Is "Choosing Wisely" (ordering less tests) legit or purely a money saving attempt?

[VA Hopeful Dr]

I’m going to be the PITA. Also I wouldn’t expect you to list everything you’re doing during your exam for us. But please palpate the thyroid. It’s completely anecdotal/firsthand bias but it saved me a world of hurt. Most patients don’t advance past ultrasound to biopsy but even those who do, tissue genetic testing often prevents surgery if not indicated. You won’t find a ton of nodules but even with “Choosing Wisely” serial ultrasounds isn’t a huge waste of resources or dollars in my opinion. I’m hypervigilant over thyroid exam/workup but follow the ATA guidelines. It’s an added perk our radiologists include the ATA biopsy guidelines on their ultrasound reports.

No that was pretty much exactly what I do. I go back and forth on thyroids and listening to carotids.

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[Clean7795]

And then you end up with cases like: Med Mal Case: Hospitalist, Ischemic Leg | Student Doctor Network

Ironic because this is a perfect example of when needless testing ****s the medical team over.

Patient presents with leg pain and a documented examination of cold pulseless legs. Clinically this should be considered acute ischemic limb, vascular surgery urgently consulted, and CTA requested for treatment planning. Ordering an ultrasound and then waiting for the results is absolutely a delay in acute care. It's like a patient with cardiac chest pain, ST elevations, and elevated troponin, but deciding to wait on a cardiac CT and MR before consulting cardiology.

Ultrasound is not part of the decision-making algorithm here at all. All the ultrasound did was provide a false sense of security and ultimately incriminate the physicians involved, especially the initial ones who lacked the clinical skills to make "do not miss" diagnoses. This is becoming more common in modern physicians because many rely too much on radiology and subspecialists consults to do the heavy lifting for them.

I agree the modern medicolegal environment certainly encourages over-testing, but if you just shotgun tests and/or consults on everyone then it just further validates the idea that a midlevel can do everything you do (because that is what they typically do).

 

[MedicineZ0Z]

Ironic because this is a perfect example of when needless testing ****s the medical team over.

Patient presents with leg pain and a documented examination of cold pulseless legs. Clinically this should be considered acute ischemic limb, vascular surgery urgently consulted, and CTA requested for treatment planning. Ordering an ultrasound and then waiting for the results is absolutely a delay in acute care. It's like a patient with cardiac chest pain, ST elevations, and elevated troponin, but deciding to wait on a cardiac CT and MR before consulting cardiology.

Agree on the first but that's a silly analogy with the cardiac thing lol.

Ultrasound is not part of the decision-making algorithm here at all. All the ultrasound did was provide a false sense of security and ultimately incriminate the physicians involved, especially the initial ones who lacked the clinical skills to make "do not miss" diagnoses. This is becoming more common in modern physicians because many rely too much on radiology and subspecialists consults to do the heavy lifting for them.

I agree the modern medicolegal environment certainly encourages over-testing, but if you just shotgun tests and/or consults on everyone then it just further validates the idea that a midlevel can do everything you do (because that is what they typically do).

It's more to have a formal documented objective study (ordering tests). A lot of physical exams are garbage. Literally seen ultra experienced docs be miles off with their diagnosis against an ultrasound study. A lot of it is due to simple inaccuracy in a physical exam and increasing obesity.

I fully agree with pan-consults. And as seen in that case, they don't actually save you either. Shotgun tests can help when the patient is undifferentiated.

 

[Bacchus]

Ironic because this is a perfect example of when needless testing ****s the medical team over.

Patient presents with leg pain and a documented examination of cold pulseless legs. Clinically this should be considered acute ischemic limb, vascular surgery urgently consulted, and CTA requested for treatment planning. Ordering an ultrasound and then waiting for the results is absolutely a delay in acute care. It's like a patient with cardiac chest pain, ST elevations, and elevated troponin, but deciding to wait on a cardiac CT and MR before consulting cardiology.

Ultrasound is not part of the decision-making algorithm here at all. All the ultrasound did was provide a false sense of security and ultimately incriminate the physicians involved, especially the initial ones who lacked the clinical skills to make "do not miss" diagnoses. This is becoming more common in modern physicians because many rely too much on radiology and subspecialists consults to do the heavy lifting for them.

I agree the modern medicolegal environment certainly encourages over-testing, but if you just shotgun tests and/or consults on everyone then it just further validates the idea that a midlevel can do everything you do (because that is what they typically do).

US to rule VTE? Couldn’t they just do that at the bedside? Or was it to demonstrate waveforms? Handheld Doppler could have done that instead of formal study.

 

[hallowmann]

That case reminds me of something I saw as a second year on call. Patient had been a transfer Friday PM from MICU after having a GI bleed that GI didn't want to touch and IR did embolization for 3 days earlier. Patient was literally accepted 30 min before handoff by the day team to the night team. Apparently they had been complaining of abdominal pain for 2 days in the MICU, and it was barely addressed, just more Dilaudid, and since H/H was stable they were like "peace!"

So she's transferred to our service, and the night team "laid eyes", don't think they did an abdominal exam, but patient said they felt OK after getting more Dilaudid from MICU right before transfer. The next morning (Sat AM) completely new day team sees patient, they don't love the abdominal exam (no overt peritoneal signs reportedly, but just not reassuring) and said, we need to consult surgery to make sure there's no bowel ischemia 2/2 embolization, ordered CT, but it's Saturday and who knows when thats gonna happen. Intern sent the page to surgery, never heard anything. The attending was leaving at 1 pm and told the senior make sure surgery sees them and let him know.

I come in the evening for Sat night shift, and getting handoff from senior they're like, oh I paged them a bit ago and I'll let you know. Hear like 10 min after sign out that senior talked to Surg (honestly I think they forgot), and they're seeing the patient soon, they got held up earlier. 30 min into the night shift (patient was on our service just over 24 hrs) we're getting ready to round on the people we wanted to lay eyes on, and we notice that the patient fell off our list, and we're like, what happened? Paged the surgery resident to ask, and she proceeds to chew me out telling me that we've been sitting for 3 days on bowel ischemia and they're taking the patient class A, and "I don't know if she's gonna make it because of you". I was literally less than an hour into a random call shift and that was the start of the night.

Patient was OK. Lost a bit of bowel, but it reportedly wasn't that bad when they went in there.

Could have been worse, patient was actually not mad, just glad it worked out. I knew to watch the MICU transfers, but damn, how do you sit on that for days without imaging or something. I mean you know it's one of the major complications to embolization.

EDIT: Anticipating questions about this - MICU is staffed by 50/50 teaching teams to hospitalists (CC docs and midlevels). I honestly don't remember who had them while they were in the MICU, but typically the "stabilized" patients waiting to transfer get passed to the midlevels, and honestly the weekend before a new block there's a lot of handoffs up there.

 

[Bacchus]

That case reminds me of something I saw as a second year on call. Patient had been a transfer Friday PM from MICU after having a GI bleed that GI didn't want to touch and IR did embolization for 3 days earlier. Patient was literally accepted 30 min before handoff by the day team to the night team. Apparently they had been complaining of abdominal pain for 2 days in the MICU, and it was barely addressed, just more Dilaudid, and since H/H was stable they were like "peace!"

So she's transferred to our service, and the night team "laid eyes", don't think they did an abdominal exam, but patient said they felt OK after getting more Dilaudid from MICU right before transfer. The next morning (Sat AM) completely new day team sees patient, they don't love the abdominal exam (no overt peritoneal signs reportedly, but just not reassuring) and said, we need to consult surgery to make sure there's no bowel ischemia 2/2 embolization, ordered CT, but it's Saturday and who knows when thats gonna happen. Intern sent the page to surgery, never heard anything. The attending was leaving at 1 pm and told the senior make sure surgery sees them and let him know.

I come in the evening for Sat night shift, and getting handoff from senior they're like, oh I paged them a bit ago and I'll let you know. Hear like 10 min after sign out that senior talked to Surg (honestly I think they forgot), and they're seeing the patient soon, they got held up earlier. 30 min into the night shift (patient was on our service just over 24 hrs) we're getting ready to round on the people we wanted to lay eyes on, and we notice that the patient fell off our list, and we're like, what happened? Paged the surgery resident to ask, and she proceeds to chew me out telling me that we've been sitting for 3 days on bowel ischemia and they're taking the patient class A, and "I don't know if she's gonna make it because of you". I was literally less than an hour into a random call shift and that was the start of the night.

Patient was OK. Lost a bit of bowel, but it reportedly wasn't that bad when they went in there.

Could have been worse, patient was actually not mad, just glad it worked out. I knew to watch the MICU transfers, but damn, how do you sit on that for days without imaging or something. I mean you know it's one of the major complications to embolization.

EDIT: Anticipating questions about this - MICU is staffed by 50/50 teaching teams to hospitalists (CC docs and midlevels). I honestly don't remember who had them while they were in the MICU, but typically the "stabilized" patients waiting to transfer get passed to the midlevels, and honestly the weekend before a new block there's a lot of handoffs up there.

I’m an out patient FP but it didn’t take me past the first paragraph to think ischemia. Granted it was mesenteric ischemia (pain out of proportion), but still. Hindsight is 2020.

 

[turkeyjerky]

That case reminds me of something I saw as a second year on call. Patient had been a transfer Friday PM from MICU after having a GI bleed that GI didn't want to touch and IR did embolization for 3 days earlier. Patient was literally accepted 30 min before handoff by the day team to the night team. Apparently they had been complaining of abdominal pain for 2 days in the MICU, and it was barely addressed, just more Dilaudid, and since H/H was stable they were like "peace!"

So she's transferred to our service, and the night team "laid eyes", don't think they did an abdominal exam, but patient said they felt OK after getting more Dilaudid from MICU right before transfer. The next morning (Sat AM) completely new day team sees patient, they don't love the abdominal exam (no overt peritoneal signs reportedly, but just not reassuring) and said, we need to consult surgery to make sure there's no bowel ischemia 2/2 embolization, ordered CT, but it's Saturday and who knows when thats gonna happen. Intern sent the page to surgery, never heard anything. The attending was leaving at 1 pm and told the senior make sure surgery sees them and let him know.

I come in the evening for Sat night shift, and getting handoff from senior they're like, oh I paged them a bit ago and I'll let you know. Hear like 10 min after sign out that senior talked to Surg (honestly I think they forgot), and they're seeing the patient soon, they got held up earlier. 30 min into the night shift (patient was on our service just over 24 hrs) we're getting ready to round on the people we wanted to lay eyes on, and we notice that the patient fell off our list, and we're like, what happened? Paged the surgery resident to ask, and she proceeds to chew me out telling me that we've been sitting for 3 days on bowel ischemia and they're taking the patient class A, and "I don't know if she's gonna make it because of you". I was literally less than an hour into a random call shift and that was the start of the night.

Patient was OK. Lost a bit of bowel, but it reportedly wasn't that bad when they went in there.

Could have been worse, patient was actually not mad, just glad it worked out. I knew to watch the MICU transfers, but damn, how do you sit on that for days without imaging or something. I mean you know it's one of the major complications to embolization.

EDIT: Anticipating questions about this - MICU is staffed by 50/50 teaching teams to hospitalists (CC docs and midlevels). I honestly don't remember who had them while they were in the MICU, but typically the "stabilized" patients waiting to transfer get passed to the midlevels, and honestly the weekend before a new block there's a lot of handoffs up there.

Sounds like IM, CC and Surg are all complicit in delaying care, passing the buck and blaming others...
Only surprise is that you guys aren’t blaming the ER for missing it on arrival 😒

 

[VA Hopeful Dr]

Sounds like IM, CC and Surg are all complicit in delaying care, passing the buck and blaming others...
Only surprise is that you guys aren’t blaming the ER for missing it on arrival 😒

IM and surgery have a very long history of hating each other, you guys are too new.

 

[hallowmann]

I’m an out patient FP but it didn’t take me past the first paragraph to think ischemia. Granted it was mesenteric ischemia (pain out of proportion), but still. Hindsight is 2020.

Yeah, literally its the first thing I think of with embolization from med school, its like the most dangerous, "never miss" diagnosis. Its also physiologically what you would expect in addition to perf. Obviously our attending about it too. I just don't get how no one thought about it before they were transferred from the MICU. It was just problematic how many hands that patient passed through in that short period of time. Weekends are a terrible time to be admitted to the hospital.

IM and surgery have a very long history of hating each other, you guys are too new.

Yeah, usually Surg is a bit more friendly with FM at our institution, but we rotate through the SNICU with them. They generally have an overall disregard for IM, often times related to disagreements with MICU management and MICU overflow in the SNICU. Honestly, it was annoying getting chewed out, but a ball was definitely dropped. Would it have been different, probably not.

Sounds like IM, CC and Surg are all complicit in delaying care, passing the buck and blaming others...
Only surprise is that you guys aren’t blaming the ER for missing it on arrival 😒

I mean, EM gets enough blame as it is and it wasn't their fault what happened. Besides, they're good at knowing when someone needs to be admitted. Now knowing why they are being admitted seems to be very hit or miss. For the first 6 mos of the year, I basically assume we will be redoing the workup upon admission, unless we need urgent imaging, so I don't put much into asking the EM resident what's going on. The downside is lately, when I am asking some of them what they think is up, they keep telling me, "I don't know". Come on man, make something up, give me a differential, put a little effort in, I'm not pushing back on the admit, I'm just curious what you think.

 

[MedicineZ0Z]

Yeah, literally its the first thing I think of with embolization from med school, its like the most dangerous, "never miss" diagnosis. Its also physiologically what you would expect in addition to perf. Obviously our attending about it too. I just don't get how no one thought about it before they were transferred from the MICU. It was just problematic how many hands that patient passed through in that short period of time. Weekends are a terrible time to be admitted to the hospital.


Yeah, usually Surg is a bit more friendly with FM at our institution, but we rotate through the SNICU with them. They generally have an overall disregard for IM, often times related to disagreements with MICU management and MICU overflow in the SNICU. Honestly, it was annoying getting chewed out, but a ball was definitely dropped. Would it have been different, probably not.


I mean, EM gets enough blame as it is and it wasn't their fault what happened. Besides, they're good at knowing when someone needs to be admitted. Now knowing why they are being admitted seems to be very hit or miss. For the first 6 mos of the year, I basically assume we will be redoing the workup upon admission, unless we need urgent imaging, so I don't put much into asking the EM resident what's going on. The downside is lately, when I am asking some of them what they think is up, they keep telling me, "I don't know". Come on man, make something up, give me a differential, put a little effort in, I'm not pushing back on the admit, I'm just curious what you think.

I think EM as a specialty would benefit from doing a bit of IM ward time. It increases breadth of diagnostic knowledge beyond what ICU time offers. Being a rapid triage and stabilize system is great but it also makes other services respect the specialty less if you can't offer much from a diagnostic point of view for complex patients.

 

[TwistedTea]

Ironic because this is a perfect example of when needless testing ****s the medical team over.

Patient presents with leg pain and a documented examination of cold pulseless legs. Clinically this should be considered acute ischemic limb, vascular surgery urgently consulted, and CTA requested for treatment planning. Ordering an ultrasound and then waiting for the results is absolutely a delay in acute care. It's like a patient with cardiac chest pain, ST elevations, and elevated troponin, but deciding to wait on a cardiac CT and MR before consulting cardiology.

Ultrasound is not part of the decision-making algorithm here at all. All the ultrasound did was provide a false sense of security and ultimately incriminate the physicians involved, especially the initial ones who lacked the clinical skills to make "do not miss" diagnoses. This is becoming more common in modern physicians because many rely too much on radiology and subspecialists consults to do the heavy lifting for them.

I agree the modern medicolegal environment certainly encourages over-testing, but if you just shotgun tests and/or consults on everyone then it just further validates the idea that a midlevel can do everything you do (because that is what they typically do).

+occult blood hg 14 hemorrhoids, GI consult
troponin 0.03- cardiology consult
albuterol inhaler in room, might not be this patient's maybe last patient in rooms but idk - pulm consult
potassium 3.4- nephro consult
glucose 114- consult inpatient diabetes management



Noone docs mids for this type of garbage so no wonder they keep doing it.

 

[MedicineZ0Z]

+occult blood hg 14 hemorrhoids, GI consult
troponin 0.03- cardiology consult
albuterol inhaler in room, might not be this patient's maybe last patient in rooms but idk - pulm consult
potassium 3.4- nephro consult
glucose 114- consult inpatient diabetes management



Noone docs mids for this type of garbage so no wonder they keep doing it.

Each consult service bills the patient a crap ton. Then we wonder why we have unnecessary costs. We have too many specialists, and generalists are not doing enough. You can actually provide drastically more cost effective care if you have a generalist who over-orders tests to a degree but minimizes consults.

 

[VA Hopeful Dr]

Each consult service bills the patient a crap ton. Then we wonder why we have unnecessary costs. We have too many specialists, and generalists are not doing enough. You can actually provide drastically more cost effective care if you have a generalist who over-orders tests to a degree but minimizes consults.

You sure about that? Because that doesn't pass the smell test to me. A consult doesn't usually cost more than around $200. So unless the specialist orders the exact same (or more) tests than the generalist it's not going to save anything.

 

[TwistedTea]

I’m not saying to not consult but most consults by mids are garbage stuff an M4 could sniff out

 

[DocWinter]

Let's say you get a CBC on a young female patient who has an IUD so no menses in over 2 years. Iron is borderline low so you send for EGD/colonoscopy. During the colonoscopy there is a perforation (0.5% risk) leading to a hemicoloectomy. Turns out the patient is a strict vegan and really just wasn't getting enough iron from her diet.

I have to disagree with this. As someone who routinely gets a CBC on young women, with result of borderline low iron, I would never choose to get colonoscopy and EGD rather than expanded history, maybe iron panel, or some other non invasive response. Your choice is not logical, it is an invasive reaction to a likely benign concern, and would be an example of why the choosing wisely campaign was created.

I err on the side of assessing when to order more and usually do so when the patient desires and after the conversation takes place. The campaign is all about the patient-physician conversation, and once you discuss with the pt the very low likelihood of this or that, why to not order this or that and document appropriately, your true risk of harming the patient through inaction or risk of lawsuit is incredibly low.

Discuss and document clinical judgement in each and every scenario.

 

[VA Hopeful Dr]

I have to disagree with this. As someone who routinely gets a CBC on young women, with result of borderline low iron, I would never choose to get colonoscopy and EGD rather than expanded history, maybe iron panel, or some other non invasive response. Your choice is not logical, it is an invasive reaction to a likely benign concern, and would be an example of why the choosing wisely campaign was created.

I err on the side of assessing when to order more and usually do so when the patient desires and after the conversation takes place. The campaign is all about the patient-physician conversation, and once you discuss with the pt the very low likelihood of this or that, why to not order this or that and document appropriately, your true risk of harming the patient through inaction or risk of lawsuit is incredibly low.

Discuss and document clinical judgement in each and every scenario.

But how do you KNOW it's not colon cancer? It is rising in young adults after all.

Snark aside, do remember that this is not an example of what I do, this was in direct response to another poster who claims they order lots of tests that are not necessarily indicated to make sure that they don't ever miss anything and possibly get sued

 

[MedicineZ0Z]

You sure about that? Because that doesn't pass the smell test to me. A consult doesn't usually cost more than around $200. So unless the specialist orders the exact same (or more) tests than the generalist it's not going to save anything.

Inpatient consults can often result in an enormous panel of tests. And blatantly unnecessary consults are literal wastes of money.

 

[fldoctorgirl]

This has been an interesting conversation to read as an M3. I've honestly never put much thought into why my PCP does a CBC/CMP/thyroid/FLP/etc on me annually without any symptomatic considerations, I've kind of just accepted it as the standard practice (and what I've been seeing on rotations as well). This has given me something to think about and further educate myself on as someone who wants to do IM.

I did an inpatient cards rotation and we were consulted on every troponin 0.1 above the normal, it was very irritating. Often by midlevels, but also by hospitalists. I get the argument for "covering yourself", but that just seems dumb? Patient has no indication of anything cardiac going on..

Also, @MedicineZ0Z , you mentioned not seeing annual paps done but on both my family medicine rotation and my ob/gyn rotation, paps were still being done annually, even on those 65+ in a lot of cases. I tried bringing up the updated guidelines once and was told that once you catch a case of advanced cervical cancer in a 25 year old, you'll want to screen annually too. My IM preceptor was still doing PSAs annually on everyone 50+. I don't think anyone who is set in their ways will change.

 

[VA Hopeful Dr]

Inpatient consults can often result in an enormous panel of tests. And blatantly unnecessary consults are literal wastes of money.

So you started this thread complaining about the trend to not do tests and now you're saying we do too many tests? Which is it?

And unnecessary consults are in the eye of the beholder.

 

[VA Hopeful Dr]

This has been an interesting conversation to read as an M3. I've honestly never put much thought into why my PCP does a CBC/CMP/thyroid/FLP/etc on me annually without any symptomatic considerations, I've kind of just accepted it as the standard practice (and what I've been seeing on rotations as well). This has given me something to think about and further educate myself on as someone who wants to do IM.

I did an inpatient cards rotation and we were consulted on every troponin 0.1 above the normal, it was very irritating. Often by midlevels, but also by hospitalists. I get the argument for "covering yourself", but that just seems dumb? Patient has no indication of anything cardiac going on..

Also, @MedicineZ0Z , you mentioned not seeing annual paps done but on both my family medicine rotation and my ob/gyn rotation, paps were still being done annually, even on those 65+ in a lot of cases. I tried bringing up the updated guidelines once and was told that once you catch a case of advanced cervical cancer in a 25 year old, you'll want to screen annually too. My IM preceptor was still doing PSAs annually on everyone 50+. I don't think anyone who is set in their ways will change.

Its a combination of things. Some, like MZ0Z and your OB preceptor have mentioned, are people that have found pathology on screening labs (that aren't strictly evidenced based) and so continue to do so. Some are doing out, as you say, out of pure habit. And some do it for other reasons. I get a fair number of people in the 20s whose work requires an insurance physical that requires a fasting lipid and glucose every year. Even if it was stone cold normal last year and they've gained no weight or anything else.

As for consults, that's pure CYA. We're all guilty of that. I order lots of unneeded stress tests for that exact reason.

 

[MedicineZ0Z]

This has been an interesting conversation to read as an M3. I've honestly never put much thought into why my PCP does a CBC/CMP/thyroid/FLP/etc on me annually without any symptomatic considerations, I've kind of just accepted it as the standard practice (and what I've been seeing on rotations as well). This has given me something to think about and further educate myself on as someone who wants to do IM.

I did an inpatient cards rotation and we were consulted on every troponin 0.1 above the normal, it was very irritating. Often by midlevels, but also by hospitalists. I get the argument for "covering yourself", but that just seems dumb? Patient has no indication of anything cardiac going on..

Also, @MedicineZ0Z , you mentioned not seeing annual paps done but on both my family medicine rotation and my ob/gyn rotation, paps were still being done annually, even on those 65+ in a lot of cases. I tried bringing up the updated guidelines once and was told that once you catch a case of advanced cervical cancer in a 25 year old, you'll want to screen annually too. My IM preceptor was still doing PSAs annually on everyone 50+. I don't think anyone who is set in their ways will change.

Annual labs are also part of the patient satisfaction experience for a check up. We complain about men not seeing a doctor for years for example, then when they come in - we don't want to check anything if they're so called asymptomatic. Another example is, "asymptomatic" is also a bold label to place on someone. A few minutes of history taking is not likely to pick up on early symptoms of a disease process. Patients also don't disclose everything upfront. So doctors are likely to want to rely on objective data.
And annual paps are a bit silly to do in low risk people in the context of the prevalence of cervical cancer. Annual PSAs on healthy males over 50 (key word is healthy) is generally a smart move.

So you started this thread complaining about the trend to not do tests and now you're saying we do too many tests? Which is it?

And unnecessary consults are in the eye of the beholder.

No I'm saying that consults will yield in a very large number of tests anyway. It's much more efficient and cost effective if the generalist can do the workup themselves without involving a consultant.

Its a combination of things. Some, like MZ0Z and your OB preceptor have mentioned, are people that have found pathology on screening labs (that aren't strictly evidenced based) and so continue to do so. Some are doing out, as you say, out of pure habit. And some do it for other reasons. I get a fair number of people in the 20s whose work requires an insurance physical that requires a fasting lipid and glucose every year. Even if it was stone cold normal last year and they've gained no weight or anything else.

As for consults, that's pure CYA. We're all guilty of that. I order lots of unneeded stress tests for that exact reason.

If your diagnosis and management is correct, consulting doesn't change anything. It just wastes money. If you've been doing the wrong stuff, consulting doesn't save you. Like if the patient is going to sue, everyone is being named - especially the primary team.

 

[VA Hopeful Dr]

Annual labs are also part of the patient satisfaction experience for a check up. We complain about men not seeing a doctor for years for example, then when they come in - we don't want to check anything if they're so called asymptomatic. Another example is, "asymptomatic" is also a bold label to place on someone. A few minutes of history taking is not likely to pick up on early symptoms of a disease process. Patients also don't disclose everything upfront. So doctors are likely to want to rely on objective data.
And annual paps are a bit silly to do in low risk people in the context of the prevalence of cervical cancer. Annual PSAs on healthy males over 50 (key word is healthy) is generally a smart move.



No I'm saying that consults will yield in a very large number of tests anyway. It's much more efficient and cost effective if the generalist can do the workup themselves without involving a consultant.



If your diagnosis and management is correct, consulting doesn't change anything. It just wastes money. If you've been doing the wrong stuff, consulting doesn't save you. Like if the patient is going to sue, everyone is being named - especially the primary team.

Sure everyone is going to be named, but if I consult cardiology for what I think (and document) is X problem and they don't work it up the bad outcome is 100% on them.

So I'll be named but I won't worry all that much about actually staying in the suit or losing it.

 

[deleted87716]

Annual PSAs on healthy males over 50 (key word is healthy) is generally a smart move.

Really...?

 

[MedicineZ0Z]

Sure everyone is going to be named, but if I consult cardiology for what I think (and document) is X problem and they don't work it up the bad outcome is 100% on them.

So I'll be named but I won't worry all that much about actually staying in the suit or losing it.

Why can't you do the medical workup yourself and refer once you need a procedure?

Really...?

View attachment 328212

Those numbers don't actually workout like that in real life. They also change quite a bit depending on your source (there have been more than just a couple trials done, which is what you're citing), which varies quite a bit by the studied patient population. I also emphasized that it should be for healthy patients who may have a very long life expectancy.

 

[deleted87716]

Those numbers don't actually workout like that in real life. They also change quite a bit depending on your source

OK, so go ahead and quote your sources.

 

[InternistDO]

Why can't you do the medical workup yourself and refer once you need a procedure?

Because if you’re performing exhaustive work ups on all your asymptomatic patients as you suggest, you probably don’t have time to work up someone for ischemic heart disease.