Any other hospitalists become jaded and terrified of lawsuits that you just panscan everyone?

[wamcp]

Family awarded $29 million in lawsuit against Salem Hospital

SALEM — Salem Hospital has been ordered to pay a local family $29 million, most of it over the next 28 years, after the father died from an undiagnosed and

www.salemnews.com

Looks like standard of care to me but somehow ER doc and hospitalist were both nailed by the jury for $29M for missing an aortic dissection in someone without classic symptoms. Diagnosis was “delayed for 15-20 hours” is worth 29M.

I’ve given up on best practices long ago and have low threshold to shoot everyone full of radiation on my admissions now.

Two ER docs in our hospital have unfairly lost to lawsuits worth 8 figures as well over the past few years. Just disgusting how “jury of your peers” can screw anyone over.

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[timpview]

Agree. See the patient as quick as possible. Low threshold to scan. Extra diligence for younger patients, especially if they don’t seem like the type routinely coming in. Then it’s just the luck of walking through a mine field for the rest of your career.

 

[FutureInternist]

New Mexico has an arbitration/peer review set up where lawsuits can go to a 3 doc-3 lawyer panel where we hear the presentation from both sides and then get to question the patient and doctors.

Once the votes are in it gives both sides an inkling as to how things may likely go in a trial.

Its frightening that 7 out of 8, is somehow considered a failure…yet they probably have someone breathing down their necks about throughput, and EMR alerts for “what is your justification for ordering this”, and pts later complaining about getting billed for “so many things”

Its a no win situation… and thats why I try not to give any pushback to any ED doc, when they ask for an admit

 

[bronx43]

Pan-scan. Society has spoken... and they want them Sieverts.

 

[DrMetal]

Family awarded $29 million in lawsuit against Salem Hospital

SALEM — Salem Hospital has been ordered to pay a local family $29 million, most of it over the next 28 years, after the father died from an undiagnosed and

www.salemnews.com

Looks like standard of care to me but somehow ER doc and hospitalist were both nailed by the jury for $29M for missing an aortic dissection in someone without classic symptoms. Diagnosis was “delayed for 15-20 hours” is worth 29M.

I’ve given up on best practices long ago and have low threshold to shoot everyone full of radiation on my admissions now.

Two ER docs in our hospital have unfairly lost to lawsuits worth 8 figures as well over the past few years. Just disgusting how “jury of your peers” can screw anyone over.

If there's even the slightest clinical indication for a test, I order it. Blast away with labs/rads.

We were taught in medical school/residency that the most important part of a patient's presentation is their History and Physical Exam. Bull****! The problem with is, most patients are terrible historians, and most physical exam features are equivocal. Don't believe me? As a fun exercise, walk around your hospital and take note of how many Cardiologists are actually carrying a stethoscope. At least half wont be, b/c they dx with tele, echo's, EKGs, stress tests, etc. Nobody diagnoses via heart sounds, half the time which you can't hear b/c of ambient noise and body habitus.

 

[NewYorkDoctors]

If there's even the slightest clinical indication for a test, I order it. Blast away with labs/rads.

We were taught in medical school/residency that the most important part of a patient's presentation is their History and Physical Exam. Bull****! The problem with is, most patients are terrible historians, and most physical exam features are equivocal. Don't believe me? As a fun exercise, walk around your hospital and take note of how many Cardiologists are actually carrying a stethoscope. At least half wont be, b/c they dx with tele, echo's, EKGs, stress tests, etc. Nobody diagnoses via heart sounds, half the time which you can't hear b/c of ambient noise and body habitus.

yep agreed. when the puzzle pieces are not clicking and I do not have a clear trajectory in mind, I will go for the advanced imaging without hesitation.

unless the classic history and physical and basic evaluation is good enough, scan away if there is any uncertainty. if not for preventing lawsuits, just think of helping your patient out from dying... even if you weren't sued you would (and should) feel bad for missing a diagnosis that led to an unnecessary death.

all of those "classic physical exam" findings are harder to find in obese patients. JVD in an obese OSA patient? puhlease. I have my pocket butterlfy IQ ultrasound for IVC evaluation (and even then its hard to detect due to the obesity....)

pulsus paradoxus for cardiac tamponade? puhlease. the Beck's triad was described in tamponade due to hemorrhagic pericarditis due to TB back in the 1800s. pocket U/S to support the diagnosis and can do PP after the fact once patient is in CCU.

the EKO 500 core stethoscope is nice though. i just picked one up. I like to record murmurs and lung sounds for the fellows I teach.
im not shilling for these companies but I just like new technology.
but even though im like cool AS murmur or TR murmur or a loud P2 wide split S2 (in a PAH patient i have), the advanced workup is still being done.

it seems physical exam is only paramount in the office/clinic setting without imminent easy access to the hospital technology to help justify getting something or to sit back and let things ride a bit. even then I POCUS everyone anyway in the office (even if I cannot bill for it all the time. It just improves my diagnostic certainty. IF there is anything I hate, it is uncertainty. Plus patients think i'm a ***** if I am being honest and saying it could be this it could be that)

 

[TooMuchResearch]

Family awarded $29 million in lawsuit against Salem Hospital

SALEM — Salem Hospital has been ordered to pay a local family $29 million, most of it over the next 28 years, after the father died from an undiagnosed and

www.salemnews.com

Looks like standard of care to me but somehow ER doc and hospitalist were both nailed by the jury for $29M for missing an aortic dissection in someone without classic symptoms. Diagnosis was “delayed for 15-20 hours” is worth 29M.

I’ve given up on best practices long ago and have low threshold to shoot everyone full of radiation on my admissions now.

Two ER docs in our hospital have unfairly lost to lawsuits worth 8 figures as well over the past few years. Just disgusting how “jury of your peers” can screw anyone over.

I would just cta every sick adult (within reason) if it wouldn't completely annihilate my department (ED).

 

[Señor S]

Anybody who holds back on a CT or other imaging because it's not "high value care" or to save their employer a few nickels is a fool. If I could wish for one thing at my current job it's that we could do the CT triple rule out protocol.

 

[NewYorkDoctors]

i think that MKSAP high value care was really meant for don't CT or MRI something because you didn't do a clinical assessment

if the pain is clearly GERD, constipation, gastroenteritis, or something then no point in doing a low value CT scan
if someone's CXR clearly has consolidation and they have fever , leukocytosis, sputum production, dyspnea, hypoxemia, then treat first and no need for CTC

it's when you DID a clinical assessment and the classical story, lab work, EKG, CXR and medication review are not giving you any apparent answers and there is no clear cut book diagnosis present, scan away and don't feel shy. yes you want to cover your butt but I look at it as potentially saving the patient's life.

 

[BicepsTriceps]

I liberally order CTs, MRIs, ECHOs, USs... Etc

I consult unnecessarily ID, nephrology, GI, cardiology... Etc

Life is too short to stress about patients and future lawsuits.

Until society decide they want proper cost effective standardized medical care I'll continue to do the above.

 

[NotAProgDirector]

It's a double edged sword. If your threshold for scanning people is very low, then you'll likely pick up additional rare findings that might have gotten missed. But you're also certain to find many more incidental findings that now need more follow up. And it's easy for those to slip through the cracks, and then a lawsuit is generated from that. Exactly whose responsibility it is to follow up on some unexpected nodule is unclear -- if you just put it in your DC summary and it doesn't get done, you're still at some risk. So pick your poison.

 

[TooMuchResearch]

I liberally order CTs, MRIs, ECHOs, USs... Etc

I consult unnecessarily ID, nephrology, GI, cardiology... Etc

Life is too short to stress about patients and future lawsuits.

Until society decide they want proper cost effective standardized medical care I'll continue to do the above.

The number of times I've had an old person who feels somewhat "blah" or "meh" with normal vital signs and severe sepsis from cholecystitis without any significant abdominal pain or tenderness makes me quite fast to just click the irradiation button.

 

[FutureInternist]

The number of times I've had an old person who feels somewhat "blah" or "meh" with normal vital signs and severe sepsis from cholecystitis without any significant abdominal pain or tenderness makes me quite fast to just click the irradiation button.

If they’re old enough, something else will kill them before any ED doctor induced cancer 😏

 

[collegestud2013]

The Choosing Wisely campaign was supposed to try to get clinicians to order less unnecessary or low-yield testing including imaging. It has been criticized quite a bit, notably by ED physicians and and ED societies, namely for the current medicolegal environment. Following all their guidelines would likely increase most physicians' risk of malpractice lawsuits, especially in emergency medicine and probably hospital medicine as well. Not clear how clear the Choosing Wisely guidelines would hold up as expert standard of care in a lawsuit.

The only long-term solution to this would be tort reform, and probably on a federal level. Right now every state has slightly differing standards for malpractice claims and how much can be paid. For example, having umbrella caps for each case for both economic and non-economic damages (eg Colorado it's $1 million IIRC while for many states there's currently no cap), lowering the statue of limitations to no more than 1 year (It's 2-4 years in most states right now), and raising the standard to gross negligence to be able to get a successful claim (instead of just 1 "expert witness" saying you feel below the standard of care) would probably significantly decrease the number of lawsuits that get filed.

 

[LoudBark]

If there is ever a board exam (or now a LKA) question, the correct answer is always don't MRI, CT, ultrasound, or an echo or whatever.

In real life medicine, the correct answer is almost always (with decent amount of uncertainty with the diagnosis) to do it.

The reality is we live in a very litigious society and you have to look out for yourself because no one else will. When you are being interrogated by a malpractice lawyer, sorry, saying "but the board exam question says not to MRI because there were no alarm signals....." will not fly.

 

[CRRT]

I have managed to dodge lawsuits just by ordering imaging. Everyone else on team got sued ( and lost at trial ) but the family said that since I ordered a CT they were not going to be named in the lawsuit.

It was a big blessing not to have to go through all the question / answers from lawyers / board of public health /state board.

I have a very low threshold to order CT abd /pelvis without contrast for ruling out obstructing stone in a UTI with sepsis or getting a CT chest to get a better look at a PNA.

 

[NewYorkDoctors]

my personal take is don't order excessive things as OUTPATIENT for something that is most likely a nothing burger.

"Sir William Osler once said the difference between cigarette paper edema and brawny edema..."

"pardon me. Sir William Osler only practiced outpatient medicine." (i made this up. you get the point)

cough chest pain as outpatient - no insurance (except straight Medicare and united health care Medicare no PA need) will allow a CT off the bat.

but if they were sick enough to go to the ED or even be admitted, then the pretest probability of something bad rises straight up.

Admitted patients are sicker than any of us (likely) have ever been. they may not be critically illl on death's door but just because someone is a "floor patient" does not mean they are healthy.

 

[NewYorkDoctors]

this is a good read for anyone who wants to learn the "real deal" about the "classical full physical exam." the real deal includes citing the papers that looked at each exam findings diagnostic accuracy when comparing it to gold standard. the truth is many exam findings are worthless.

I always cite this book and its findings when im doing the POCUS course of the fellows I teach (and any residents who attend the lectures)
One cannot do POCUS without doing a physical exam. But one should not waste time with useless physical exam findings.

on the other hand, this also has some pearls about which ones ARE USEFUL and should be done more often.

its dirty cheap on amazon or other book sites. there are free PDFs online but... I leave it to your discretion if you want to risk the malware.

 

[jm192]

Anytime you hear chest pain+back pain, you have to rule out dissection. You'll lose this lawsuit 100% of the time.

I'm not taking sides or judging the medical decision making. I wasn't there. For all I know the patient never actually said back pain.

But for CYA purposes--if you have that combination, dissection until proven otherwise.

 

[jm192]

To the actual intent of the post:

I started ordering MRI's that were ridiculous when the patient's family pushed for them. Usually in the setting of delirium where the Stroke isn't going to explain their behavior/confusion. But so help me, someone in 2 weeks will do an MRI and that doctor missed this stroke that doesn't explain any of your symptoms.

Some families show so much grace. Thanks for trying to save mom. Some families and even patients--are looking to be mad at someone.

I don't know how many times I've heard the "Well why didn't my PCP Catch this?" Probably because you haven't been in 4 years.

 

[NewYorkDoctors]

To the actual intent of the post:

I started ordering MRI's that were ridiculous when the patient's family pushed for them. Usually in the setting of delirium where the Stroke isn't going to explain their behavior/confusion. But so help me, someone in 2 weeks will do an MRI and that doctor missed this stroke that doesn't explain any of your symptoms.

Some families show so much grace. Thanks for trying to save mom. Some families and even patients--are looking to be mad at someone.

I don't know how many times I've heard the "Well why didn't my PCP Catch this?" Probably because you haven't been in 4 years.

Community PCps make money by not doing a proper physical exam and history and not bothering to do a prior authorization
condense a 99213 to 5 minutes to make money

at least if they referred to specialist then the patient might get proper care