasis in textbooks and I personally know of patients who went on to need a CABG or presented with CHF for this very reason (stopped taking the BP med because of ED). I looked this up and it's a common problem from what I can tell, but by no means the only compliance issue. What makes this tricky is that men are often very embarrassed to say that they have ED so you might get other excuses.

 

[Trail Boss]

And your point is? That we shouldn't be screening for RAS?



You're right. I forgot how wasteful our system was and had a Freudian slip there not realizing that we get the most expensive person to do a job so that we can cash in more. Radiologists do read X-rays. I'm sure the techs could learn to do many of the things that radiologists do (in fact, they do them sometimes) if they were allowed to. If it didn't require a medical license to read X-rays, tech's would be doing it; that I'm certain of. Techs and nurses would be doing a lot of things if a medical license wasn't required (things are certainly moving that way in primary care it seems). For simple X-ray reading, a tech can be trained to do it. Radiologists do bring a lot of value; it just depends on what it is you are looking at or what you are concerned about.

Ultrasound techs already read the images they take. That's more what I was thinking of.

Techs reading x-rays? Are you for real?

 

[OncoCaP]

Techs reading x-rays? Are you for real?

They read ultrasounds now. Ever gone to see an ultrasound of a baby? The radiologist is nowhere to be seen. They measure and check all kinds of things, from the kidneys to the heart and brain. They do a great job. I would assume when there is a problem the radiologist reviews the images and writes a report. I'm sure the radiologist is also responsible for the work.

Let's make this more concrete. Just as they work with ultrasound, they could work with X-ray images. Ms. Jones, I have an X-ray for Mr Smith's left leg at the knee that I would like you to look at. Could you take a quick look and let me know if you see any obvious problems?

I think I see a problem. Femur fracture. This level of assessment would require very little training.

Here's another example that is obvious.
Ms. Jones. Could you take a look at Mr. Kruger's X-ray and tell me if you see any bullet fragments?

Yes, Dr. Hines. I see the bullet fragments. Again, not much training involved here.

Clearly there is more work that would need to be done by radiologists to read and interpret these. However, the physicians dealing with these patients may not need all that information right away. For routine and simple assessments, techs could be trained to perform a number of useful tasks.

 

[LadyWolverine]

I forgot how wasteful our system was and had a Freudian slip there not realizing that we get the most expensive person to do a job so that we can cash in more. Radiologists do read X-rays. I'm sure the techs could learn to do many of the things that radiologists do (in fact, they do them sometimes) if they were allowed to. If it didn't require a medical license to read X-rays, tech's would be doing it; that I'm certain of. Techs and nurses would be doing a lot of things if a medical license wasn't required (things are certainly moving that way in primary care it seems). For simple X-ray reading, a tech can be trained to do it. Radiologists do bring a lot of value; it just depends on what it is you are looking at or what you are concerned about.

Ultrasound techs already read the images they take. That's more what I was thinking of.

I have never wanted to hit someone in the face as much as I do after reading this post. What a ridiculous, ignorant thing to say.

There is a reason that radiology residency takes as long as it does. Just because a tech has helped take/develop 100s of x-rays doesn't meant that he or she has had any medical training whatsoever. If you go down to a reading room to speak with a radiologist, you'd realize that these folks know their anatomy, medicine, and pathology inside and out. You can't learn that in a vocational tech program. And furthermore, what the hell is a "simple x-ray reading?" You can get sued pretty easily for missing miniscule things in those otherwise "simple" x-rays. You need a well-trained eye.

And those images that you put up are ridiculously extreme. I'd love to see a tech try to interpret the multitudes of morning CXRs from the ICU. Give me a break. I previously thought that you were relatively knowledgable and had some good arguments. Now I realize that you have no clue what the hell you are talking about.

 

[OrangeA]

Make sure you do a urinalysis for metanephrines and VMA.

 

[Droopy Snoopy]

I have never wanted to hit someone in the face as much as I do after reading this post. What a ridiculous, ignorant thing to say.

 

[OncoCaP]

I have never wanted to hit someone in the face as much as I do after reading this post. What a ridiculous, ignorant thing to say.

There is a reason that radiology residency takes as long as it does. Just because a tech has helped take/develop 100s of x-rays doesn't meant that he or she has had any medical training whatsoever. If you go down to a reading room to speak with a radiologist, you'd realize that these folks know their anatomy, medicine, and pathology inside and out. You can't learn that in a vocational tech program. And furthermore, what the hell is a "simple x-ray reading?" You can get sued pretty easily for missing miniscule things in those otherwise "simple" x-rays. You need a well-trained eye.

And those images that you put up are ridiculously extreme. I'd love to see a tech try to interpret the multitudes of morning CXRs from the ICU. Give me a break. I previously thought that you were relatively knowledgable and had some good arguments. Now I realize that you have no clue what the hell you are talking about.

You want to hit people in the face because they disagree with you and have a different perspective, and you're only human in that respect. People beat and kill people all the time that they disagree with ... just visit any big city hospital's emergency room. Some spouses also beat one another physically and it's very unfortunate and unnecessary (and a big problem despite being illegal). I'm not suggesting you will give in to that desire. I suggest talking things out rather than resorting to violence, but that's a discussion you should have with your therapist.

Thanks for illustrating my point. My illustrations are simple, but I'm not suggesting that techs are limited to such simple interpretation. They can do more complex interpretation than that but there comes a point where it would be more appropriate to use a radiologist. We could train them for particular tasks. We don't need to do is turn them into radiologists, mainly because we can't afford to and secondarily because it isn't necessary (we have radiologists who can do their work just fine).

In too many cases our patients have two options: no/shoddy/spotty care or unaffordable high-quality care provided by staff who have significantly more training than needed for a given task. You are justifying this system with your arguments. Next time you see a woman present with Stage IV breast cancer to the emergency room or see a newborn child die due to inadequate prenatal medical care, give yourself a good pat on the back. Arguments like yours protected them from medical care that could have saved their lives but was beneath your standards and thus should not be allowed. That's the system we have today. Yes, this is a hard thing to say, but it's true. By creating a system where simple X-ray reading requires a radiologist no matter what, we make X-rays more expensive than they need to be, even for routine very simple conditions. When we make them expensive, it means many people who need them will no longer be able to afford them, and thus will not get the care to save their health and in some cases, their lives. I realize there is a balance. There comes a point where you lower your standards so much that you actually allow more harm than good. There would need to be some guidelines as to what techs could interpret on X-rays, the conditions involved, etc. We need to better understand where those break-points are. We shouldn't unnecessarily limit access to care in the pursuit of perfection in the way that medicine is practiced. This also ties into the management of the HTN patient in the OP's question. We know there are certain DDx conditions we can screen for that would change the diagnosis and treatment. We know we can't screen for everything, and thus we cut off the DDx somewhere (also in terms of the kinds of tests we do). I wish you would have some sympathy for those who cannot afford the care we provide today because of inefficiencies that you support. You'll earn a good income and will be able to afford the high quality care, and so it really doesn't matter to you. I would contend that considering improvements that save lives can actually be the more intelligent and beneficial thing to do than the status quo. At the same time, when we make improvements we need to make sure that the adverse effects aren't more serious than the problem we are trying to treat. I do agree with this.

With respect to techs reading X-rays, I like the OB/GYN ultrasound model. When you're expecting a child and you go in for a routine ultrasound, a tech will get the images and do basic calculations and analysis. You won't see the radiologist. On the other hand, if you are an older mom, and you go in for nuchal translucency, the tech (who probably hasn't had the special training required for this) may not do the imaging and analysis. Although I've read that tech's can do this if they get the extra training, I've only see the radiologist do an NT, from taking the images to analyzing them. I propose we could have a similar system for X-rays and improve care for our patients and reduce cost. It's a matter of thinking critically about what training a particular task requires. Not all X-rays and associated conditions are the same. Some require a radiologist level of training but for others a trained tech can do the job very effectively at a lower cost. It's a good system and it works well with ultrasounds. It's nothing to get worked up about. This idea could improve access to care and thereby save lives.

 

[smq123]

I have only heard a few abdominal bruits (like maybe 2 or 3) and they were pretty obvious; I heard them in young (20ish or younger) thin females in the epigastric area. I guess they were systolic, but certainly not systolic-diastolic and nothing pathological. You might try that and see if you can pick them up that way.

Thank you, Dr. Osler, in today's lesson in physical diagnosis.

You're not telling me anything that I don't know. I have also heard obvious epigastric bruits. Pathological bruits, quiet bruits, and especially carotid bruits, are very different. Just like severe aortic stenosis is ridiculously easy to auscultate....but mild, mild TR is a totally different story.

Given the prevalence of 1-5% (the kind of numbers that get quoted) you should have had between 2 and 13 RAS's. Do you think it's that you mainly had a patient population that was at low risk for RAS or do you think it's possible you had a patient with RAS but didn't know it because you weren't looking for it (there wasn't a lab result screaming "problem" at you)? I did some more reading on this and it does appear that RVHT pts will respond to HTN meds (particularly ACEIs and probably ARBs) but that additional management is indicated to avoid ischemic nephropathy. Did you have any patients that did not respond to the diuretics very well but did better on the ACEIs? Did any of these patients have kidney problems that might be consistent with RAS?

Nope.

And a patient population at "low risk" for RAS? I live in Philadelphia...so no.

Let's take a look at the "most important" Hx item again. Again, you are taking my words out of context. You are more interested in proving me wrong than you are in finding out what my intent was. I have no problem admitting when I make an incorrect suggestions or recommendation. The issue here is that you interpreted my statements about ED and the Hx in a way that I did not intend.

You honestly seem to have a serious, serious lack of self-awareness. I don't think you're reading your own posts as you write them.

When you say "the most important thing," that's what I'm going to assume that that's what you mean. And that's what you said. I am not a mind-reader, and I'm not going to use my non-existent ESP to decipher what you "intended."

Honestly, if you do not watch what you say, and use imprecise terms, and then later say that that's "not what you intended," you will be eaten alive next year. Residents and attendings, particularly in surgery, OB, IM and peds, get REALLY frustrated when you use imprecise terms, or do not say EXACTLY what you intend to say. I mean, these are people who will be unhappy if you say "vital signs are stable" because they don't know what that means - does that mean that the vitals are within normal limits, or are they "stable" because they're abnormal, but unchanged from yesterday? These are people who will also tell you not to refer to Depo-Provera as "Depo," because depo is just the oil. Provera is the actual medication.

Heck, some attendings don't like the term "lab values are within normal limits," because "high normal" is almost as bad as "abnormal."

I put emphasis on it because it receives no emphasis in textbooks and I personally know of patients who went on to need a CABG or presented with CHF for this very reason (stopped taking the BP med because of ED).

And you're falling into the trap that JetPropPilot described - wanting to let unusual instances guide your clinical practice. You can't base your clinical habits solely on "exceptions." You have to be flexible to accomodate those unusual cases and those exceptions, but you cannot let them guide your practice. If you do, you run the risk of not having a set "routine" when you see patients....and when you don't have a routine that you always follow, you make mistakes. Because you can't recognize when things deviate from the norm when you don't have a norm!

They read ultrasounds now. Ever gone to see an ultrasound of a baby? The radiologist is nowhere to be seen. They measure and check all kinds of things, from the kidneys to the heart and brain.

- BPPs and anatomy scans are different from echos. Anatomy scans and BPPs aren't that hard....echos, though, are very complicated.

The thing is, you do anatomy scans and BPPs even on normal babies. And you do a lot of them. So you have a lot of "normals" to compare them to.

Echos are almost always done on abnormal hearts. So it's harder to realize when you're looking at something that is diseased versus something that is normal.

- Echos are also just naturally harder than anatomy scans and BPPs. Anatomy scans and BPPs measure things, and that's about it. Echos measure dimensions, rigidity, and fluid flow. That's a lot harder.

If you go down to a reading room to speak with a radiologist, you'd realize that these folks know their anatomy, medicine, and pathology inside and out. You can't learn that in a vocational tech program.

I know. Those radiologists always amaze me, because you will look at something that looks normal, but they are able to see 3 different things that are actually abnormal. It's quite something. They're also at home with all modalities....whereas looking at MRIs is always a crapshoot for everyone else.

In too many cases our patients have two options: no/shoddy/spotty care or unaffordable high-quality care provided by staff who have significantly more training than needed for a given task.

No. I don't think that you fully understand where the money in this healthcare system goes to.

Remember back a few posts, when you said that you thought it'd be a good idea for you to scan your own patients, "just to see," even though you're not a trained radiologist? You assumed that this would save them money, because they wouldn't have to pay the radiologist, and you wouldn't charge them for an "unofficial scan".

Actually, it wouldn't save your patients anything. Because, for you to own your own ultrasound machine, you'd have to buy it - and it would cost you around $25,000. How are you going to recoup that $25,000...and the money required for the upkeep? (Ultrasound machines do require a fair amount of maintenance.) You're going to have to charge your patients, just to recoup some money - and it's not going to be a trivial amount, it's going to be $50-$75, otherwise that machine is going to cost you waaay too much.

Suppose you argue that you'll be a cheap, used machine that is really old. Well, those machines are older, so they'll break more often. Plus, since they're old, their images are going to be crappy....so scanning won't tell you anything. If it gave you an equivocal scan each time, why bother doing it?

Now, THINK about what a $hitty thing you just did for your patient. You charged them $50-$75 for a scan that doesn't give you a definitive result. Since you're not trained in ultrasound, you can't be confident that you didn't miss something important....so you either send the patient home (to possibly suffer because you missed a diagnosis) or you send the patient to get an official ultrasound read by a certified radiologist. Which is an EXTRA expense, on top of the $50-75 that you already charged them! SO YOU HAVEN'T DONE YOUR PATIENTS ANY FAVORS AT ALL! No matter what you choose to do then, the patient loses!

The system may be broken, but your suggestions would just make it worse.

 

[45408]

And your point is? That we shouldn't be screening for RAS?

Only if it's indicated. My point is that this stuff costs a lot more than most people realize - even a lot of the M3/M4s don't know how much this stuff is.

For simple X-ray reading, a tech can be trained to do it.

Not going to happen, unless the tech is willing to be sued for hundreds of thousands if not millions of dollars. They might glance at it and make a preliminary comment, but you're still not grasping this concept of liability. I'm not sure what you consider "simple," but just about anything can seem benign but have a serious finding. There is no "simple" chest x-ray, which is probably the most common film in a hospital, and any x-ray of any long bone could have an occult malignancy that only a highly trained eye would spot.

 

[45408]

They read ultrasounds now. Ever gone to see an ultrasound of a baby? The radiologist is nowhere to be seen. They measure and check all kinds of things, from the kidneys to the heart and brain. They do a great job. I would assume when there is a problem the radiologist reviews the images and writes a report. I'm sure the radiologist is also responsible for the work.

You can't have one without the other. Is the radiologist responsible or nowhere to be found? The radiologist usually doesn't have to be in the room, but that's not the same as "nowhere to be found." Besides, in this case, you might have a maternal-fetal medicine specialist evaluate an abnormal fetal ultrasound.

I think I see a problem. Femur fracture. This level of assessment would require very little training.

Oh, my God, dude. You know who does the preliminary read on those? The orthopedic surgeon, as he calls the OR to get ready for the patient. Likewise, the trauma surgeons I worked with in October would do their own preliminary reads (hell, I could do the preliminary reads). The point is that if it's on film, it has to be read by an expert.

By the way, you just got sued. That was actually a pathological fracture due to an occult malignancy in the diaphysis of the femur. You said to just go ahead and repair the femur without calling the orthopedic oncologist, and your patient died of cancer.

Yes, Dr. Hines. I see the bullet fragments. Again, not much training involved here.

Clearly there is more work that would need to be done by radiologists to read and interpret these. However, the physicians dealing with these patients may not need all that information right away. For routine and simple assessments, techs could be trained to perform a number of useful tasks.

Again, you're clearly speaking from a serious lack of experience. Unless Dr. Hines is a *****, he'll just look at this himself to see the bullet fragments. Two to seven years of med school and residency are often more than enough for most physicians to diagnose MOST of the common problems that they're looking for on the diagnostic studies that they order.

 

[45408]

Next time you see a woman present with Stage IV breast cancer to the emergency room or see a newborn child die due to inadequate prenatal medical care, give yourself a good pat on the back. Arguments like yours protected them from medical care that could have saved their lives but was beneath your standards and thus should not be allowed. That's the system we have today. Yes, this is a hard thing to say, but it's true.

No, it's not.

 

[OncoCaP]

Thank you, Dr. Osler, in today's lesson in physical diagnosis.

You're not telling me anything that I don't know. I have also heard obvious epigastric bruits. Pathological bruits, quiet bruits, and especially carotid bruits, are very different. Just like severe aortic stenosis is ridiculously easy to auscultate....but mild, mild TR is a totally different story.

Ah, OK.

But, what's with the Dr. Osler remark? Is that supposed to be a signal that you want to engage in a few rounds of namecalling or ridicule? Do you need me to trash you in a few message in some kind of dysfunctional forum codependency?

Nope.

And a patient population at "low risk" for RAS? I live in Philadelphia...so no.

You honestly seem to have a serious, serious lack of self-awareness. I don't think you're reading your own posts as you write them.

When you say "the most important thing," that's what I'm going to assume that that's what you mean. And that's what you said. I am not a mind-reader, and I'm not going to use my non-existent ESP to decipher what you "intended."

I can see where you are getting hung up. I consider this to be pretty informal discussion board and if I read a post that doesn't make sense to me, I'll ask the poster what they meant before I assume something silly like a med student thinking that asking about a sexual history is more important than PMH. How you could honestly think that a medical student would think that getting a sexual history is more important than asking about MI's is beyond me. Maybe the medical students you are around struggle with this kind of thing. The thought would never even cross my mind. If that's what came across, I would clarify if I understood the poster correctly. That's my take anyway.

Honestly, if you do not watch what you say, and use imprecise terms, and then later say that that's "not what you intended," you will be eaten alive next year. Residents and attendings, particularly in surgery, OB, IM and peds, get REALLY frustrated when you use imprecise terms, or do not say EXACTLY what you intend to say. I mean, these are people who will be unhappy if you say "vital signs are stable" because they don't know what that means - does that mean that the vitals are within normal limits, or are they "stable" because they're abnormal, but unchanged from yesterday? These are people who will also tell you not to refer to Depo-Provera as "Depo," because depo is just the oil. Provera is the actual medication.

Heck, some attendings don't like the term "lab values are within normal limits," because "high normal" is almost as bad as "abnormal."

Precise language is important. Understanding context is also important as is clarifying when you hear something that doesn't make sense to you. I'll aim to please the attendings next year. I'm going to make mistakes, and I'm not going to worry about it neurotically. Despite the repeated drum beat about how bad medical school is, it has been one of the absolute best times of my life. I love the attendings I have met so far. Even the "bad ones" haven't bothered me. I don't take their behavior personally. My classmates are amazing. The people I come in contact with are wonderful human beings who are fun just to be around. That might change next year when I rotate through clinics, but my plan is to enjoy it and to focus on the positive rather than living in fear of making an error.

And you're falling into the trap that JetPropPilot described - wanting to let unusual instances guide your clinical practice. You can't base your clinical habits solely on "exceptions." You have to be flexible to accomodate those unusual cases and those exceptions, but you cannot let them guide your practice. If you do, you run the risk of not having a set "routine" when you see patients....and when you don't have a routine that you always follow, you make mistakes. Because you can't recognize when things deviate from the norm when you don't have a norm!

Secondary hypertension is thought to be found in about 5 to 10 % of HTN cases. That's not a small number and not unusual. We have already agreed that there is a limit to what can be considered here. It is a balancing act, but anyone who sees a lot of hypertension cases (like you now and eventually me) will run into secondary hypertension cases from time to time. If you aren't seeing them, then I would start to wonder why you weren't. Onusko (2003) in AAFP has a nice secondary hypertension mnemonic ABCDE: Accuracy of diagnosis, obstructive sleep Apena, Aldosteronism, Bruits (RAS), Bad Kidneys (parenchymal dz), Catecholamines, Coarctation of the aorta, Cushings's syndrome, Drugs, Diet, Erythropoetin, and Endocrine. Routine urinalysis, CBC, blood chemistry (potassium, sodium, creatinine, fasting glucose, fasting lipid levels) with the ECG are good for screening. His article can be found here: www.aafp.org/afp/20030101/67.html and gives a lot of practical advice.

At this point you probably grant the fact that RAS is not "unusual" or very rare. It's not the most common cause by far, but it should be considered. Pheos are a very rare cause but potentially lethal cause of hypertension and optimal evaluation even with patients who are suspected of having them is controversial. Even though they are very rare, I would nevertheless briefly consider it in the DDx and look for "panic attacks," episodic hypertension, palpitations, headache, sweating, angina, patients with FH of VHL, MEN-2. Although the 24 hour urine collection is inconvenient, the test is readily available and relatively inexpensive. There are plasma catecholamine tests available also if the urine test is not desired.

- BPPs and anatomy scans are different from echos. Anatomy scans and BPPs aren't that hard....echos, though, are very complicated.

The thing is, you do anatomy scans and BPPs even on normal babies. And you do a lot of them. So you have a lot of "normals" to compare them to.

Echos are almost always done on abnormal hearts. So it's harder to realize when you're looking at something that is diseased versus something that is normal.

- Echos are also just naturally harder than anatomy scans and BPPs. Anatomy scans and BPPs measure things, and that's about it. Echos measure dimensions, rigidity, and fluid flow. That's a lot harder.

That makes sense.

No. I don't think that you fully understand where the money in this healthcare system goes to.

Remember back a few posts, when you said that you thought it'd be a good idea for you to scan your own patients, "just to see," even though you're not a trained radiologist? You assumed that this would save them money, because they wouldn't have to pay the radiologist, and you wouldn't charge them for an "unofficial scan".

Actually, it wouldn't save your patients anything. Because, for you to own your own ultrasound machine, you'd have to buy it - and it would cost you around $25,000. How are you going to recoup that $25,000...and the money required for the upkeep? (Ultrasound machines do require a fair amount of maintenance.) You're going to have to charge your patients, just to recoup some money - and it's not going to be a trivial amount, it's going to be $50-$75, otherwise that machine is going to cost you waaay too much.

Suppose you argue that you'll be a cheap, used machine that is really old. Well, those machines are older, so they'll break more often. Plus, since they're old, their images are going to be crappy....so scanning won't tell you anything. If it gave you an equivocal scan each time, why bother doing it?

Now, THINK about what a $hitty thing you just did for your patient. You charged them $50-$75 for a scan that doesn't give you a definitive result. Since you're not trained in ultrasound, you can't be confident that you didn't miss something important....so you either send the patient home (to possibly suffer because you missed a diagnosis) or you send the patient to get an official ultrasound read by a certified radiologist. Which is an EXTRA expense, on top of the $50-75 that you already charged them! SO YOU HAVEN'T DONE YOUR PATIENTS ANY FAVORS AT ALL! No matter what you choose to do then, the patient loses!

The system may be broken, but your suggestions would just make it worse.

The cheapest thing to do would be just to send the patients to a local drugstore or wherever they can get a blood pressure monitor and then prescribe them meds over the phone without even seeing them. We could have a web site where you enter your blood pressure, age, previous HTN medications that either worked or did not work for you and all that, and it generates a prescription for you if your blood pressure is high. The cost would be very low, a few dollars. No one is advocating this because no one in this discussion thinks that is an acceptable way to practice medicine. It does illustrate that cost is by far not the only factor. There are certainly legitimate traditions of seeing the patient you treat, issues of accuracy of diagnosis, detecting illnesses that the patient may not be aware of, and providing appropriate treatment (preferably for the root cause rather than just the symptom). Thus, it's generally considered preferable (and more effective) to treat the underlying cause of hypertension if you can find it. There is a balance here as we have discussed many times above.

When it comes to the ultrasound machine, I wouldn't have to buy it if it was otherwise available and not being used. There is always a cost for maintenance, and that would need to be considered no matter what. I'm not suggesting that we buy a machine for tests that are not indicated unless it can be shown that they provide significant value. Also, I believe that proper training is essential, but that proper training in using an ultrasound machine does not require a radiology residency as some here seem to suggest. I wouldn't suggest buying it for "unofficial scans" unless it was pretty cheap relative to the payoff that can be expected and I found it to be very useful in detecting conditions that were otherwise missed.

Now, you have made a big deal of the cost of such machine. What about the benefit of such an expense. If a properly trained practitioner (and this is really the only way I would feel comfortable with it being used) was able to detect conditions that would otherwise be missed, even if s/he didn't to everything that a specialist with the tool could accomplish, the machine and time spent could be worth it. It's perhaps an open question and I'm certainly interested in studies that examine the cost-benefit of ultrasound being used by internists or other practitioners for various scans that are not as extensive as those done by ultrasound techs.

How expensive do you think the ultrasound machine is compared to managing thousands of seriously ill patients ... who are seriously ill because their condition was not diagnosed earlier? How many seriously ill patients who presented with say, premature kidney failure, would it take to justify a $60 test? My impression is that there are certain patient populations that are at higher risk for various conditions where a scan with an ultrasound machine would be justified. In some of those cases, the $1000 ultrasound test would be useful for screening, but from what I have been reading, it's too expensive. Maybe a less extensive test that a practitioner could do could provide an acceptable cost-benefit ratio.

Using such a tool would clearly require training and would not be worth it for just any practitioner. Some thought would need to be given to the application, cost and benefit. My suggestion is that we look at the need, cost, and benefit in numerical terms rather than our emotional affinity to making such a change or whether it's the way it's always been done before.

For example, it's my understanding than even preventing even a single patient from needing dialysis would easily pay for a $25,000 ultrasound machine and its maintenance.

 

[OncoCaP]

No, it's not.

Yes it is!

Now we have some intelligent conversation going on Prowler style. Reminds me of talking to my two year old.

I guess I should act offended to go with the requisite berating of the intelligence .... ;-)