Chest pain case

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Eh. I was in academics with resident minions, now in community practice just seein' folks myself. Still order just as few tests, don't write z-packs when I know it's not medically necessary, and still have enough 5s on the PG to keep my job.

The pre-test likelihood this 28 y/o is Sick is extremely low. Sounds like LRTI, chances are he Looks Just Fine, and gets a viral syndrome/supportive care talk, follow-up in a couple days. Or you walk in the room and Something Is Really Wrong, but that's going to be 1 out of 50 presentations like this, where there's some other previously undiagnosed comorbid disease blowing this all out of proportion.

Is it PE? Maybe? "Without ordering $3,000 worth of tests, I can't tell you whether you have a clot in your lungs or not. Given your baseline risk and the entire clinical picture, it is more likely this test will falsely diagnose you with a clot you do not have, than actually diagnose a clot you do. Adding in the small additional cancer risk from radiation, an even smaller, but real, risk of kidney damage, doing these tests is more likely to harm you than help." Some people are cray, and you end up doing the tests, but I rarely have folks take me up on tests I don't think they need if I take the time to talk with them.

And then you document "Offered CT r/o PE; patient declined."

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It just so happens that your greegree is different than mine.

There are many perspectives, but just one clear fact, to be taken from this thread:

Gris-Gris, Dr. John's debut album, is one of the best records of all time.
 
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Also, anyone who counters PERC with "If a patient looks sick, and I'm worried about PE, I'll order a CTA no matter what PERC says" doesn't understand how PERC is supposed to be applied.
 
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I love it when people recite that quote. And people love to recite that quote about "the pleural of anecdotes." It's a popular way to say to someone, "your stories don't mean anything to me" as a way to shut them down. But what is an anecdote, as told by a physician?

It's an event, a clinical case, recited to others by a physician.

What is the pleural of anecdotes?

The sum of all the clinical cases and experiences you've had as a physician, ie, your experience as a physician which forms your clinical judgement.

What is the absolute number one thing each and every physician bases just about every single clinical decision we ever make, on?

They base just about all of their clinical decisions across all of their years on "the pleural of all their anecdotes" or the sum of their clinical experiences.

Data people love to recite that quote. And they don't like it when someone says, "What a minute. I saw a patient that tells me otherwise. I've had clinical experiences that tell me your 'data' is incomplete or flawed." But God forbid, whatever you do, do not discount your own clinical experience and the "plural of your own anecdotes."

Exactly guess what Medicine isn't a hard science. What I mean by that is that there are no rules like physics or chemistry which definitively say this. Sure you have evidence but there can be any multitude of factors affecting a patient. Sure a patient may have a virus but in that slight immune compromised state he gets a bacterial infection. Sure it is not likely no evidence shows that it is so unlikely that you should give that patient antibiotics but then he gets a bacterial infection and you could of helped him.

Emergency medicine is high risk you practice by evidence and miss a few cases well those cases could be a pregnant woman who died of PE who was the daughter of a famous actor. Yeah sure it is rare but the thing about reality is that RARE EVENTS HAPPEN ALL THE TIME! Seriously whats the chance that you wore the outfit that you wore while doing what you did today meeting the people that you met? If you did a hard calculation it would be highly improbably for your day to happen how it did!

Take home point anecdotes do have value.
 
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Yes but that was a low pretest probability but still PERC positive scenario where a dimer wasn't obtained--apples to oranges comparison

I use PERC and d-dimers in low risk patient's fairly frequently, but I don't think this case was either. I'm a pretty low resource utilizer, but I would have scanned this kid every day of the week. 1 week out from orthopedic surgery? In whose book is this low risk?
 
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Also, anyone who counters PERC with "If a patient looks sick, and I'm worried about PE, I'll order a CTA no matter what PERC says" doesn't understand how PERC is supposed to be applied.
PS: One of my favorite all time Allman Brothers Band songs is a Dr. John Cover from that album:

Gilded Splinters

#5

Live At Jazz Fest 2007 by The Allman Brothers Band
https://itun.es/us/ZfhBp
 
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I will elect to go with my experience over any rule any day. I am sure my experience and PERC coincides 90% of the time.

Anyhow, this is why medicine is an art. Some practice by the book. I don't like to practice that way. I am not a robot and will never let some equation dictate my practice. I remember studying about Ottowa Ankle rule, 1st day I worked and someone came with a sprained ankle. He absolutely did not need an xray per the rule. I told him that. He gave me this look like, "WTF..... I came for an xray". Much easier to shoot the xray and let them be on their way.

Same thing happens with abx. I have spent 5 minutes talking about viral vs bacterial, come back if worse, blah blah blah.... at the end of my talk, they give me this look "WTF.... can you give me abx". I only reserve this talk to people I am sure will understand the risks of abx. The other 95% that comes in the ER gets amoxil
 
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I use PERC and d-dimers in low risk patient's fairly frequently, but I don't think this case was either. I'm a pretty low resource utilizer, but I would have scanned this kid every day of the week. 1 week out from orthopedic surgery? In whose book is this low risk?

This case would have easily changed with a dimer rather than directly going to CT. With that said, I'd agree that all of the good work that Rosen has done has been wiped out by his need to extract every ounce of compensation to destroy it. As far as I'm concerned, he's pondscum on top of the cesspool of american medicine
 
I will elect to go with my experience over any rule any day. I am sure my experience and PERC coincides 90% of the time.

Anyhow, this is why medicine is an art.

For some reason, post-shift, I always get philosophical. So here it goes:

For any study to work, it is necessary to distill a patient down to a finite (usually very small) number of parameters. However, real patients (i.e., "experience") presents the physician with a vast set of usually non-quantifiable data on which to make a decision.

For example, when a 65 year old man is having the "big one" (MI) you almost always KNOW with a quick glance at him. In the same way, HE knows, as well as his wife or kid or whoever the companion is who brought him in/called 911. Often, the objective data supports this impression. However, there are times when the EKG/labs/imaging is initially inconclusive, but you know something bad is going on. And I can't really remember any occasion on which that feeling has turned out wrong. You can say it is experience, or art or whatever. If you want to be scientific, you can say that it is based on the rapid processing of many non-quantifiable multi-sensory clues.

Radiology has their Aunt Minnie's. EM has to a lesser extent the same. It is not a denial of evidence based medicine, it is a recognition that in an actual patient encounter you have far more data available to you than an EBM study can handle. For example, how do you quantify the stare of someone suffering from acute schizophrenia? Someone will have to figure out the exact flavor, and there may be debate about the best treatment both long term and in the ED. But very quickly after seeing them, you just know. Of course you go through the process of exam, and think about a differential, but it rarely changes the initial impression.

The integration of sight, hearing, smell, touch along with the evolution of patient behavior along with their companions along with experience along with the usual medical data will almost always provide a far better set of information on which to make a decision than the few parameters taken into account with an EBM study. These studies can be very helpful, but they don't replace the - quite literally - "big picture."
 
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For some reason, post-shift, I always get philosophical. So here it goes:

For any study to work, it is necessary to distill a patient down to a finite (usually very small) number of parameters. However, real patients (i.e., "experience") presents the physician with a vast set of usually non-quantifiable data on which to make a decision.

For example, when a 65 year old man is having the "big one" (MI) you almost always KNOW with a quick glance at him. In the same way, HE knows, as well as his wife or kid or whoever the companion is who brought him in/called 911. Often, the objective data supports this impression. However, there are times when the EKG/labs/imaging is initially inconclusive, but you know something bad is going on. And I can't really remember any occasion on which that feeling has turned out wrong. You can say it is experience, or art or whatever. If you want to be scientific, you can say that it is based on the rapid processing of many non-quantifiable multi-sensory clues.

Radiology has their Aunt Minnie's. EM has to a lesser extent the same. It is not a denial of evidence based medicine, it is a recognition that in an actual patient encounter you have far more data available to you than an EBM study can handle. For example, how do you quantify the stare of someone suffering from acute schizophrenia? Someone will have to figure out the exact flavor, and there may be debate about the best treatment both long term and in the ED. But very quickly after seeing them, you just know. Of course you go through the process of exam, and think about a differential, but it rarely changes the initial impression.

The integration of sight, hearing, smell, touch along with the evolution of patient behavior along with their companions along with experience along with the usual medical data will almost always provide a far better set of information on which to make a decision than the few parameters taken into account with an EBM study. These studies can be very helpful, but they don't replace the - quite literally - "big picture."

It's funny you say that. I was driving with my wife a few days ago and saw a homeless guy. I said "He's schizophrenic." My wife assumed he was a regular in the ED since we were pretty close to the hospital. I told her that I'd never seen him before. She said "there's no way for you to know that - you didn't even hear him talk." I thought it was a kind of funny interaction. I tried to explain it to her, but she didn't get it (not in medicine).
 
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I agree with practicing in a way that lets you sleep at night. Disregarding your duty to do what's best for the patient because you think they're too ignorant or too ungrateful rubs me wrong.
 
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For some reason, post-shift, I always get philosophical. So here it goes:

For any study to work, it is necessary to distill a patient down to a finite (usually very small) number of parameters. However, real patients (i.e., "experience") presents the physician with a vast set of usually non-quantifiable data on which to make a decision.

For example, when a 65 year old man is having the "big one" (MI) you almost always KNOW with a quick glance at him. In the same way, HE knows, as well as his wife or kid or whoever the companion is who brought him in/called 911. Often, the objective data supports this impression. However, there are times when the EKG/labs/imaging is initially inconclusive, but you know something bad is going on. And I can't really remember any occasion on which that feeling has turned out wrong. You can say it is experience, or art or whatever. If you want to be scientific, you can say that it is based on the rapid processing of many non-quantifiable multi-sensory clues.

Radiology has their Aunt Minnie's. EM has to a lesser extent the same. It is not a denial of evidence based medicine, it is a recognition that in an actual patient encounter you have far more data available to you than an EBM study can handle. For example, how do you quantify the stare of someone suffering from acute schizophrenia? Someone will have to figure out the exact flavor, and there may be debate about the best treatment both long term and in the ED. But very quickly after seeing them, you just know. Of course you go through the process of exam, and think about a differential, but it rarely changes the initial impression.

The integration of sight, hearing, smell, touch along with the evolution of patient behavior along with their companions along with experience along with the usual medical data will almost always provide a far better set of information on which to make a decision than the few parameters taken into account with an EBM study. These studies can be very helpful, but they don't replace the - quite literally - "big picture."
Great post. I agree.
 
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I agree with practicing in a way that lets you sleep at night. Disregarding your duty to do what's best for the patient because you think they're too ignorant or too ungrateful rubs me wrong.

I get why you think it rubs you the wrong way. There is a big difference b/t textbook medicine and practical medicine. I hope you do not believe that typical EM patients gives a good representation of the general population. I am quite certain that their IQ and education level is 1-2 standard deviation from the norm.

Regarding my Duty to do what is best for the pts...... I would love to if it is productive.

1. Abx and cough. How many well appearing pts do we see with this presentation. Do you really think they came to the ED for an education about why they do not need abx? If they were educated enough, they would know not to come and just stay home and ride it out. Pts who comes to the ED with a benign cough are very ignorant and you will not be able to change their mind. I could be a hard liner and tell everyone that they do not need abx and just take ibuprofen but this fails more often than not. Why would I spend 5 minutes of my day educating them, disagree with me, leave unhappy, and get a complaint when they happen to get a superimposed bacterial pneumonia or tonsillitis. Or get a complaint when they didn't get better in 2 dys, saw their PCP, got abx, got better, and think I am a Quack?

2. Drug seekers. In Texas there is a DPS website where I can track anyone's narcotic use in Texas no matter where they got the script from. I can tell you that I am one of the few docs that regularly uses this site and this is the most concrete evidence I can present to pts on why I would not be giving them narcs. So I catch many more than my partners. What has this gotten me? An Award? Increased compensation? Administrative applause?

Nope.... It gets me in heated confrontations during my shift with these pts. I get complaints to the medical board about my lack of pain management. Yes.... I got 4 this past year. And for every complaint requires me to spend my evening writing a letter explaining why my care was appropriate. Another 4 this year and I will join the drug giving crowd just to avoid all of the headache.
 
I don't think it rubs me the wrong way, it does rub me the wrong way. The impressive number of recent board complaints and the >50% failure rate of being able to communicate basic medical information to your patients in a way they accept indicates that you either need to change your style of communication or start serving a different population.
 
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The impressive number of recent board complaints and the >50% failure rate of being able to communicate basic medical information to your patients in a way they accept indicates that you either need to change your style of communication or start serving a different population.
I'm all for effective communication, but I think it's interesting that we have a system set up to punish those doctors doing what is likely the right thing in not contributing to identified addiction and medication abuse, yet rewards others who do the wrong thing and enable.

Why the assumption that he's solely the problem, without considering he may be getting backlash from standing up to a societal problem he did not create with patients willing to feed an addiction at all costs, while others evade detection by their enabling and worsening the disease of addiction in the name of "patient satisfaction"?

Isn't that the exact thing you preach in favor of, medical, ethical and statistical purity in medical decision making, while standing up to all outside pressures, bias and influence?
 
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There is a frank and obvious conflict between appropriate/safe ED pain management (i.e. don't hand out oxys like candy, don't refill oxys to heroin addicts, check the state Rx database before giving oxys) and the patient satisfaction-press gainey culture.

In Mass, the state/board has made in mandatory for physicians to sign up for the controlled substance website when you get your license. They've made it mandatory to check said database before giving prescriptions for opiates (with some exceptions). I personally applaud this as one more step in helping to fight the opiate epidemic.

However, trust me when I tell you that a significant portion of our written complaints and negative press gaineys revolve around our MDs/PAs NOT giving opiates to a patient who wants them and thus is dissatisfied. Thankfully, we typically have overall very good satisfaction scores, so I can safely maintain my ethical stance that we're going to do things CORRECTLY and not bend to to pressure of patient demands for opiates when they are not indicated.

However, I know other shops aren't in the same situation. And as pay-for-performance shifts to pay-for-satisfaction, ED physicians will have a distinct and perverse incentive to just hand out oxys and antibiotics like candy. Yes, with excellent communication skills you can stave off half the complaints... but not all of them.
 
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Society now faces a clash between two fundamental belief systems. Unfortunately physicians - particularly EM physicians - are right at the boundary between the two and are frequently struck with the resulting lightning.

1) We have the old 1940's view of medicine and the physician. The physician is supposed to do what is best for the patient even if the patient doesn't like it. Back then, it could mean not telling the patient the true diagnosis, not obtaining (what today we would consider) consent, or prescribing a placebo. Today, this takes the idea that the physician is supposed to enforce correct use of abx or narcotics, or is supposed to be the one effectively rationing medical resources.

2) We also have the idea that the patient should be free to do whatever she wants. If a patient wants to take vancomycin or 100mg/day of oxycodone, it is their body and their right. If they think they need an MRI - that "insurance" pays for - after a headache post spending all day weeding the garden, what right does a physician have to say "no'?

As long as we are located at the tectonic plate boundary between these two ideas of what a physician should - or should not do - we are going to be caught in a lot of earthquakes.
 
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Society now faces a clash between two fundamental belief systems. Unfortunately physicians - particularly EM physicians - are right at the boundary between the two and are frequently struck with the resulting lightning.

1) We have the old 1940's view of medicine and the physician. The physician is supposed to do what is best for the patient even if the patient doesn't like it. Back then, it could mean not telling the patient the true diagnosis, not obtaining (what today we would consider) consent, or prescribing a placebo. Today, this takes the idea that the physician is supposed to enforce correct use of abx or narcotics, or is supposed to be the one effectively rationing medical resources.

2) We also have the idea that the patient should be free to do whatever she wants. If a patient wants to take vancomycin or 100mg/day of oxycodone, it is their body and their right. If they think they need an MRI - that "insurance" pays for - after a headache post spending all day weeding the garden, what right does a physician have to say "no'?

As long as we are located at the tectonic plate boundary between these two ideas of what a physician should - or should not do - we are going to be caught in a lot of earthquakes.
"2050" a novel, by John Birdstrike MD

The synopsis- Government and insurers will demand that patients are given the EMR tablet and the last right of refusal, after you place your orders, to select or delete what lab tests, CT scans or MRIs they want or disagree with, in the ultimate act of patient satisfaction.

The government regulators, hospital and insurance company profiteers will enable patients to access their EMR through their home portal, to delete their diagnoses (obesity, addiction, mental illness) and replace them with a more "patient satisfying" or pleasing ones.

This is where our healthcare leaders are taking us. This is Medicine in 2050.
 
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"2050" a novel, by John Birdstrike MD

The synopsis- At what point will government and insurers demand that patients are given the EMR tablet and the last right of refusal, after you place your orders, to select or delete what lab tests, CT scans or MRIs they want or disagree with, in the ultimate act of patient satisfaction?

At what point do the government regulators, hospital and insurance company profiteers enable patients to access their EMR through their home portal, to delete their diagnoses (obesity, addiction, mental illness) and replace them with a more "patient satisfying" or pleasing one's?

This is Medicine in 2050.

You left out the "best" part. At the same time, physicians will be responsible for ensuring that these patient choices also reflect correct use of pharmaceuticals and "chose wisely" with respect to testing/interventions. If not, it will still be the physician's fault because he should have somehow convinced the patient to do the right thing of their own free will.

Between the Seinfeld episode about Elaine's medical records, and the new European "right to be forgotten", I am sure the right of a patient to edit medical records will come up soon.
 
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I'm all for effective communication, but I think it's interesting that we have a system set up to punish those doctors doing what is likely the right thing in not contributing to identified addiction and medication abuse, yet rewards others who do the wrong thing and enable.

Why the assumption that he's solely the problem, without considering he may be getting backlash from standing up to a societal problem he did not create with patients willing to feed an addiction at all costs, while others evade detection by their enabling and worsening the disease of addiction in the name of "patient satisfaction"?

Isn't that the exact thing you preach in favor of, medical, ethical and statistical purity in medical decision making, while standing up to all outside pressures, bias and influence?
I considered it and it's possible he has the most malignant patient population ever. Hence the suggestion about changing shops. However, the idea that there are only two outcomes with drug seekers doesn't ring true in my experience. It's not exclusively candyman vs. unlicensed/unemployed martyr and I reject that false dichotomy. I work in the same state and in a system that cares very highly about PG and I manage to avoid inappropriately dispensing narcs and yet still remain employed and licensed. While my ego likes to think I'm special, it's unlikely that I have some unique gift for messaging my medical decision making to patients. I'm not saying the drug seekers and URI patients leave ecstatic but they leave having received appropriate medical care and they don't feel disrespected/pissed off enough to complain about it.

I'm preaching that you should do what you think is right for the patient (preferably with that opinion backed up by at least a vague correlation with reality) because not doing to is toxic to your soul and bad for the patient. Nothing involving people is pure and there's nowhere near enough (quality) evidence for one to base practice solely on EBM so I don't care if every recommendation is followed to the letter every time. Medicine is an art and there's enough uncertainty as to make a broad range of practice patterns reasonable. What I can't condone is clearly knowing what you're doing is wrong (and be clear that in this case I am referencing the abx for viral infections, not checking state CSR databases) and still doing it because you perceive it to be easier. That way lies burnout and the death of compassion. And if you don't care, medicine (and EM in particular) is a horrifically painful job.
 
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I considered it and it's possible he has the most malignant patient population ever. Hence the suggestion about changing shops. However, the idea that there are only two outcomes with drug seekers doesn't ring true in my experience. It's not exclusively candyman vs. unlicensed/unemployed martyr and I reject that false dichotomy. I work in the same state and in a system that cares very highly about PG and I manage to avoid inappropriately dispensing narcs and yet still remain employed and licensed. While my ego likes to think I'm special, it's unlikely that I have some unique gift for messaging my medical decision making to patients. I'm not saying the drug seekers and URI patients leave ecstatic but they leave having received appropriate medical care and they don't feel disrespected/pissed off enough to complain about it.

I'm preaching that you should do what you think is right for the patient (preferably with that opinion backed up by at least a vague correlation with reality) because not doing to is toxic to your soul and bad for the patient. Nothing involving people is pure and there's nowhere near enough (quality) evidence for one to base practice solely on EBM so I don't care if every recommendation is followed to the letter every time. Medicine is an art and there's enough uncertainty as to make a broad range of practice patterns reasonable. What I can't condone is clearly knowing what you're doing is wrong (and be clear that in this case I am referencing the abx for viral infections, not checking state CSR databases) and still doing it because you perceive it to be easier. That way lies burnout and the death of compassion. And if you don't care, medicine (and EM in particular) is a horrifically painful job.
Fair enough. I happen to agree.
 
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We must have really reasonable patients here. Almost all my ambulatory probably has a virus patients that want antibiotics are satisfied with "I don't think antibiotics will help you feel better any faster, but there is a real chance they will give you diarrhea and that diarrhea is rarely life threatening. What I propose we do is (some combination of ibuprofen, Tylenol, Decadron), which I think will get you feeling better a lot faster and not give you diarrhea." It's a very short conversation. If they insist on antibiotics after the talk, then I provide them. That balance works for me.


I think the conversation about what to do with OP's patient is a little silly as this is a probably a patient you need to lay eyes on to get a better feel for appropriate workup.
 
We must have really reasonable patients here. Almost all my ambulatory probably has a virus patients that want antibiotics are satisfied with "I don't think antibiotics will help you feel better any faster, but there is a real chance they will give you diarrhea and that diarrhea is rarely life threatening. What I propose we do is (some combination of ibuprofen, Tylenol, Decadron), which I think will get you feeling better a lot faster and not give you diarrhea." It's a very short conversation. If they insist on antibiotics after the talk, then I provide them. That balance works for me.


I think the conversation about what to do with OP's patient is a little silly as this is a probably a patient you need to lay eyes on to get a better feel for appropriate workup.

From Arcan's High moral EM practice, you must have a really crappy job. How can you give someone abx eventhough they insist while knowing that you are poisoning their body?
 
I don't think it rubs me the wrong way, it does rub me the wrong way. The impressive number of recent board complaints and the >50% failure rate of being able to communicate basic medical information to your patients in a way they accept indicates that you either need to change your style of communication or start serving a different population.

Fair enough. I do not judge how other doctors practice medicine. I just hope you practice what you preach. If not, you are just being a Hippocrate.

Please refuse to do 90% of bony xrays b/c you know they will likely be negative. Please refuse abx unless you know its bacterial. Please refuse many workups b/c you know they will likely be fruitless. I hope your practice consists of mostly exam/discharge b/c as most doctors know, most of the labs/imaging we run will likely be fruitless.

But medicine is similar to many customer oriented job. We sometimes have to give them what they want.

From your high horse, we should shut down most fast food joints. How dare they serve that obese pt their big mac and fries.
 

That's the point. Many of us went into medicine because we had a bit more idealism and wanted to do more than business. Many easier ways to make a buck. Unfortunately, society pressures us to turn it into nothing more than fast food, but isn't it up to physicians to stand their ground and do what's right? Somewhere along the line you probably took something approximating the Hippocratic Oath. Sad to see so many people discard that so easily. But perhaps my idealism is quaint and unrealistic.
 
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From Arcan's High moral EM practice, you must have a really crappy job. How can you give someone abx eventhough they insist while knowing that you are poisoning their body?
...or his decadron for a cold virus. The pure EBM treatment of a cold virus is: no treatment. One guy throws antibiotics at it and he's a heathen EBM-o-phobe. Another throws equally unnecessary hyperglycemia-inducing, immune system-suppressing steroids at it and he's "thinking outside the box."

It just shows you how we all, to some degree or another, selectively pick and choose from the so-called "evidence" much of which isn't very good to begin with, to service our preconceived notions and biases.
 
That's the point. Many of us went into medicine because we had a bit more idealism and wanted to do more than business. Many easier ways to make a buck. Unfortunately, society pressures us to turn it into nothing more than fast food, but isn't it up to physicians to stand their ground and do what's right? Somewhere along the line you probably took something approximating the Hippocratic Oath. Sad to see so many people discard that so easily. But perhaps my idealism is quaint and unrealistic.
A lot of people feed into these unrealistic idealisms because they don't want to discourage young people or be labeled as overly negative. But ultimately they're not doing anyone any favors when reality strikes later. I think this is part of why so many doctors, in all specialties, are so disgruntled: Unrealistic and idealistic expectations, more so than due to a lack of positives.

It's not because Medicine can't be a great career, with many excellent aspects, because it can. It's because so many are fed, and drink up, unrealistic and idealistic Kool-Aid from the days of wooden teeth, men with white wigs, before student loans were the size of a small countries' national debts and when doctors did house calls and took broods of chickens as payment in return. That set of ideals is not good preparation for a career heavily regulated by government, influenced by big business and a web of medical-legal concerns. That's why I try to come to this forum to give some balance, and share the good along with the warts and blemishes of our plight. It just so happens that people tend to remember and respond to the negative, overwhelmingly over the positive which they often ignore or forget, but that I can't control. Ultimately it's about finding realism amongst the cynicism and idealism.
 
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Fair enough. I do not judge how other doctors practice medicine. I just hope you practice what you preach. If not, you are just being a Hippocrate.

Please refuse to do 90% of bony xrays b/c you know they will likely be negative. Please refuse abx unless you know its bacterial. Please refuse many workups b/c you know they will likely be fruitless. I hope your practice consists of mostly exam/discharge b/c as most doctors know, most of the labs/imaging we run will likely be fruitless.

But medicine is similar to many customer oriented job. We sometimes have to give them what they want.

From your high horse, we should shut down most fast food joints. How dare they serve that obese pt their big mac and fries.

1. I'm arguing that we should do what we think is in the patient's best interest, I'm not exactly setting the bar unrealistically high.

2. In terms of practice pattern, I screen more patients out and order fewer tests than the majority of my peers. I'm paid off of RVUs so this results in having to see more patients (ie work harder) in order to get the same pay.

3. If I was a better clinician I could probably get away with doing even less testing. However, there's enough unusual and uncommon presentations that testing is needed to move into the "low enough to dismiss" category of risk. The fact that the tests come back negative doesn't mean they didn't have potential value when they were ordered as you well know.

4. Fast food restaurants don't have a fiduciary duty to the health of their customers except in not causing food-borne infectious diseases. I don't have the skills to make this not sound condescending or confrontational in the context of an internet discussion with someone I've never met, but I would seriously suggest checking out the book "Stop Physician Burnout: What to Do When Working Harder Isn't Working". I've had periods where I hated the patients I was caring for and felt like everything would great if everyone else around me would just get their s%^# together and leave me alone to do my job. While it seemed to help at the time, things I did to cope like: caring less about the patient, divorcing myself of responsibility for my actions, and bitching about admin interference while doing nothing to change it didn't help and actually made things worse.
 
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