Are you a Dr Big Workup or a Dr Minimalist?

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Docinthetrenches

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So I think ER doctors pretty much fall into one of two camps - the big worker-uppers and the with minimalists. Obviously there is a spectrum to it and there may be certain things certain doctors workup more than other things (ie abdominal pain vs headache vs rashes, etc) depending on one's interest in the topic, comfort level in dealing with a certain complaint and or history of lawsuits or missing things based on a certain organ system.
I think the goal of all of us should be to try to be somewhere left (towards the minimal side) of centre - where we don't order tons of unnecessary, expensive crap but know when to workup certain complaints in certain patients more thoroughly so we don't miss something bad (like in aortic dissection or SAH to name a few obvious examples).
Anyway, since residency I was always more of a minimalist - basically I have always felt our job was to rule out bad stuff, not make diagnoses (of course we make some along the way) and thus if something is not emergent, it can be done as an inpatient or outpatient but not in the ER. I think big workups are a huge reason that patients stay here so long (besides the lack of inpatient beds) and cost our health care system tons of wasted $$. With my 13 years of experience now I have only become more so - I proudly accepted the stat that of all the attendings at my old hospital, I had ordered the fewest CT scans and my patients have not done any worse and I have not been sued since my 2nd year out of residency (which I was dropped from luckily).
I think with experience this is where we all should be heading - nothing drives me nuts more than getting sign out from a big worker-upper or signing out to one and having to cancel stuff (or discharge patients) or have them add all this stuff on and gum up the works.

What does everyone think? What are you??

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I think it's easy to assume lack of death/lawsuits is skill and not luck...I'm not going to get sued or risk missing something just to save "the system" a few bucks
 
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Pretty sure it's mostly luck whether you miss something.

And missing something + getting sued seems to mostly relate to whether you're likable or not.

I order very few CTs and send many home, but those are the patients I end up in the room with 15+ minutes sitting and chatting about stuff, not being dismissive their problem is "nothing". It helps I can tie folks into pretty good follow-up.

Haven't seen any specific literature showing where excessive testing is somehow protective against lawsuits. Certainly the fee-for-service/payment structure disincentivizes resource stewardship at the expense of diagnostic certainty, but that's another matter entirely.
 
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I appreciate minimalism in music and film. In medicine I prefer appropriateness. It is often appropriate to do no testing, but not always.

If I can exclude the concerning diagnoses on my differential with history and physical (and sometimes with validated decision rules) then I don't order testing.

If I have a low suspicion, but can't rule things out, I explain the situation to the patient and tailor the amount of testing to the patient's risk tolerance.

If I can't rule out a concerning condition, either because there are no good ways to do so without a test or because my patient answers "yes" to every question, then I order the test and I don't feel bad about it.
 
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Yes, I agree no one wants to be sued - but as we often see, suits are not because we didn't order the "right" tests but because of bad luck, natural progression of disease, bad communication, etc. Bad outcomes (truly bad) often are not even the cause of lawsuits. Still, one will know over time if you are routinely missing big things - word of mouth, returning patients, people going down the tubes on the floor, etc. I would argue that we can rule most stuff with history and physical and protect ourselves with good documentation more than just getting tests. Of course many tests are necessary but there is nothing I hate more than seeing doctors just reflexively order "abdominal workups" for every abdominal pain, etc. It's just a total waste. Not just of money, but you'll find "incendental-omas" that you have to deal with as well as spurious unrelated lab abnormalities. That makes you have to do more tests and subject the patients to more invasive procedures, etc with their associated complications.
I feel we went into ER for one reason - to put our fires so to speak. Not to do the big investigations as to why something caught on fire or to deal with kittens up a tree (even though we spend a lot of our time on these things). Thus we should try to cut things to a minimum.
 
I'm a minimalist, and always get compliments from the nurses for doing so. There is no correlation between ordering more tests/studies and lawsuits. It also helps to practice in Texas where a lawsuit is very unlikely.

In younger people, I do minimal testing. You're under 40 with headache, chest pain, abdominal pain, vomiting? You get a good H&P, a decision rule applied, and minimal testing to make sure there is nothing emergent.

In old GOMERs, they get the kitchen sink.
 
Last year of residency. My work-up is pretty much hospital dependent.
One of my hospitals is very affluent where most patient's have good follow-up. For those people, I lean towards the left. The other hospital has a ton of homeless, uninsured, unreliable, and people with crappy follow-up. Those people usually get a much larger follow-up.
 
I feel like I'm squarely in the middle... But when it comes to the chart, I am Dr. William Faulkner. Some of my students joke that I document the patient's comparison of their flatus to roses... And then I document why that is important.
 
Senior resident and minimalist. When I moonlight, it's not when I skimp on the work ups.
 
It should be a sliding scale. Someone that looks great and has a physical exam that readily points to a benign process should be discharged without further testing (but with specific and understandable verbal and written instructions regarding red flags). Someone that looks bad and has a non evaluatable or unreliable exam should be tested until a disease process serious enough to warrant the patient's condition is found. That's why it's vanishingly rare for me to order labs on a 5 yo and common for me to scan 80 yo's. It's when you start screening out 70 yo epigastric pain or scanning most pediatric vomiting that you need to reconsider your practice pattern.
 
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Most of my colleagues order a CMP on everyone. I'm not sure why someone with chest pain, or SOB needs a CMP, especially when it extends the patient's length of stay by 30-40 minutes versus ordering a simple BMP.

The other thing that gets me are the the PE workups on young people with normal vital signs and low-risk decision rules. I don't do a D-dimer on these people, yet it seems common practice among my colleagues.
 
Most of my colleagues order a CMP on everyone. I'm not sure why someone with chest pain, or SOB needs a CMP, especially when it extends the patient's length of stay by 30-40 minutes versus ordering a simple BMP.

The other thing that gets me are the the PE workups on young people with normal vital signs and low-risk decision rules. I don't do a D-dimer on these people, yet it seems common practice among my colleagues.

This.

PERC-negative and no suspicion ? See yahhh.
 
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I tend to be more liberal with ordering labs, and more careful with imaging. My main goal is not primarily to avoid lawsuit, but to prevent folks from being harmed because I was careless/lazy/busy/off my game. That includes unnecessary radiation, time, expense, or anything else that is going to make my patient in a worse-off place than they were when they walked in the door. Good communication is key, and getting at the patient's motivation for being in the ED is so important. Do they want to know that they're not having a heart attack, do they want to know exactly why they're having this pain in their chest, or do they just need some help with their symptoms they've been dealing with for a while. Those are 3 different questions that could potentially arise from the same patient, and while you try to answer all three, your strategy and resource utilization (workup, disposition, referral, etc) should reflect which question really needs answering. And common sense goes a long way.
 
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I'm generally known as one of the faster docs in my groups, but I'm definitely one of the "big worker-uppers." I just happen to see the end from the beginning and order it all upfront. I see two types of minimalists. The first is like the OP who pride themselves on their academic knowledge and ability to save the system money. The second just can't see the end from the beginning and engages in serial work-ups, driving patients and nurses mad. Same expense in the end but worse customer service and probably worse outcomes due to the ridiculously long work-ups.

I suspect both my practice style and my documentation style (rather thorough but luckily I type fast) were both significantly affected by the two letters of intent I received in residency. One from my first month out of medical school and one from my second month.

Now, all that said, there is no excuse for ordering tests patients don't need. But the fact is that what someone needs is highly variable and depends on your interpretation of the literature, your comfort with risk, and your patient's comfort with risk.

And the rant about the CMP? Give me a break. If ordering a CMP instead of a BMP increases your length of stay you must have a ridiculously well-oiled hospital. My lab runs the exact same test no matter which I order, but if I only order a BMP they only report that part of the test.
 
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I'm generally known as one of the faster docs in my groups, but I'm definitely one of the "big worker-uppers." I just happen to see the end from the beginning and order it all upfront. I see two types of minimalists. The first is like the OP who pride themselves on their academic knowledge and ability to save the system money. The second just can't see the end from the beginning and engages in serial work-ups, driving patients and nurses mad. Same expense in the end but worse customer service and probably worse outcomes due to the ridiculously long work-ups.

I suspect both my practice style and my documentation style (rather thorough but luckily I type fast) were both significantly affected by the two letters of intent I received in residency. One from my first month out of medical school and one from my second month.

Now, all that said, there is no excuse for ordering tests patients don't need. But the fact is that what someone needs is highly variable and depends on your interpretation of the literature, your comfort with risk, and your patient's comfort with risk.

And the rant about the CMP? Give me a break. If ordering a CMP instead of a BMP increases your length of stay you must have a ridiculously well-oiled hospital. My lab runs the exact same test no matter which I order, but if I only order a BMP they only report that part of the test.

I can order a POC BMP which I get back in about 10-15 minutes. A CMP routinely takes 45 minutes as it has to go through lab.
 
Chest pain could represent choly. Having lfts for no extra time makes sense. I'm not going to save the system 1 set of lfts at a time.

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I think part of it, too, comes with experience (the "10k hours" issue) and being cut off from the training parachute.

It's one thing to minimalist ad a resident, when you have an attending to (hopefully, we all know there are bad ones) prevent you from making a big mistake.

Plus, transitioning from a training program to your actual clinical practice has a learning curve that can sometimes be ameliorated by shotgunning - with all the "new" coming at you, it's easy to go on autopilot, order a ton of $hit, and buy time to think.

As you progress, though, in the real world your diagnostic acumen ought improve and pan-testing decrease.

It's about finding your happy medium, and your own practice pattern. To echo WCI, it's much more important to be efficient than frugal. Seeing the dispo & needing how to get there will make even the gagillion dollar workups speedy.

I personally fall in the middle on average, about half minimal & half extensive, but 95% or more of the time, I know where that patient is going before I leave the room.

Just my $0.02,
-d
 
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In the middle! And proud of it.
I will say I too often see people come back for unscheduled repeat visits that could very well have been found the first time...interestingly, I can see a disproportionally large amount to be CP/lower CP not investigated initially, to be cholecystisi or biliary in origin. And even if YOU considered biliary colic (at least in the note;) the PT often dos not and comes BACK.
Just tell them!
Do I always order a CMP or US on CP, heck no. But I do do a very good exam and if any concern I investigate it or specifically tell the PT about it.

Older folks with abdominal pain with no decent investigation or imaging of some kind..,you are just punting till the next shift when they return and you know it!

But as above, it is on a pt per or basis. Some days I am dr minimal, others I am dr workup, it just depends!
 
I fall in the middle. More minimalist in low risk patients, follow-up, and a reasonable personality. More testing in low risk patients with no follow-up or confrontational/unreasonable personalities.

I don't really care about saving the system money. Everyone soapboxes about decreasing medical expenses and then goes right back to practicing in a setting where the patient, hospital, consultants, and your lawyer all want you to order more tests to protect patient satisfaction, income, and liability. It's 1984 levels of double think. I do care about saving the patient money but the financial impact our decisions make on patients are so obscured that I can't make meaningful decisions never-mind the difficulty of predicting what will actually save them the most money in the long run.

Add to that the number of patients our system fails in the out-patient setting. I didn't go to medical school to kick people out when they need something that isn't necessarily an ED issue but don't have access to what they need in the out-patient world.

And then finally is the very real issue of decision fatigue. The time and energy you spend deciding BMP vs CMP, XR for traumatic MSK pain, EKG for chest pain, etc is taken away from the patient who actually needs some careful thought and decision making. Low cost/risk decisions should largely be auto-pilot in my opinion.

That's not to say I support reflexively pan-testing for every positive on their review of systems, I avoid tests because either I think the test itself or chasing down the false-positive/incidentaloma will harm the patient or needlessly back up the department potentially causing harm to patients in the waiting room. In the end, being too far either way is a mistake...
 
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The rate limiting step isn't the lab. It's all the other chaos of the ED. Staffing, boarding, etc. everything that prevents the nurses and ancillary staff from doing their jobs. Do the work up you feel appropriate. Don't worry what everyone else does. When you start keeping up with the jonses in terms of trying too hard to be a minimalist or by shot gunning everything, mistakes begin.
 
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That's not to say I support reflexively pan-testing for every positive on their review of systems, I avoid tests because either I think the test itself or chasing down the false-positive/incidentaloma will harm the patient or needlessly back up the department potentially causing harm to patients in the waiting room. In the end, being too far either way is a mistake...


Whoa whoa whoa. You do a review of systems?
 
A 14-point review of systems is always performed!
14 point ROSs may be ok if it's an emergent situation like responding to a floor code, but the astute EP should always be doing at least an 18 point review. Do you have any idea how many times I've picked up an MI in a young person with atypical symptoms by inquiring about changes in their cat's hairball consistency?
 
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14 point ROSs may be ok if it's an emergent situation like responding to a floor code, but the astute EP should always be doing at least an 18 point review. Do you have any idea how many times I've picked up an MI in a young person with atypical symptoms by inquiring about changes in their cat's hairball consistency?

Great save! I hope the nurse got a patient safety award for stopping the line when you tried to get away with <10 systems.
 
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I think I'm generally in the middle. I try to do things efficiently and not nickel and dime the nurses, so sometimes that results in some extra testing.

I generally don't take compliments from the nurses regarding minimizing workups as a good thing, necessarily. There are certain nurses who I trust and feel I can rely on for their perspective, but generally I find that we often have different motivations.

I've seen bad outcomes despite careful documentation by physicians I admire for their thoroughness. I've seen lots of workups for badness turn out negative (haven't we all?). At the end of the day, medicine is humbling like that.
 
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Left sided chest pain with no abdominal tenderness is not chole, and doesn't need a CMP.
Indeed...nor would I look for it in that case.
I was just referring to the fact that more as of the last few years I am finding a bunch of biliary causes that were seen for CP in a very recent visit to our ERs.
 
Indeed...nor would I look for it in that case.
I was just referring to the fact that more as of the last few years I am finding a bunch of biliary causes that were seen for CP in a very recent visit to our ERs.

Fortunately biliary colic is not an emergency and if you miss it, no big deal. Again, ruling out dangerous life-threatening things is our job. Once done, they can follow-up with their PCP for further Zebra testing.
 
One could argue that... Although not really a "zebra" :)
I also take a lot of enjoyment when an actual answer is in "easy" reach and I can give closure to the pt.

If it takes me a few extra tests so be it. Regardless of testing practices, still a top producer in group in pt per hour so it bothers me none.
 
And by far I think it is not the workups that are done... It's the efficiency and dispositions of your pts that prob counts more. Less admits, you seem faster. It takes the nurses a heck of a lot less everywhere I have been to DC people than to admit them.
 
And by far I think it is not the workups that are done... It's the efficiency and dispositions of your pts that prob counts more. Less admits, you seem faster. It takes the nurses a heck of a lot less everywhere I have been to DC people than to admit them.
Depends on peds volume. If you get cxr, ua, flu, rapid strep on every peds fever then you're going to watch your department blow up.
 
Depends on peds volume. If you get cxr, ua, flu, rapid strep on every peds fever then you're going to watch your department blow up.

I know this wasn't your point, but I want to come out and say it - flu and strep testing play next to no role in EM. I'm not saying I'll never order them under any circumstances, but when people let the results of a rapid flu or rapid strep test change their ED management, they're doing it wrong.
 
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The time to be super minimalist is during your senior year of residency. You get dinged for ordering any "unnecessary" test and you are operating on someone else's license. That other person will expand your work-up if they deem it necessary.

When you are out in the real world--especially I feel if you are working in a single coverage place--you realize quickly that nobody is giving you a pat on the back or a gold medal for not ordering one more test. In fact, it is often the case that it's just better to order upfront. Example: I had a lady who came in with swelling of the leg, r/o DVT. I was 50/50 on whether she had it or not. I could've just ordered baseline labs, but instead I waited for a positive result. It ended up coming back positive for DVT, a read that came back after 2 hours. Now, I'm ordering lab tests on her. I could've saved so much time by ordering them upfront.

Also, no specialist or hospitalist will ding you for ordering an extra test. It's so much better to just say XYZ is the result of the test they ask for, instead of explaining to them why you don't think it was necessitated as part of your work-up.

I also agree with what has been said that lab tests don't dictate length of stays. It's a bunch of other things, and it is often the case that you can expedite things by ordering early, rather than nickel and dime-ing. I also agree that it is no real compliment to receive praise from nurses for being minimalistic. I've lost trust in most nurses when it comes to their assessment of who is sick and who is not, and what are the appropriate tests to ordered. I often see them coming back saying someone is being a baby or not really sick when in fact I go in the room and I realize instantly that they are incredibly sick.

Having said all that, I'm all about throughput and being efficient. I'm just guessing, but I suspect that I'm a throughput machine compared to many of the other doc's in my group. But, it's not so simple as saying it's about ordering one less test, as they obsess over in residency. (I think it's *good* they force you to think about why you order what you do, instead of just shotgun approach on everyone. However, in the real world the game is a bit different.)

Being efficient means making sure things are done in the proper order, so that labs and imaging come back at the appropriate times, usually in parallel instead of in series. And yes, ordering a CT scan on everyone with belly pain will kill your lengths of stays. However, at the same time, err on the side of caution when on the fence. I just got burned not ordering a CT scan on a lady, who ended up having a tumor. Thankfully I had admitted her to the hospital and the hospitalist ordered it, but I did look stupid in front of the hospitalist, who got to be the hero of the story.
 
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I know this wasn't your point, but I want to come out and say it - flu and strep testing play next to no role in EM. I'm not saying I'll never order them under any circumstances, but when people let the results of a rapid flu or rapid strep test change their ED management, they're doing it wrong.

There is a patient satisfaction issue here. For those with strong suspicion of strep, you give antibiotics. For a certain population that are low-medium suspicion, you can order a rapid strep test, so that patients are relieved when it's negative and don't complain about not getting antibiotics. Positive strep test and you treat. I'm sorry, but I haven't ever seen a happy patient after explaining to them all that stuff about false positives, yadda yadda.

I'm not saying you are wrong. You are certainly right, from a technical standpoint. I just think in the reality of community medicine, you have to sometimes do things a bit...artistically.
 
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One more point is this: I agree with whoever said that there is a sliding scale. You need to identify sick patients from not sick patients. The sick patients can get the kitchen sink, whereas the not sick patients get discharged home sometimes even without any tests/imaging. You allow yourself the luxury of testing heavily on sick patients if you are aggressively discharging not sick patients. If you test on everyone, then your ER overcrowds and your resources get overwhelmed, so that when that sick patient comes along, you struggle and can't do justice to that patient.

I often have a bipolar response (I know I'm using this word incorrectly) from nurses. They are often stunned when I discharge the not sick patients without a lab test or x-ray that they would order reflexively. But, then they complain when I order the kitchen sink on a sick patient. Again, I reiterate: nurses don't know anything about management. I'm starting to learn to ignore what they want or think, and to just be the captain of the ship.
 
I disagree, labs absolutely do affect length of stay. If you're young person with epigastric abdominal pain, but normal vitals, the only thing I'm ordering on you is some labs. Once the labs are back (and normal) i'm discharging you. My disposition is entirely based on how long they take to come back. Hence the POC chem 8 versus CMP.

For chest pain, if you are high risk I'm going to get 1 troponin then admit you to the hospital. I have to wait until the troponin is back. If it's back in 20 minutes, or an hour it entirely controls how long till I put that admit order in and call the hospitalist.
 
I'm a doctor don't get sued workup.

I have no issue with spending the system's resources to corroborate my clinical judgement with objective data.

Occasionally the objective data proves my clinical judgement wrong.. Most of the time it doesn't.
 
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Eh...prob a lot of variables at play like anything else (our lab is super fast and RNs get blood on just about everyone it seems). For every pt that's worked up, even for the not dying, there are more that are not so it all washes out.
 
Have to say i love the POC Chem 8.! Lab has halted running our POC trop as the results were too variable.
 
I can order a POC BMP which I get back in about 10-15 minutes. A CMP routinely takes 45 minutes as it has to go through lab.

That's a really interesting idea! Most of the time I usually only get a POC BMP on patients in extremis where I can't wait for the lab. I'd love to try this out at my shop but I feel like it won't be particularly well received
 
I am a Doctor Big Workup that is trying to reform his ways. The first step is in admitting you have a problem. If you make it out of residency as a minimalist, you are a superior individual. I think most of us are prejudiced in academia to over work things up. Just my opinion.
 
I disagree, labs absolutely do affect length of stay. If you're young person with epigastric abdominal pain, but normal vitals, the only thing I'm ordering on you is some labs. Once the labs are back (and normal) i'm discharging you. My disposition is entirely based on how long they take to come back. Hence the POC chem 8 versus CMP.

For chest pain, if you are high risk I'm going to get 1 troponin then admit you to the hospital. I have to wait until the troponin is back. If it's back in 20 minutes, or an hour it entirely controls how long till I put that admit order in and call the hospitalist.

As a general statement, "labs affect length of stay" no one is going to disagree. But my point is that if you're admitting a patient to the hospital, what are the odds that the CMP is the rate limiting step such that getting a POC BMP is somehow going to speed things up. On an admitted patient you're probably waiting on a CBC, a trop, a UA, and a CXR anyway such that the CMP isn't the last thing to come back. In fact, in my experience, the rate limiting step is usually getting the urine out of the patient.
 
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I am a Doctor Big Workup that is trying to reform his ways. The first step is in admitting you have a problem. If you make it out of residency as a minimalist, you are a superior individual. I think most of us are prejudiced in academia to over work things up. Just my opinion.

I would have said it was the opposite, although there were clearly attendings who ran the gamut from "scan and admit everything" to "why'd you order a CBC when all you needed was a crit?"
 
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I know this wasn't your point, but I want to come out and say it - flu and strep testing play next to no role in EM. I'm not saying I'll never order them under any circumstances, but when people let the results of a rapid flu or rapid strep test change their ED management, they're doing it wrong.

Right. And a urine drug screen is useless. And a CBC is useless. And a blood alcohol is useless. In fact, it turns out all our tests are useless. You should probably go through your entire shift tomorrow and not order anything. Good luck with that.

Why do we do tests? For many reasons. Patients want them. Consultants want them. You don't want to miss an unexpected disease because you care about the patient AND you don't want to get sued. You want confirmation of your clinical gestalt. You have no idea what is going on. Some of our tests suck. That's life. Deal with it. Most of them are better than our physical exam findings. Seen the data on those suckers? Terrible.

Consider testicular torsion: http://www.jfponline.com/home/artic...torsion/4c95c230c8240b46888840ba50bd44bd.html

Physical exam not good enough. So everyone gets an US. Your consultant demands an US. Everyone believes the US over the physical exam. So why do the exam at all? Your balls hurt- get a test. If your practice is to not get an US on every testicular pain, it's just a matter of time until you kill someone's testicle and maybe even have to waste a bunch of time in depositions for it.

Same thing with appendicitis/RLQ pain work ups. You've got a test that's 98% accurate and your history and physical exam is at best 3/4 of that.
http://jama.jamanetwork.com/article.aspx?articleid=208132
Why do you think your surgeons make you CT everyone? Because they got sick of taking out normal appys. It turns out they weren't nearly as good as the CT either.
 
Right. And a urine drug screen is useless. And a CBC is useless. And a blood alcohol is useless. In fact, it turns out all our tests are useless. You should probably go through your entire shift tomorrow and not order anything. Good luck with that.

Why do we do tests? For many reasons. Patients want them. Consultants want them. You don't want to miss an unexpected disease because you care about the patient AND you don't want to get sued. You want confirmation of your clinical gestalt. You have no idea what is going on. Some of our tests suck. That's life. Deal with it. Most of them are better than our physical exam findings. Seen the data on those suckers? Terrible.

Consider testicular torsion: http://www.jfponline.com/home/artic...torsion/4c95c230c8240b46888840ba50bd44bd.html

Physical exam not good enough. So everyone gets an US. Your consultant demands an US. Everyone believes the US over the physical exam. So why do the exam at all? Your balls hurt- get a test. If your practice is to not get an US on every testicular pain, it's just a matter of time until you kill someone's testicle and maybe even have to waste a bunch of time in depositions for it.

Same thing with appendicitis/RLQ pain work ups. You've got a test that's 98% accurate and your history and physical exam is at best 3/4 of that.
http://jama.jamanetwork.com/article.aspx?articleid=208132
Why do you think your surgeons make you CT everyone? Because they got sick of taking out normal appys. It turns out they weren't nearly as good as the CT either.

I think you misunderstood me. How do you get from my statement to the idea that the physical exam is perfect or that I want to go through my shifts ordering zero tests?

My point was simply that rapid strep and rapid flu tests aren't very good and that they should rarely determine the important parts of your ED management (culture and PCR are a different story, but they do not come back during my shift, and thus don't change my management).

If you want to do rapid strep and flu tests for patient or consultant satisfaction, then go right ahead. If someone's chief complaint is "wants a strep test" then I'll order them a strep test and not think twice about it. I know that we have to work in the real world and I am not dogmatic in my practice. I just enjoy using the internet to go for a ride on a high horse every once in awhile.
 
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It comes down to a couple things.
Some systems require a significant workup before the patient can be admitted, others allow you to admit before labs.
Some people refuse to step outside their comfort zone, and are busy trying to rule things out instead of ruling things in (cliffs notes, sensitivity is almost always worse than specificity). Thus, they order 20 tests on every patient, with the smug knowledge that 100% of the time, 1 of the 20 will be abnormal. Thus, they are never wrong, and can always admit every patient. These are the people who judge their CT success rate by the number of anecdotal incidentalomas instead of the CTs that come back with what they were looking for.

There are reasons to test, and reasons not to. The point is, you should always think before ordering anything, instead of doing it reflexively (don't we always order belly labs for complaint xyz?). If the test result doesn't change your management (and you aren't admitting them), then don't do it. You're not preventing lawsuits that way. You're just stroking your own psyche.
 
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What really rules something in?
Epigastric pain + gallstones = are you really done?
Or do you just have an incidental finding?

It is harder to rule stuff out, but I think that's my job.
I don't try to rule everything out on every patient, but I think you can get suckered in with a positive finding and an inadequate workup.
 
So I think ER doctors pretty much fall into one of two camps - the big worker-uppers and the with minimalists. Obviously there is a spectrum to it and there may be certain things certain doctors workup more than other things (ie abdominal pain vs headache vs rashes, etc) depending on one's interest in the topic, comfort level in dealing with a certain complaint and or history of lawsuits or missing things based on a certain organ system.
I think the goal of all of us should be to try to be somewhere left (towards the minimal side) of centre - where we don't order tons of unnecessary, expensive crap but know when to workup certain complaints in certain patients more thoroughly so we don't miss something bad (like in aortic dissection or SAH to name a few obvious examples).
Anyway, since residency I was always more of a minimalist - basically I have always felt our job was to rule out bad stuff, not make diagnoses (of course we make some along the way) and thus if something is not emergent, it can be done as an inpatient or outpatient but not in the ER. I think big workups are a huge reason that patients stay here so long (besides the lack of inpatient beds) and cost our health care system tons of wasted $$. With my 13 years of experience now I have only become more so - I proudly accepted the stat that of all the attendings at my old hospital, I had ordered the fewest CT scans and my patients have not done any worse and I have not been sued since my 2nd year out of residency (which I was dropped from luckily).
I think with experience this is where we all should be heading - nothing drives me nuts more than getting sign out from a big worker-upper or signing out to one and having to cancel stuff (or discharge patients) or have them add all this stuff on and gum up the works.

What does everyone think? What are you??
I prefer to take an imagined snarky dirty-look from the cost containment Gods due to an extra test ordered, over...

...lost sleep, depositions, subpoenas and meetings with lawyers over a test not ordered due to the false hope that I'd please the bow-tie wearing Gods of cost containment.

If I need a test, I order it, and I'm not afraid to do so. That's why they call me doctor.
 
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