Defensive Medicine...How do you deal with working with these attendings??

[Killa Beez MD]

It gets so tiring working as a resident with attendings that are so afraid of being sued. I'm just coming off a couple of shifts with some of our most paranoid attendings that will order every test under the sun on pretty much every single patient that walks into the ED just so they don't get sued. They have us consult pretty much every service in the hospital for complete BS and I always struggle on the phone when our consultants ask what we are actually consulting them for. Usually I'm just honest with them and say "this is a BS consult but my attending requested it." It is so draining and tiring and I feel like it makes us look like a complete joke of a department. I bet if our attendings had to actually call these consults in themselves, they might think twice about it because they would be so embarrassed.

When working with these attendings, we will radiate pretty much anything that moves. If you mention belly pain, you bought yourself a CT. You mention the word headache, you get a CT. You mention the word chest pain? There is no way you are getting out of the hospital without an admission. It doesn't matter that you had a complete cardiac work-up last month including a cardiac cath showing no CAD and all of your labs, imaging, troponins, and EKG in the ED are normal. You mention the word dizzy or lightheaded? We better call neuro to come see you! Seriously, its so exhausting.

What is everyone else's experience with this? I just feel like it's wearing me out as a resident and I'm not even that far into residency. It's such a breath of fresh air to actually work with attendings that order tests and consults and admit pts that legitimately need it.

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[RustedFox]

I had ... specifically... two attendings that 'were' this way when I was a senior resident. I do remember one case where there was a 12 year old female with adnexal pain that was very clearly just plain ol' menarche that had the following ordered on her:

CBC. BMP. Amylase. Lipase. LFTs. Lactate. U-preg. U-drug screen. D-Dimer. GC/Chlamydia. Wet prep. UA. ... and who knows what else.

I remember saying to this person, to her face.... "you're ******ed". I signed the case out to her, and I went home at the end of my shift. I dealt with all of her venom and backlash afterwards, knowing full well that I "was not going to practice like a ******ed platypus" after that.

I remember one of my co-residents saying this about her: "Dr. XXXXX is proof that you can be ******ed, and still practice emergency medicine."

Whateevvvver. She's still ******ed... and I know this from the residents that have come after me that tell me the same story.

Would you call an OBGYN consult for every... female... that walks in the ED? Some people can, and they do.

Let your teachers, teach you what NOT to do, too.

 

[da8s0859q]

We've got a couple of them, too.

As for me? "Oh, okay, you do want that right fourth toe MRI? Sure."

Not worth fighting. Rarely worth fighting in general.

It's residency. It's temporary. While we can be sued, the attending's unrestricted state license is where the buck ultimately stops, anyway.

As The Good Fox said, it's a learning opportunity. Either you get proven too cavalier and learn something from an unexpectedly positive result, or, more likely, you learn more about who you don't want to be.

 

[Birdstrike]

It gets so tiring working as a resident with attendings that are so afraid of being sued. I'm just coming off a couple of shifts with some of our most paranoid attendings that will order every test under the sun on pretty much every single patient that walks into the ED just so they don't get sued. They have us consult pretty much every service in the hospital for complete BS and I always struggle on the phone when our consultants ask what we are actually consulting them for. Usually I'm just honest with them and say "this is a BS consult but my attending requested it." It is so draining and tiring and I feel like it makes us look like a complete joke of a department. I bet if our attendings had to actually call these consults in themselves, they might think twice about it because they would be so embarrassed.

When working with these attendings, we will radiate pretty much anything that moves. If you mention belly pain, you bought yourself a CT. You mention the word headache, you get a CT. You mention the word chest pain? There is no way you are getting out of the hospital without an admission. It doesn't matter that you had a complete cardiac work-up last month including a cardiac cath showing no CAD and all of your labs, imaging, troponins, and EKG in the ED are normal. You mention the word dizzy or lightheaded? We better call neuro to come see you! Seriously, its so exhausting.

What is everyone else's experience with this? I just feel like it's wearing me out as a resident and I'm not even that far into residency. It's such a breath of fresh air to actually work with attendings that order tests and consults and admit pts that legitimately need it.

All I can say is, when you get served by a cop or process server with lawsuit papers, you'll instantly get it.

Bump bump....Bump bump...Bump..
bumpbumpbumpbumpbumpbumpbump...

Being served is worth a thousand words.

 

[gman33]

It can be difficult, but you should try to learn why they are approaching patients in this manner.
There can be lots of reasons why.
The more clinical experience you have, they more atypical presentations you have seen (and potentially missed).
It's easy to think someone should just get sent home when you aren't the one in charge.
As much as a resident thinks they are seeing a patient, it's really the attending making the decisions.
You might not want to practice in this manner, but just learn what you can from each case.

Many residents think they would send every CP home and never get a CT scan.
Then they become new attendings and realize everyone is getting scanned and CP are admitted.

As far as dealing with these types of attendings

If there are multiple attendings working, and you want the patient to go home, present to the less conservative one.
Don't sell out your attending to the consulting service. That's a good way to get kicked out of your program.
If you don't know the specific question they want answered, make sure you ask your attending.
Sometimes the reason for consults is that the consulting services are requesting more consults.
The residents and fellows will never like this, but there are decisions being made by their faculty.

As someone said above, residency is short.
Learn what you can.
Just do what you are told.
Graduate. And then you can practice any way you want.

 

[dotcb]

It's OK to vent and post in this forum, but I'd avoid digging in your heels with this person. It's not worth it for you as a resident. Just discuss the management and avoid being perceived as defensive or "difficult."

"Usually I'm just honest with them and say "this is a BS consult but my attending requested it."

As an academic attending - if I heard you say that in the clinical area, I would probably speak to you and your program director. It's quite disrespectful.

You can always tell an attending who's been sued - they're damaged. It might have not been their fault. They may have been a good doc who had a bad day. But those people are scarred. Seems like they haven't met a test or consult they didn't like.

Sometimes academic attendings who aren't so hot in the clinical realm have other redeeming qualities - like maybe they're an academic rockstar, or they're balancing 4 kids with an academic career. It may not make the shift any better, but worth considering.

Focus your efforts on being good at EM, so you can figure out how you can provide care that is even better while not behaving like these overly conservative doctors.

 

[WilcoWorld]

Questioning the workup is OK, and it should be encouraged. However, calling your attending "******ed" or talking behind his or her back to other services is not likely to be helpful. Approaches that worked for me in residency included "I don't understand the indication for [CT/consult/admission] here, could you explain it to me?" Or, "I think that once you see this patient you'll agree that there's nothing wrong with him. Do you mind talking to him before I order this [CT/consult/admission]?" Or, "In conference last week we were told about the PECARN study for pediatric head injury, why aren't we applying it here?"

There will always be attendings who will still insist on non-indicated interventions. But there will also be times where you missed something subtle, and those are great learning opportunities.

Once you graduate, you get to manage your patients as you like. Until then, these are your attending's patients on loan to you, so your attending gets to determine the workup.

 

[goodoldalky]

Just be thankful your attendings aren't letting you kill anybody.. lol

 

[sluggs]

I was an attorney and tried medical malpractice cases, mostly defense and later plaintiff, for 10 years before going to medical school. In my opinion, practicing "defensive medicine" is a complete misnomer. Being careful and thorough is what you need to do. Overtesting is completely insane. It will not "prevent lawsuits". Good clinical judgement and practicing within the standard of care is the best bet. There is no question that sometimes a case is difficult or a diagnosis is not readily apparent and you have to cast a broad net and order some expensive tests, but this should not be the rule. Be smart and do your best. You may or may not get sued. If you over order, you can still get sued and a good attorney can make you seem incompetent and paranoid if you "order everything".
I have tried "defensive medicine" cases and they can be tough to defend!
Just my 2c, but I don't practice with the specter of a plaintiff's lawyer looking over my back.

 

[GeneralVeers]

I had a jerk like this in residency too. We hated each other's guts. I could have saved myself a lot of time and trouble by just taking the advice of everyone else on this forum and ignoring him. At the end of the day if he wanted insane workups that actively harmed patients, then that was on him. I still got to leave my shift at appointed time, and it was just a temporary situation. Just ride along and don't make waves. Pretty soon you won't have to deal with him anymore.

 

[engineeredout]

It's not worth the argument with your own attendings. Sure you can diplomatically bring up "well why are we checking labs just because the patient is concerned about his 170/90 blood pressure when he is asymptomatic?" or "why are we checking a D-dimer on every single patient who has walked into the ER tonight?" but it just isn't worth the headache to really press the issue. Remember, you have to work with them multiple times for the next several years.

 

[GeneralVeers]

It actually is instructive and gives you some perspective. Now when I teach residents (yes even locums have to!) I always make sure they have a reason for every test they want to order. I want them to think about their workup rather than just shotgunning labs as many of them have been taught. So far it seems that they appreciate this approach.

 

[RustedFox]

Questioning the workup is OK, and it should be encouraged. However, calling your attending "******ed" or talking behind his or her back to other services is not likely to be helpful. Approaches that worked for me in residency included "I don't understand the indication for [CT/consult/admission] here, could you explain it to me?" Or, "I think that once you see this patient you'll agree that there's nothing wrong with him. Do you mind talking to him before I order this [CT/consult/admission]?" Or, "In conference last week we were told about the PECARN study for pediatric head injury, why aren't we applying it here?"

There will always be attendings who will still insist on non-indicated interventions. But there will also be times where you missed something subtle, and those are great learning opportunities.

Once you graduate, you get to manage your patients as you like. Until then, these are your attending's patients on loan to you, so your attending gets to determine the workup.

******ed.


Lolz.

 

[The White Coat Investor]

Lots of good advice here that I agree with.

Of course, like everything in residency, it's temporary. So no sense in making an ass of yourself dealing with the issue.

Realize a few things from someone who has been down this road.

1) There is a wide spectrum in work-ups for a given patient. It is an art, not a science. In residency, you will have attendings that are minimalists and attendings that order lots of tests and consults. Learn from that variation and figure out where you will fit in on that spectrum for the rest of your life. You may move. Typically, an intern starts out way to the right, then moves left into his second year, then moves back a little to the right after a few misses. At graduation, he's usually way back out where he was as an intern for a while before creeping back left to where he will be during the remainder of his career. Until he is sued. Then he will move dramatically right for a little while before creeping back left to a place slightly to the right of where he was before he was sued. Just as your attendings have different styles, so will your future partners (who sign patients out to you with plans you may not agree with) and consultants (who want to do something different than you do). This issue isn't going away. Learn to deal with it.

2) Attendings don't know everything. I was an academic attending for my first 3 years out of residency at a program I did not train in. I was continually challenged by residents and I learned a lot. If they had a good reason to do something additional, or not do something I wanted done, and I couldn't defend my decision, I changed my plan. And that's okay. So rather than calling your attending a ******, or selling him out on the phone, I would suggest making a habit of politely challenging decisions without being obstinate. You might be surprised how much you both learn from the interaction.

3) Often times an attending wants an additional test because his differential is broader than yours. Our worst supertester in residency was also the most well-read attending who had done the longest fellowship. He was thinking about zebras I hadn't even learned about yet. Did we find them very often? Not very often, but enough to realize why he did some of the things he did.

4) Learning why you are admitting a patient and being able to defend that decision and sell it to a consultant is such a key part of emergency medicine it's probably a good thing to have to learn to sell a soft admission and consult.

5) Community medicine is very different from residency. I had a trauma patient last night. 71 year old fell down 10 stairs. I met her with my "trauma team" (2 nurses and the 2 medics who brought her in. I also got a couple of people from radiology to come help shoot films.) She had two long bone fractures and a minor intracranial hemorrhage. I x-rayed the fractures, splinted one of them, panscanned her (finding no surprise injuries except the ICH), talked to ortho on the phone who agreed to see her in the morning, talked to neurosurg on the phone who agreed to see her in the morning, talked to the general surgeon who gave admission orders to the nurse by phone and agreed to see her in the morning. She left my ED 2 hours after arrival. I'm the only doc who will look at this patient for the next 12 hours. She is elderly and had significant trauma and had distracting injuries. Am I wrong to radiate the crap out of her? Maybe, maybe not. But I can tell you this, she did not have a headache, an LOC, vomiting, weakness, numbness, and denied hitting her head. Should I have skipped that head CT? What would you like me to do with your grandma?

In the community, 90% of consults are done by phone. The surgeons only come in for an emergent operation. The hospitalist sees them on the floor. Bogus in-person consults don't fly because you can't get them. The consultant just says "no." If you have to actually force someone to come in and see a consult very often, one of you won't be there very long. Chest pain admits? Far more rare than you might think. We have a relatively young, healthy population, but I bet 80%+ of my chest pain patients over 35 get two sets and an outpatient stress test tomorrow or the next day.

And a little extra imaging? Look at the benefit to risk ratio:

Benefits:
1) The hospital makes more money
2) You might catch something you didn't expect
2a) Increases patient satisfaction
2b) Decreases liability
2c) Makes you feel like a better doctor
3) The patient is reassured- don't underestimate the value of therapeutic radiation
4) You might make more money (billing your own USs, increasing level billed)
5) You don't have to trust half-baked clinical rules, your own intuition, a crazy patient, a "veterinary" patient etc.
6) You don't have to spend tons of time explaining to the patient and their freakish family why you won't do the test the other doctor sent them here to do

Risks:
1) You might cause cancer (1/2500 in a young person, hardly an issue in an older person) with a CT.
2) You might cause an allergic reaction to contrast that is probably easily treated
3) You might cause some kidney insufficiency that is probably easily treated
4) You might tie up an ED bed for longer than necessary
5) Your nurses will have to spend more time and effort getting blankets, drinks, and crackers because the patient is there longer
6) The MRI tech may have to come in from home (hardly bothers me- he gets paid, the hospital makes more money etc)
7) The patient goes broke. (Frankly, I think this one should be discussed a heck of a lot more than most doctors do)

Lots of good, not much bad there.

 

[littlejuan]

It actually is instructive and gives you some perspective. Now when I teach residents (yes even locums have to!) I always make sure they have a reason for every test they want to order. I want them to think about their workup rather than just shotgunning labs as many of them have been taught. So far it seems that they appreciate this approach.

One of my favorite attendings does this. He asks me what I am specifically looking for on every order I want to put in, and always follows up with, 'well, what are you going to do if x value is y.'

 

[EMIM2011]

Risks:
1) You might cause cancer (1/2500 in a young person, hardly an issue in an older person) with a CT.
2) You might cause an allergic reaction to contrast that is probably easily treated
3) You might cause some kidney insufficiency that is probably easily treated
4) You might tie up an ED bed for longer than necessary
5) Your nurses will have to spend more time and effort getting blankets, drinks, and crackers because the patient is there longer
6) The MRI tech may have to come in from home (hardly bothers me- he gets paid, the hospital makes more money etc)
7) The patient goes broke. (Frankly, I think this one should be discussed a heck of a lot more than most doctors do)

Lots of good, not much bad there.

I may add to 1), that you are underestimating the risk for some patients:
Arch Intern Med. 2009;169: 2078-86
20 yoF, multi-phase CT abd/pelvis, lifetime risk of cancer is 1 in 250 (still less than 1 percent, but certainly a few over your career)

and 8) Incidental findings. Unnecessary work-ups that will harm the patient (read this: http://www.aahs.org/medstaff/wp-content/uploads/JAMA50thousand20141.pdf). Also increases your liability if you don't have a good system for follow up in place.

 

[The White Coat Investor]

Incidental findings are not all bad. Lots of cancers get discovered early that way.

If you really believe you're killing 1/250 20 year olds you scan you are doing far more bad than good in the hospital. What do you mean "a few over you career". 1/250 may add up to a three figure amount. If 100,000 patients come to your ED every year, and you scan 1/4, and you're killing 1/250, your ED is killing 100 a year. That might be more than you're saving. The best thing you can do is burn the place to the ground. We should be seeing a massive spike in cancers which I don't think we're seeing. So I don't think I buy the 1/250 number. BTW- The abstract says it's 1/135 for 20 year olds. Sorry, don't buy it. A NNH of 135 for a test being done all day every day in thousands of hospitals across the country? Time to buy some stock in MRI machine makers.

 

[link2swim06]

I may add to 1), that you are underestimating the risk for some patients:
Arch Intern Med. 2009;169: 2078-86
20 yoF, multi-phase CT abd/pelvis, lifetime risk of cancer is 1 in 250 (still less than 1 percent, but certainly a few over your career)

and 8) Incidental findings. Unnecessary work-ups that will harm the patient (read this: http://www.aahs.org/medstaff/wp-content/uploads/JAMA50thousand20141.pdf). Also increases your liability if you don't have a good system for follow up in place.

Where is abstract for this 1/250 stat?

I suspect there are a bunch of confounding variables present. Sicker people needing a bunch of CT scans get cancer more often, no?

ACOG can't detect any effects on a fetus from a PANSCAN, it's hard for me to believe that a single CT abd/pelvis in an adult carries such a high risk.

 

[EMIM2011]

Incidental findings are not all bad. Lots of cancers get discovered early that way.

If you really believe you're killing 1/250 20 year olds you scan you are doing far more bad than good in the hospital. What do you mean "a few over you career". 1/250 may add up to a three figure amount. If 100,000 patients come to your ED every year, and you scan 1/4, and you're killing 1/250, your ED is killing 100 a year. That might be more than you're saving. The best thing you can do is burn the place to the ground. We should be seeing a massive spike in cancers which I don't think we're seeing. So I don't think I buy the 1/250 number. BTW- The abstract says it's 1/135 for 20 year olds. Sorry, don't buy it. A NNH of 135 for a test being done all day every day in thousands of hospitals across the country? Time to buy some stock in MRI machine makers.

Don't know where you see 135 - look at table 4 in the actual paper. And they are not talking about fatal cancer. And the actual number doesn't really matter, nor will we ever know it. I was just pointing out that a blanket statement of 1/2500 is not correct, and that it varies hugely based on age and type of scan. There is a bunch of literature out there on this. Arch Intern Med 2009;169:2071-2077 estimates 29000 future cancers from all 72000000 CT scans performed in the US in 2007. Whether that sounds like a lot or like nothing depends a lot on a) whether you are one of the 29000 and b) what the scan got ordered for (the intraabdominal catastrophe you would have died from or your 5th CT scan this year for chronic abdominal pain). Again, you can argue either way, and you can certainly debate the actual numbers, as they are estimates based on mathematical models. But you should at least be aware of it, and certainly discuss this with your patients before ordering a non-indicated CT for "patient satisfaction" purposes or offer them alternatives like 24-hr recheck.

 

[The White Coat Investor]

The number absolutely does matter, because it will both consciously and subconsciously change practice. Better to have a 20% negative appy rate than kill 1/135.

It should also be pointed out that none of this has really been studied at all with a longitudinal, prospective study. This all involves a lot of models, assumptions, and hand-waving. The IM literature, as a rule, is anti-CT just like the cardiology literature recommends blood thinners and the neurosurgery literature recommends against them.

Here's what the radiologists at UCSF say:

http://radiology.ucsf.edu/patient-care/patient-safety/radiation-safety/risks-of-radiation

I basically get a mammogram every month just from the altitude I live at.

 

[AmoryBlaine]

Been off the forums for awhile. I'm a community attending now, occasionally have a visiting student/resident but not very often.

This stuff used to drive me crazy in residency but I would split aggressive testers into 2 very different camps:

1. People who are scared and just don't think about patients correctly e.g. "any abdominal pain could be an appy." Yeah that's 100% true, however if you actually get a hx and do an exam and you can document WHY you don't think this person has an appy you are probably on pretty firm medicolegal ground. If you can actually sit down with the patient and explain your thought process to them and see if they are on board you are on even firmer ground. I found with the scared attendings that a) they weren't thinking, b) they weren't documenting, and c) they weren't having those conversations with patients they were just scaring patients. That's bad medicine. If you're ordering a CT scan on everyone because one time you picked up a crazy appy, that's bad medicine. You residents though, avoid getting into confrontation with these people at all costs. If someone seems like a bad doc then they probably deep down know it and are terrified of being publicly exposed as that and/or losing their job. If you do something (e.g. call them ******ed) that indicates to them that you are on to them, you may be right but you will be threatening them existentially. Their response is likely to be incredibly violent and/or vindictive.

2. People who understand (correctly) that the hx/pe is not the magic spell that your IM attendings in med school told you it was and are skeptical of it. White Coat's story is very telling. Did that lady have an "indication" for CT scan, probably not, and yet it was clearly good medicine. These docs you will notice tend not to spend time sittinig at their computers agonizing about whether or not to check this or that test. I think I practice more like this, I test more than my colleagues. But I'm also one of the faster docs in the group, one of the better resus docs I think, and the RNs constantly tell me I'm one of their favorites. I'm not posting that to brag, but part of leading the ED is making decisions and in borderline cases I think it's better to just order tests than to sit there agonizing. Order the tests and go see another patient. You'll notice that your attendings who practice like this tend not to get defensive when they're plans are challenged.

 

[The White Coat Investor]

The part about the conversation with patients is key. I explain the risks and benefits, tell them what I would do (12-24 hour recheck, return if the kid starts vomiting etc etc) but if they're set on the CT, and I think it's reasonable either way, I'll order it. But I usually try to get them to decline it, and am successful most of the time.

 

[The White Coat Investor]

BTW, I think anxiety is probably a huge risk factor for CT induced cancer.

 

[EMIM2011]

The number absolutely does matter, because it will both consciously and subconsciously change practice. Better to have a 20% negative appy rate than kill 1/135.

It should also be pointed out that none of this has really been studied at all with a longitudinal, prospective study. This all involves a lot of models, assumptions, and hand-waving. The IM literature, as a rule, is anti-CT just like the cardiology literature recommends blood thinners and the neurosurgery literature recommends against them.

Here's what the radiologists at UCSF say:

http://radiology.ucsf.edu/patient-care/patient-safety/radiation-safety/risks-of-radiation

I basically get a mammogram every month just from the altitude I live at.

Again, I am not here to argue. You are entitled to your opinion and you may interpret the numbers as you want, which is what my previous post stated. You may or may not rely on non-peer reviewed statements from an interest group. As I said before, it will be practically impossible to get a high quality study done on this. That also means that the numbers will never be known definitively, and people will use this to argue one way or the other.

 

[erdoc00]

I remember being a junior resident (specifically a second year resident) and knowing much more than my attendings. Things quickly changed as the months to graduation became fewer and fewer.

The bottom line is that there is no single way to practice emergency medicine. What you first need to do is have a great understanding of the medicine. Then, you can practice however you like based on what you feel comfortable with.

For me, I did not create the screwed up medical system. Therefore I practice to provide good care but also protect myself; there are enough idiotic and baseless lawsuits that I will do everything in my capacity to avoid having to deal with such. Patients also are not textbook encounters and the amount of bizarre or atypical presentations is much more than "rare."

I remember a 20 year old patient with 4 YEARS of abdominal pain... pain would come and go... today was worse. "I'm worried it could be my appendix." States pain is everywhere, maybe worse at RLQ. No family history of appendicitis. Belly exam unimpressive. Labs show WBC 11.xx Scan shows acute appendicitis.

60 y/o guy comes in with forearm cellulitis x 2 days after he fell and scraped his arm. Red, swollen, warm... ROS "Oh yea, i do get SOB sometimes when I walk" EKG and trop ordered. EKG nonspecific T wave inversions and q waves in III . Trop 4.xx CTA chest negative.

50 y/o DMII female with sore throat x 2 days. Look in throat, a bit red, no exudates, uvula midline, no PTA visualized, etc... Labs normal. "It still hurts doctor." Pain was more on right than left side of throat so I get a contrast CT of neck.. it's Normal. I'm thinking "Man I overtest. I should just go with my gut and discharge these people and stop worrying about zebras." Well... 10 hours later she's back in the ER and intubated because of a retropharygneal abscess that's compressing her airway to the point she can't breathe.

60 y/o with vertigo x 2 days. Also some URI sx over the past week. Some dizziness with walking. HiNTs testing equivocal. CT head negative. Staff keeps pushing me to discharge the pt. Family insists something is wrong. Finally order MRI after fighting with my radiology department about calling someone in. MRI shows cerebellar infarct.

Meanwhile, I've seen colleagues of mine treat "indigestion" that ended up with positive enzymes once I took over care... "muscle strain" in someone with an IJ CVL who ended up having venous thrombosis seen on CT.... "vertigo" that was discharged and then came back as a subacute cerebellar infarct... "costochondritis" that came back as a NSTEMI... "chest pain NOS" that came back dead in cardiac arrest...

the list goes on.

The bottom line is that every time I try to convince myself to not think about zebras, I end up catching something "rare." I use "rare" in quotes because I've had had this happen enough that it's really not as rare as we are lead to believe. And then you can try and rationalize it with "well, we can't catch everything and you need to do a 'reasonable' work-up and if a bad thing happens, then so be it." Then some 20 year old with myocarditis comes into your ER and you don't order an EKG and troponin because of their "chest pain associated with their URI"... and then when they go home and come back dead you can retire from medicine while trying to pay off a $4,000,000 lawsuit. So we can debate for days using our most "academic" arguments, but we also have to face the reality of the current medical system and medicolegal atmosphere.

Everyone seems to have an opinion on everything. In my experience, most are uninformed... and often the most uninformed are the most vocal. Be knowledgeable about the medicine and why you are doing things. Then practice with what makes you comfortable and try to provide the best care you can, and be prepared to counter any criticism with an informed and educated response. And remember that you're a physician and the reason you get paid more than PAs and NPs is to think about your differential, look for zebras and rare presentations, provide superior assessment and care, and be the final authority on decisions that ultimately can greatly impact people's and their family's lives.

 

[Birdstrike]

I remember being a junior resident (specifically a second year resident) and knowing much more than my attendings. Things quickly changed as the months to graduation became fewer and fewer.

The bottom line is that there is no single way to practice emergency medicine. What you first need to do is have a great understanding of the medicine. Then, you can practice however you like based on what you feel comfortable with.

For me, I did not create the screwed up medical system. Therefore I practice to provide good care but also protect myself; there are enough idiotic and baseless lawsuits that I will do everything in my capacity to avoid having to deal with such. Patients also are not textbook encounters and the amount of bizarre or atypical presentations is much more than "rare."

I remember a 20 year old patient with 4 YEARS of abdominal pain... pain would come and go... today was worse. "I'm worried it could be my appendix." States pain is everywhere, maybe worse at RLQ. No family history of appendicitis. Belly exam unimpressive. Labs show WBC 11.xx Scan shows acute appendicitis.

60 y/o guy comes in with forearm cellulitis x 2 days after he fell and scraped his arm. Red, swollen, warm... ROS "Oh yea, i do get SOB sometimes when I walk" EKG and trop ordered. EKG nonspecific T wave inversions and q waves in III . Trop 4.xx CTA chest negative.

50 y/o DMII female with sore throat x 2 days. Look in throat, a bit red, no exudates, uvula midline, no PTA visualized, etc... Labs normal. "It still hurts doctor." Pain was more on right than left side of throat so I get a contrast CT of neck.. it's Normal. I'm thinking "Man I overtest. I should just go with my gut and discharge these people and stop worrying about zebras." Well... 10 hours later she's back in the ER and intubated because of a retropharygneal abscess that's compressing her airway to the point she can't breathe.

60 y/o with vertigo x 2 days. Also some URI sx over the past week. Some dizziness with walking. HiNTs testing equivocal. CT head negative. Staff keeps pushing me to discharge the pt. Family insists something is wrong. Finally order MRI after fighting with my radiology department about calling someone in. MRI shows cerebellar infarct.

Meanwhile, I've seen colleagues of mine treat "indigestion" that ended up with positive enzymes once I took over care... "muscle strain" in someone with an IJ CVL who ended up having venous thrombosis seen on CT.... "vertigo" that was discharged and then came back as a subacute cerebellar infarct... "costochondritis" that came back as a NSTEMI... "chest pain NOS" that came back dead in cardiac arrest...

the list goes on.

The bottom line is that every time I try to convince myself to not think about zebras, I end up catching something "rare." I use "rare" in quotes because I've had had this happen enough that it's really not as rare as we are lead to believe. And then you can try and rationalize it with "well, we can't catch everything and you need to do a 'reasonable' work-up and if a bad thing happens, then so be it." Then some 20 year old with myocarditis comes into your ER and you don't order an EKG and troponin because of their "chest pain associated with their URI"... and then when they go home and come back dead you can retire from medicine while trying to pay off a $4,000,000 lawsuit. So we can debate for days using our most "academic" arguments, but we also have to face the reality of the current medical system and medicolegal atmosphere.

Everyone seems to have an opinion on everything. In my experience, most are uninformed... and often the most uninformed are the most vocal. Be knowledgeable about the medicine and why you are doing things. Then practice with what makes you comfortable and try to provide the best care you can, and be prepared to counter any criticism with an informed and educated response. And remember that you're a physician and the reason you get paid more than PAs and NPs is to think about your differential, look for zebras and rare presentations, provide superior assessment and care, and be the final authority on decisions that ultimately can greatly impact people's and their family's lives.

Great post. I agree completely.

 

[engineeredout]

85 YO male came in last night. Watery diarrhea X 1 week, feeling weak and fatigued. Son reports he fell down several times. Clinically dehydrated. VSS though, denies any CP/SOB. EKG no acute changes. On exam, mild tenderness in b/l lower quadrents without rebound/guarding. Put him in for labs and CT abdomen. CT shows colitis.

Troponin 12.9 wtf. Gets admitted, his echo showed chordae tendinae rupture. I can't even remember my definitive thought process for checking a trop in him, I think it was just old man weakness but I can't even remember - it was 5am and I just wanted to get a workup going. I'm still in shock at that Trop. It really makes me want to order one on EVERYONE, cause of this old guy with watery diarrhea and lower abdomen cramping. How easy would it have been to miss a major MI in this guy?

 

[BoardingDoc]

85 YO male came in last night. Watery diarrhea X 1 week, feeling weak and fatigued. Son reports he fell down several times. Clinically dehydrated. VSS though, denies any CP/SOB. EKG no acute changes. On exam, mild tenderness in b/l lower quadrents without rebound/guarding. Put him in for labs and CT abdomen. CT shows colitis.

Troponin 12.9 wtf. Gets admitted, his echo showed chordae tendinae rupture. I can't even remember my definitive thought process for checking a trop in him, I think it was just old man weakness but I can't even remember - it was 5am and I just wanted to get a workup going. I'm still in shock at that Trop. It really makes me want to order one on EVERYONE, cause of this old guy with watery diarrhea and lower abdomen cramping. How easy would it have been to miss a major MI in this guy?

So confused. Did he have an insane cardiac history? Why did you order a trop on him? I mean, lucky thing you did but based on that history why the heck would you order one?

 

[engineeredout]

So confused. Did he have an insane cardiac history? Why did you order a trop on him? I mean, lucky thing you did but based on that history why the heck would you order one?

Yeah he had a history of CAD s/p CABG I think 3-4 years ago. I think I just ordered the troponin for old man weakness. Believe me, I was really confused too when it came back.

 

[The White Coat Investor]

85 YO male came in last night. Watery diarrhea X 1 week, feeling weak and fatigued. Son reports he fell down several times. Clinically dehydrated. VSS though, denies any CP/SOB. EKG no acute changes. On exam, mild tenderness in b/l lower quadrents without rebound/guarding. Put him in for labs and CT abdomen. CT shows colitis.

Troponin 12.9 wtf. Gets admitted, his echo showed chordae tendinae rupture. I can't even remember my definitive thought process for checking a trop in him, I think it was just old man weakness but I can't even remember - it was 5am and I just wanted to get a workup going. I'm still in shock at that Trop. It really makes me want to order one on EVERYONE, cause of this old guy with watery diarrhea and lower abdomen cramping. How easy would it have been to miss a major MI in this guy?

At least there's no radiation, although you may end up killing someone for an unindicated cath. But according to the data posted in this thread, a belly CT is riskier than a cath.

 

[sum dude]

I used to be one of those residents who hated ordering everything and questioned what the attendings did. Hated the consults and CT scanning everyone. Then I went and moonlighted. Then I went and worked in a community hospital. I don't judge my attendings any more.

My first day in community, smart doc told me, (paraphrasing) "nuke everyone." First day, 18 yo fell off of bike. HR 105, nl CBC, mild L rib ttp, LUQ ttp. acting nl. Belly soft. PT NAD. Scanned him...lacerated spleen. Ended up getting transfused later. That was a good first day lesson.

When you get out of residency, you should overwork-up everyone, mostly b/c your clinical skills aren't as good as you think they are. Does that mean order shot-gun labs on everybody? No. But you should be conservative in ordering labs, CT's, admitting, etc. One day, you might be a brilliant clinician, but I'll take a "******ed" attending who moves the meat quickly over a cocky grad who has been a doc a whopping 3-4 years and brazenly discharges every patient w/o working them up (mostly b/c that's the one who will get all the complaints). Once you see a few flank pain appys w/ nl labs, silent MI's, occult septic patients, pneumonias w/ clear lungs, and "bronchitis" PE's, you learn to have a little more appreciation for those crazy attendings.

 

[TooMuchResearch]

I used to be one of those residents who hated ordering everything and questioned what the attendings did. Hated the consults and CT scanning everyone. Then I went and moonlighted. Then I went and worked in a community hospital. I don't judge my attendings any more.

My first day in community, smart doc told me, (paraphrasing) "nuke everyone." First day, 18 yo fell off of bike. HR 105, nl CBC, mild L rib ttp, LUQ ttp. acting nl. Belly soft. PT NAD. Scanned him...lacerated spleen. Ended up getting transfused later. That was a good first day lesson.

When you get out of residency, you should overwork-up everyone, mostly b/c your clinical skills aren't as good as you think they are. Does that mean order shot-gun labs on everybody? No. But you should be conservative in ordering labs, CT's, admitting, etc. One day, you might be a brilliant clinician, but I'll take a "******ed" attending who moves the meat quickly over a cocky grad who has been a doc a whopping 3-4 years and brazenly discharges every patient w/o working them up (mostly b/c that's the one who will get all the complaints). Once you see a few flank pain appys w/ nl labs, silent MI's, occult septic patients, pneumonias w/ clear lungs, and "bronchitis" PE's, you learn to have a little more appreciation for those crazy attendings.

And had you not scanned him, would the outcome have been different? Would he have gone home and ignored his increasing belly pain and shock as his abdomen filled with blood and then died?

 

[AmoryBlaine]

It's worth noting that our patients create some of these problems for us and themselves.

I have just gotten used to the fact that basically everyone I see is going to tell me they are dying. All pain is 10/10. Every HA is the worst HA of life. Kids are brought in with fever x 1 hour and despite jumping on bed parents insist they are "lethargic." Everyone with a cold is a"so weak I can't stand up."

In situations like that it's basically impossible not to test aggressively.

It really gets thrown into relief when you see someone like a Marine or an old Polish dude who tells you "doc this REALLY hurts" and you realize they are telling the truth and distinguishing from the toe they stubbed last week.

Not trying to make this a discussion about the pain scale, but if the CC written on the chart is "weak, 10/10 chest pain, lethargic" it's hard not to go looking even if seems just like a URI.

 

[GeneralVeers]

It's worth noting that our patients create some of these problems for us and themselves.

I have just gotten used to the fact that basically everyone I see is going to tell me they are dying. All pain is 10/10. Every HA is the worst HA of life. Kids are brought in with fever x 1 hour and despite jumping on bed parents insist they are "lethargic." Everyone with a cold is a"so weak I can't stand up."

In situations like that it's basically impossible not to test aggressively.

It really gets thrown into relief when you see someone like a Marine or an old Polish dude who tells you "doc this REALLY hurts" and you realize they are telling the truth and distinguishing from the toe they stubbed last week.

Not trying to make this a discussion about the pain scale, but if the CC written on the chart is "weak, 10/10 chest pain, lethargic" it's hard not to go looking even if seems just like a URI.

It's because patients want more testing. They think the more they exaggerate their symptoms, the more testing they will get done. It's really a very bizarre psychological problem in our country, but it's driven by the "me" culture, and by patient satisfaction. Patients like to think that they are special and unique. They are absolutely convinced that their run-of-the-mill URI is really a strange, undiscovered tropical disease that needs testing and big gun antibiotics to cure.

 

[Birdstrike]

It's because patients want more testing. They think the more they exaggerate their symptoms, the more testing they will get done. It's really a very bizarre psychological problem in our country, but it's driven by the "me" culture, and by patient satisfaction. Patients like to think that they are special and unique. They are absolutely convinced that their run-of-the-mill URI is really a strange, undiscovered tropical disease that needs testing and big gun antibiotics to cure.

I think you're absolutely right. They want lots of tests and they want them now. They don't care about a "one in 250 chance of whatever." They just want an assurance there's "zero chance" anything bad is going on NOW. I once thought that the key to reducing testing, defensive medicine and tort reform was to convince the masses that over testing and defensive medicine hurt them. But I'm convinced now they don't care. They want their "I was checked out in the ER" guarantee nothing can be wrong and whatever what-can-you-do-for-me-now pleaser, for instant gratification, such as a work note, antibiotic for virus, party-pack of pills or an imaging study to irradiate away their uncontrollable anxiety. I'd tried posting this, a while back hoping it would get some traction and stir up some consciousness, but it largely went over with a yawn, other than a few positive comments from like-minded healthcare workers.

http://www.kevinmd.com/blog/2012/10/death-defensive-medicine.html

I think for the most part you have to acquiesce to a certain extent and give the "customer" what they want, within certain ethical boundaries, of course.

 

[gman33]

We work in a zero miss culture.
Any doc can pull out stories of the patient with no indication for x, but they got it anyway and found something terrible.
This is touted as a great catch, which it is.

Less brought up are the cases of patients they harmed by meds or tests that weren't needed.
These probably happen at least as often as finding the zebra.
As EM docs we probably don't recognize this because we don't follow up on all of our patients.

I try to practice with some constraint. I still get way more tests than are probably truly indicated from an EBM standpoint.
I have no real answer to the current situation.
If we could implement some changes that limited defensive medicine, it would likely lead to better overall patient outcomes.

 

[VentJockey]

I'm an IM resident, and I can tell you that the ENTIRE HOSPITAL knows which ER docs run around ordering consults and dumping liability and which docs actually use their brains. Every department complains about the same ER attendings. The resident calling the consult doesn't even have to apologize. We know who the attending is, so we expect it to be a stupid or a good consult based on that.

A lot of my co residents are openly hostile to the bad ER docs, including one time I heard a guy ask straight up, "did you even go to medical school?" This open hostility does not increase the quality of the consults. In the end, personally, I just deal with them. If they want a patient admitted I just admit the patient. Its better for me that way.

 

[GeneralVeers]

I'm an IM resident, and I can tell you that the ENTIRE HOSPITAL knows which ER docs run around ordering consults and dumping liability and which docs actually use their brains. Every department complains about the same ER attendings. The resident calling the consult doesn't even have to apologize. We know who the attending is, so we expect it to be a stupid or a good consult based on that.

A lot of my co residents are openly hostile to the bad ER docs, including one time I heard a guy ask straight up, "did you even go to medical school?" This open hostility does not increase the quality of the consults. In the end, personally, I just deal with them. If they want a patient admitted I just admit the patient. Its better for me that way.

If any resident questioned my medical school credentials, he would find himself in front of his director very quickly explaining why he should keep his job.

 

[da8s0859q]

A lot of my co residents are openly hostile to the bad ER docs, including one time I heard a guy ask straight up, "did you even go to medical school?" ... In the end, personally, I just deal with them. If they want a patient admitted I just admit the patient. Its better for me that way.

There is a line between stupid and ballsy. It's a thin line. It's easy to cross. But this is about four zip codes deep into stupid. Those co-residents need to learn to pick and choose their battles... good lord.

 

[Gadofosveset]

"A lot of cancers are picked up that way" Yup. Thyroid cancers. Small indolent RCCs. IPMNs. Facile argument: over-imaging picks up a lot of cancers that would have been better not picked up: Lead time bias. Length time bias. To my mind, this is a much more practical reason to avoid over-imaging than models of radiation risk, which the UCSF website quotes at 1/2000 risk per belly CT, not 0 risk. "Too low to be detectable and may be nonexistent" is a hedge.

 

[Brigade4Radiant]

If any resident questioned my medical school credentials, he would find himself in front of his director very quickly explaining why he should keep his job.

Would directors really do this? I really don't think so especially for surgery you will get an apology but no one will harm a resident's job for critiquing someone who is not in there own department.

 

[VentJockey]

For the incident I mentioned, the ER attending did complaint to the medicine attending. Who didn't care and did nothing. I have no doubt that if it had been a respected ER attending instead of a liability dumper things would have gone differently. But if you run around dumping liability on people instead of practicing medicine, people tend not to take you seriously in anything you say or do. But yes, it was stupid to say that. The point I was making is that I just avoid fights with them and admit the patient. It's not my money they're wasting, only my time.

 

[WilcoWorld]

one time I heard a guy ask straight up, "did you even go to medical school?"

I hope the faculty replied, "Yes, I did. Have you completed a residency training? No, you haven't."

That being said, it appears you recognize that this is not an effective way to interact with someone you disagree with.

 

[The White Coat Investor]

It's because patients want more testing. They think the more they exaggerate their symptoms, the more testing they will get done. It's really a very bizarre psychological problem in our country, but it's driven by the "me" culture, and by patient satisfaction. Patients like to think that they are special and unique. They are absolutely convinced that their run-of-the-mill URI is really a strange, undiscovered tropical disease that needs testing and big gun antibiotics to cure.

I agree. I see this all the time. I'm not even convinced they're doing it consciously. But when I point out their 10/10 pain allows them to watch TV it just generates complaints.

 

[The White Coat Investor]

Would directors really do this? I really don't think so especially for surgery you will get an apology but no one will harm a resident's job for critiquing someone who is not in there own department.

"They can always hurt you more." They applies both to the nursing staff and to the ER.

 

[Birdstrike]

For the incident I mentioned, the ER attending did complaint to the medicine attending. Who didn't care and did nothing. I have no doubt that if it had been a respected ER attending instead of a liability dumper things would have gone differently. But if you run around dumping liability on people instead of practicing medicine, people tend not to take you seriously in anything you say or do. But yes, it was stupid to say that. The point I was making is that I just avoid fights with them and admit the patient. It's not my money they're wasting, only my time.

"Liability dumper?"

Seriously, y'all must be joking. You must be a resident and not practiced in the real world yet. Everybody "dumps liability," constantly. EPs, Internists, surgeons....evvvvverybody. It's utterly all of what Medicine has become. You'll see. It's called being smart, doing what you gotta do, and staying out of court. A wise person has no choice. When you're in practice, there's no incentive to be Mr. "I Love Lots of Liability!" (In fact, it's a great idea for a hilarious youtube or SNL skit, of a doctor who inexplicably loves to except ridiculous amounts of liability). Or, maybe that how you like to play the game: In court. I don't know. Lol

The internist "liability dumps" a patient to the ER because it's too complicated for a 30 patient clinic day with 10 min patient-slots. The neurosurgeon refuses to operate on someone because he's "too fat" or "a diabetic" = "liability dump." A cardiologist recommends medical management instead of cath because a patient is "too risky" or refers them back to the PCP or to CT Surg or whoever, because they're a train wreck = "liability dump." The Ortho who consults for medical clearance on every single stinkin' patient no matter what = liability dump.

When I hear someone complaining about others "dumping liability," my brain hears, "I have no idea how the real world works."

Google translate:

Modern Medicine equals Libility Dumping

 

[GeneralVeers]

So when the internist sends the 70 year old with asymptomatic BP of 170/100 to the ER, they aren't dumping liability? How about the urgent cares that send 30 year olds with musculoskeletal chest pain? Or the fact that everyone who is a little sad or psychotic must be "medically cleared" in the ER?

Most of medicine now is liability dumping. If something bad does happen, you just don't want to be the last one holding the hot potato.

 

[WilcoWorld]

So when the internist sends the 70 year old with asymptomatic BP of 170/100 to the ER, they aren't dumping liability? How about the urgent cares that send 30 year olds with musculoskeletal chest pain? Or the fact that everyone who is a little sad or psychotic must be "medically cleared" in the ER?

Most of medicine now is liability dumping. If something bad does happen, you just don't want to be the last one holding the hot potato.

Completely agree. I don't even get mad about this anymore. I only get mad when patients are promised something they should not get. If you want to send me some BS head injury so I can share some liability, I'll take it. Just don't tell the patient that they "need" a CT. The same goes for admits - I'll admit the low-but-not-no-risk chest pain, but I don't tell them that they "need" a catheterization.

 

[oldanddone]

sounds like a situation that is bordering on workplace bullying and harrassment for this ER attending. which of course cannot be addressed reasonably in medicine, which tends towards a 'lord of the flies' mentality. there's always gotta be a scapegoat and an (un)healthy dose of letting off steam via bullying. hopefully the attending will end up in a better workplace and not be too affected by having been the piggy scape-goat in the past. wondering if there is some aspect of the attending, other than their 'liability-focused practice' that bears stigma and so had them draw the straw for this blatant rudeness and disrespect that apparently will go unchallenged by those in positions that could change it. in a situation like this, there is really no hope for transformation of their style of practice, especially if they feel no-one has their back - it will just lead to more defensive medicine. no real chance to support a change in style of practice in this kind of atmosphere.

 

[deleted547339]

"Liability dumper?"

Seriously, y'all must be joking. You must be a resident and not practiced in the real world yet. Everybody "dumps liability," constantly. EPs, Internists, surgeons....evvvvverybody. It's utterly all of what Medicine has become. You'll see. It's called being smart, doing what you gotta do, and staying out of court. A wise person has no choice. When you're in practice, there's no incentive to be Mr. "I Love Lots of Liability!" (In fact, it's a great idea for a hilarious youtube or SNL skit, of a doctor who inexplicably loves to except ridiculous amounts of liability). Or, maybe that how you like to play the game: In court. I don't know. Lol

The internist "liability dumps" a patient to the ER because it's too complicated for a 30 patient clinic day with 10 min patient-slots. The neurosurgeon refuses to operate on someone because he's "too fat" or "a diabetic" = "liability dump." A cardiologist recommends medical management instead of cath because a patient is "too risky" or refers them back to the PCP or to CT Surg or whoever, because they're a train wreck = "liability dump." The Ortho who consults for medical clearance on every single stinkin' patient no matter what = liability dump.

When I hear someone complaining about others "dumping liability," my brain hears, "I have no idea how the real world works."

Google translate:

Modern Medicine equals Libility Dumping

"Never carry the casket alone."