Is gastroenteritis that difficult to diagnose clinically....or does EVERYONE need a CT abd/pel?

[RustedFox]

Moderator note: content removed due to TOS violations

Are we gonna do this again, like we did last time?
I'm game; I'm just asking before I put the gloves on.

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[rickylafleur]

But this is a place for the ER docs to converse and commiserate. Here’s a thread with rads complaining about us ordering too many tests. We can’t point out that more than their share are ordered by the mid levels ? To each other?

If you’re one of the better ones, then you know it’s true !

I do agree to a point. The point I am trying to make and admittedly not taking the best approach towards is we started to see some admit and share the blame. And it is a good thing to realize. And then can be followed with the reasons why this occurs. But pointing towards one group and saying "they do it more" is just weak. But it quells the agitated egos.

 

[rickylafleur]

Are we gonna do this again, like we did last time?
I'm game; I'm just asking before I put the gloves on.

I guess we can. I just thought every once in a while a little jab back might be fun. Was it not fun?

 

[RustedFox]

I guess we can. I just thought every once in a while a little jab back might be fun. Was it not fun?

Hey, it was. We kissed and made up via PM.

So, listen - When I want your opinion, I'll have to ask you before I have to sign your chart, because chances are it won't be easily understood.

If you were on shift with me, and you decided to call in a whirlybird for a patient because he's *unstable*, and at no point did you consider things like... oh, I don't know... asking the physician to place a central line and start pressors... AND after I get involved to cancel the bird, I find out that he's DNR, then the hubris and Dunning-Kruger for which you PLPs are notorious and reviled for is merited.

I actually said to the PLP: "If you think anyone in this department, at any time, is unstable... then the first thing you had better do is come get me, because that's what I do. I stabilize them. The fact that you didn't do that tells me all that I need to know... about what you don't know."

Respect is earned, not given. Once upon a time, the PLP crowd did as they were told and things were effective. They learned, and it was good. Now, the PLPs give me attitude about why "I'm not doing it right".

Stop making more work for me, like you used to do.

 

[rickylafleur]

Hey, it was. We kissed and made up via PM.

So, listen - When I want your opinion, I'll have to ask you before I have to sign your chart, because chances are it won't be easily understood.

If you were on shift with me, and you decided to call in a whirlybird for a patient because he's *unstable*, and at no point did you consider things like... oh, I don't know... asking the physician to place a central line and start pressors... AND after I get involved to cancel the bird, I find out that he's DNR, then the hubris and Dunning-Kruger for which you PLPs are notorious and reviled for is merited.

I actually said to the PLP: "If you think anyone in this department, at any time, is unstable... then the first thing you had better do is come get me, because that's what I do. I stabilize them. The fact that you didn't do that tells me all that I need to know... about what you don't know."

Respect is earned, not given. Once upon a time, the PLP crowd did as they were told and things were effective. They learned, and it was good. Now, the PLPs give me attitude about why "I'm not doing it right".

Stop making more work for me, like you used to do.

First off, that situation should not have happened obviously but it did. You provided excellent supervision and righted the course. Hopefully the PA or NP learned from the experience.
In this particular case, are you saying they gave you attitude, disagreed or someway other were obstinate?

 

[CoolDoc1729]

Hey, it was. We kissed and made up via PM.

So, listen - When I want your opinion, I'll have to ask you before I have to sign your chart, because chances are it won't be easily understood.

If you were on shift with me, and you decided to call in a whirlybird for a patient because he's *unstable*, and at no point did you consider things like... oh, I don't know... asking the physician to place a central line and start pressors... AND after I get involved to cancel the bird, I find out that he's DNR, then the hubris and Dunning-Kruger for which you PLPs are notorious and reviled for is merited.

I actually said to the PLP: "If you think anyone in this department, at any time, is unstable... then the first thing you had better do is come get me, because that's what I do. I stabilize them. The fact that you didn't do that tells me all that I need to know... about what you don't know."

Respect is earned, not given. Once upon a time, the PLP crowd did as they were told and things were effective. They learned, and it was good. Now, the PLPs give me attitude about why "I'm not doing it right".

Stop making more work for me, like you used to do.

Ok I read your original message like a PLP from another hospital was sending you a hospice train wreck via heli .. this was occurring in your own dept under “your supervision”/liability and you had no idea ? Whaaaaaaaat?

It’s neat to know there’s a PLP inferno circle below mine holy cow

 

[rickylafleur]

Alright guys. I get the feeling maybe I am not wanted or welcome here.
I am going to back out and stop inflaming or derailing.
I do value and respect physicians and get that you guys are venting here after dealing with some pretty horrendous conditions.
I think where I get baited is being included in the group with some really bad apples.
And it is kind of fun to bait back. But I will go back to lurker status....for now.

 

[GonnaBeADoc2222]

Alright guys. I get the feeling maybe I am not wanted or welcome here.
I am going to back out and stop inflaming or derailing.
I do value and respect physicians and get that you guys are venting here after dealing with some pretty horrendous conditions.
I think where I get baited is being included in the group with some really bad apples.
And it is kind of fun to bait back. But I will go back to lurker status....for now.

The End.....Or Is it.....????

Wait wait wait!! Is there a scene after the credits?!?!?!

 

[rickylafleur]

The End.....Or Is it.....????

Wait wait wait!! Is there a scene after the credits?!?!?!

Well if you are asking for an encore....then maybe
I can feel the love.

 

[Arcan57]

I am for real real coolio.

Too soon

 

[RustedFox]

First off, that situation should not have happened obviously but it did. You provided excellent supervision and righted the course. Hopefully the PA or NP learned from the experience.
In this particular case, are you saying they gave you attitude, disagreed or someway other were obstinate?

Yes.
Here's the point you're missing:

Bro, we're not here to teach you how to medicine. On shift, I need one of two things:

1. Either another competent and functional physician that can do the medicine independently, or:

2. An MLP who takes my orders and does the things I ask because I know the medicine.

The LAST thing I need is someone to run around having a very limited idea of what to do and then pulling me in once they get in over their head, THEN telling me that I'm wrong when it's my name on the chart.

It's like running around after a toddler who makes a mess in the kitchen, then in the living room, then in the bathroom, etc.

 

[rickylafleur]

Yes.
Here's the point you're missing:

Bro, we're not here to teach you how to medicine. On shift, I need one of two things:

1. Either another competent and functional physician that can do the medicine independently, or:

2. An MLP who takes my orders and does the things I ask because I know the medicine.

The LAST thing I need is someone to run around having a very limited idea of what to do and then pulling me in once they get in over their head, THEN telling me that I'm wrong when it's my name on the chart.

It's like running around after a toddler who makes a mess in the kitchen, then in the living room, then in the bathroom, etc.

I do get the point.
I am not being a baby (too much) here but even the use of MLP above is helpful.
Again it sucks to be associated with some of these I read about on here.
I have and will again contend that the PA education/training I received is not indicative of this kind of practice.
But then again there are good and bad in every category, even MD or DO.
And some of these places that accept this kind of behavior?? I feel for sure I would be sent packing if this was my response to your direction.

 

[RustedFox]

I do get the point.
I am not being a baby (too much) here but even the use of MLP above is helpful.
Again it sucks to be associated with some of these I read about on here.
I have and will again contend that the PA education/training I received is not indicative of this kind of practice.
But then again there are good and bad in every category, even MD or DO.
And some of these places that accept this kind of behavior?? I feel for sure I would be sent packing if this was my response to your direction.

I hear you, bro. But here's how it has shaken out for me in 10 years as an attending:

1. For as much as the MLP crowd loves to yap about how their training is "equivalent" and such (they love to say dumb **** like - we do 4 years of med school in 2 years lolz), they sure as hell can't display understanding of the basic sciences.

2. They want to "do the thing" (intubate, place a central line, reduce a fracture), but have no idea how to troubleshoot situations if and when they go sideways secondary to (1) above. Hell, they can't even identify what drugs to use, let alone know how they work and what to do about them. They just see the big kid on the bike and say: "I want to ride the bike too."

3. They get pissy and cry when you tell them that they can't "do the thing" because you're "not supporting their education" or whatever. Ready? THIS ISN'T YOUR EFFING EDUCATION.

**** Community ERs aren't MLP education and development sites. ****

Yet... the vast majority of them seem to insist that (the above) is what they're here for. No. Hard stop. You don't get to come to me and say: "I want to do the thing; I'm tired of seeing ankle sprains and dumb@sses who are simply can't adult and are awake". THAT'S WHAT YOU WERE HIRED TO DO; SEE ANKLE SPRAINS AND DUMB@SSES WHO CANT ADULT AND ARE AWAKE.

Are we a team? Sure. Now, play your position. Don't walk out of right field and say "I want to play shortstop now". You're a right fielder. Get back in right field.

4. Are there totally ostriched EPs? Yes. I work with two of them. Difference is; I don't have to sign their charts or police their class. YOYOMFer.

 

[GonnaBeADoc2222]

I hear you, bro. But here's how it has shaken out for me in 10 years as an attending:

1. For as much as the MLP crowd loves to yap about how their training is "equivalent" and such (they love to say dumb **** like - we do 4 years of med school in 2 years lolz), they sure as hell can't display understanding of the basic sciences.

2. They want to "do the thing" (intubate, place a central line, reduce a fracture), but have no idea how to troubleshoot situations if and when they go sideways secondary to (1) above. Hell, they can't even identify what drugs to use, let alone know how they work and what to do about them. They just see the big kid on the bike and say: "I want to ride the bike too."

3. They get pissy and cry when you tell them that they can't "do the thing" because you're "not supporting their education" or whatever. Ready? THIS ISN'T YOUR EFFING EDUCATION.

**** Community ERs aren't MLP education and development sites. ****

Yet... the vast majority of them seem to insist that (the above) is what they're here for. No. Hard stop. You don't get to come to me and say: "I want to do the thing; I'm tired of seeing ankle sprains and dumb@sses who are simply can't adult and are awake". THAT'S WHAT YOU WERE HIRED TO DO; SEE ANKLE SPRAINS AND DUMB@SSES WHO CANT ADULT AND ARE AWAKE.

Are we a team? Sure. Now, play your position. Don't walk out of right field and say "I want to play shortstop now". You're a right fielder. Get back in right field.

4. Are there totally ostriched EPs? Yes. I work with two of them. Difference is; I don't have to sign their charts or police their class. YOYOMFer.

Remember that thing...that we paid 200k for....to get education....medical school thats what it was. Go do that thing.

 

[thegenius]

Yeah and it's entirely useless. I pre copy paste my reasoning (which I actually type out to help rads out, small hx, exam) and click reasoning not found and can free text and just paste my own reasoning. The CDSM is a complete waste and has never ever changed my decision to image someone or modality.

I do the exact same thing. Free text a reason and bypass that entire thing. Not once have I even bothered to try to navigate it. Complete waste of money

 

[RustedFox]

Remember that thing...that we paid 200k for....to get education....medical school thats what it was. Go do that thing.

TWO hundred k?
Bro, you got out cheap.

 

[TooMuchResearch]

why is not possible for you guys to say, 'hey listen, i think it's mostly likely enteritis, there is no need to work you up and send you a 3k ER bill'. If the pain worsens, come back and we will do further workup'. Seems like everyone with nausea/vomiting gets a scan. Teenagers too. When I was a teen and had N/V/D, my mom told me to drink some soup. When I had a gash on my leg from a bike accident, my dad to rub some sand it in.

this way it saves everyone time and the rads can get back reading studies with actual pathology

and there is no need to call for reads. We aren't sitting back there jerkin it. We're drowning in a monsoon of studies from multiple hospitals, inpts, etc. Job security, yes true, but also adds more stress to an already stressful situation. If it is in fact that critical, open the studies and take a look yourselves. No dissection, large PE, etc, it's ok for them to wait a few minutes.

You see the difference: Your parents wouldn't have brought you to the ED for minor illness. I see 22-30 year olds routinely who come to the ED immediately for minor pain or minor illness because no one taught them how to care for minor problems at home and therefore they've determined it's an emergency.

 

[TooMuchResearch]

Less resources. If I'm at an academic hospital where I have residents in all specialties full time, that is very helpful.
For instance, pt comes in with some throat problem or globus sensation. I would rather have someone just do direct visualization of the glottis, and if I could or get an ENT resident to do it, fine that is good. But in community that is hard. So lots of people will just scan the neck.

Lots of docs here scan peritonsillar abscesses regularly for instance. I don't really understand why as it's a visual diagnosis. ENT drains them all the time without scanning. Unless there is something goofy with the history or physical, it isn't needed. At an academic hospital we can just drain it ourselves or call ENT to do it. In the community these are scanned for some reason.

And basically what @DoctorJDO said above. Happens all the time.

I stop our PAs from ordering CT on PTA whenever I can. Just stab it.

 

[TooMuchResearch]

It gets settled down to policy limits. Our group, as an example, carries some type of overhead policy beyond each doc's policy limit. It's either 10 or 20 million. I honestly hope I never need to know the details.

Can someone who understands malpractice cases explain how this award works? Most docs have a 3M or 5M malpractice insurance cap. That's 10M between rads and the ed doc. Where does the other 65M come from?

 

[NYEMMED]

Rad here. I can’t wait for the hammer to drop on the insane ED outliers ordering all these garbage studies. There’s usually one at every hospital and one of our ED MDs orders 2-3x more studies than the CLOSEST provider. She’s insane. Everyone knows she is insane. I just need CMS to tell her she’s insane and can no longer work in the ER.

Appropriate Use Criteria Program | CMS

Current StatusAs announced in the CY 2024 Physician Fee Schedule (PFS) Final Rule, effective January 1, 2024, CMS has paused efforts to implement the AUC program for reevaluation and rescinded the AUC regulations at 42 CFR 414.94. See pages 79256-79265 of the final rule.

www.cms.gov

As far as the argument that we need to just STFU and do our job because you’re making us rich, the random vagrant being pan scanned for the 3rd time in as many days does not, in fact, pay all that well.

New rule coming to your facility. The radiologist needs to consult and physically asses each patient to approve or disapprove imaging studies, and then document it in the chart. When radiologists have a stake in the game and hold the liability bag, then do what you want. Until then, you are paid to read films.

 

[NYEMMED]

It gets settled down to policy limits. Our group, as an example, carries some type of overhead policy beyond each doc's policy limit. It's either 10 or 20 million. I honestly hope I never need to know the details.

Then the lawyers get their 40% cut of the lottery win...

Also a question, Why are 60% of the entire worlds lawyers in the US? Could it be that they are incentivized to keep us a litigious society?

 

[TooMuchResearch]

Yeah, I feel the amount of time I would spend trying to delete problematic scribe documentation that would be malpractice self destructs (see my post about nurses being court room stenographers and writing **** people say verbatim) is longer than it takes me to write my own notes from scratch.

This is solved with a few emails to the scribe boss. Scribe gets more training or is invited to explore other opportunities. You have to own the scribe program though.

 

[TooMuchResearch]

Contrast allergies definitely exist.
It's the "shellfish/iodine" thing that doesn't.

95% of contrast allergies I just give Benadryl and steroids 30-60 minutes before study.

 

[TooMuchResearch]

Do

That's fine man...so there are a handful of ER docs or midlevels out of thousands that order too many imaging studies with impunity. As your colleague said above, we are all in this together and we are trying our hardest. There are a handful of radiology docs who I don't trust, but I'm not on your forum complaining about that and hoping that they stop practicing radiology or get in trouble.

Just a few days ago, there had to be a radiology overread on a serious miss of spinal cord pathology. I had a pt in the ED with weakness in his legs and non-localizing asymmetric, objective paresthesias and paresis going up to the mid abdomen. The initial prelim read on an MR Thoracic Spine w/wo Contrast was "Syrinx within the spinal cord spanning T3 through T6 approximately 8.6 cm and 2 mm in AP dimensions." and the reread in the morning was "Abnormal T2 hyperintense signal extending longitudinally within the ventral aspect of the spinal cord bilaterally and centrally with enhancement from approximately the T3 vertebra to the T6-7 disc level. No discrete mass lesion is identified. Differential considerations include a nonspecific demyelinating process, transverse myelitis and ischemia." The reread occurred because I initially saw the MRI and the read didn't make sense, I notified the Neurologist to discuss it as he had seen the patient as well and confirmed his neurologic findings, and the Neurologist spoke to Rads the next morning. Turned out those lesions were ischemic as we later discovered he had been stroking his C-spine, Brain (and T-spine) for the last 2 weeks or so. Had silent pAF as the source, which was finally picked up briefly on telemetry while in the hospital.

Do you not get sub-specialty rads reads at night? Or not able to talk to the rad?

 

[RustedFox]

Wait, homey got the banhammer?
He did NOTHING to warrant that.

 

[Arcan57]

Wait, homey got the banhammer?
He did NOTHING to warrant that.

Plot twist: he was the ICU MLP in the $75m locked in suit.

 

[RustedFox]

Plot twist: he was the ICU MLP in the $75m locked in suit.

Hilarious, but really... He didn't violate any rules, he's just a guy with something to say: just like any of us.

Unless he did something else that we don't know about, I see no reason why he was banned... and this de facto proves that mods need to relax the grip.

 

[NYEMMED]

Hilarious, but really... He didn't violate any rules, he's just a guy with something to say: just like any of us.

Unless he did something else that we don't know about, I see no reason why he was banned... and this de facto proves that mods need to relax the grip.

Probably because 90% of his posts were attacking a member or physicians...
And I'm sure he got warnings, which our mods usually send out prior to banning.

 

[RustedFox]

Probably because 90% of his posts were attacking a member or physicians...
And I'm sure he got warnings, which our mods usually send out prior to banning.

Were they??

I mean, AngryBird and I would joust with regularity.

If you read the posts, Lafleur and I even agreed to the donnybrook beforehand like two hockey players observing "the code".

Guy get booted, and here I am defending him.

 

[Apollyon]

Were they??

I mean, AngryBird and I would joust with regularity.

If you read the posts, Lafleur and I even agreed to the donnybrook beforehand like two hockey players observing "the code".

Guy get booted, and here I am defending him.

"I'm talking and I can't shut up!"

That's why, I'm guessing. Single subject poster. What's the definition of a fanatic? "Someone who can't change their mind, and won't change the subject."

 

[thegenius]

Do

Do you not get sub-specialty rads reads at night? Or not able to talk to the rad?

We can talk to rads overnight. I happened to be off shift and looked at the imaging from home later, and then phoned the neurologist and spoke to him, and then he took care of it.

 

[Siggy]

I hear you, bro. But here's how it has shaken out for me in 10 years as an attending:

1. For as much as the MLP crowd loves to yap about how their training is "equivalent" and such (they love to say dumb **** like - we do 4 years of med school in 2 years lolz), they sure as hell can't display understanding of the basic sciences.

More importantly I've never seen an PLP actually self educate. I doubt that most PLPs have ever picked up a medical journal or read a national guideline. I would love for a PLP to actually come up and say can we [do thing] because [national guidelines].

Want to be better at medicine than the vast majority of physicians? Start reading and applying guidelines. In my mind, it takes a lot of hubris to routinely say, "Hey, this group that's at the top of their specialty who studied thing and gave recommendations for working up and treating thing? The same people who can cite 100 studies about just that thing? Yep... they're wrong.

Nope... instead I have PLPs who keep ordering prealbumins for nutritional workups in ICU patients "because" despite there being an entire ASPEN position paper that can be summed up as, "albumin and prealbumin are inflammatory markers in acutely ill patients, not nutritional markers."

Sure, so and so other doc wants them... cool... same with antibiotics for aspiration. As mentioned, I'm not signing those doc's orders or charts. However it's always shocked Pikachu face when I ask, "What are the society guidelines for this disease?"

 

[RustedFox]

More importantly I've never seen an PLP actually self educate. I doubt that most PLPs have ever picked up a medical journal or read a national guideline. I would love for a PLP to actually come up and say can we [do thing] because [national guidelines].

Want to be better at medicine than the vast majority of physicians? Start reading and applying guidelines. In my mind, it takes a lot of hubris to routinely say, "Hey, this group that's at the top of their specialty who studied thing and gave recommendations for working up and treating thing? The same people who can cite 100 studies about just that thing? Yep... they're wrong.

Nope... instead I have PLPs who keep ordering prealbumins for nutritional workups in ICU patients "because" despite there being an entire ASPEN position paper that can be summed up as, "albumin and prealbumin are inflammatory markers in acutely ill patients, not nutritional markers."

Sure, so and so other doc wants them... cool... same with antibiotics for aspiration. As mentioned, I'm not signing those doc's orders or charts. However it's always shocked Pikachu face when I ask, "What are the society guidelines for this disease?"

I had one PLP back at Country Club Medical Center bring me an article to prove to me her point that "Clindamycin is no more risky for the development of c.diff than any other antibiotic."

She pointed to a graph and said: "See? SEE?! I'm right!"

She ignored the scale on the graph altogether.

The paper concluded the exact opposite of her assertion.

But damn, she can tell everyone that she has the "brain of a doctor, heart of a nurse".

I wanted to say something super ignorant to her. I even had "the thing" to say.

But I didn't.

 

[Splenda88]

Emergency Department Nonphysician Practitioners’ Diagnostic Imaging Ordering for Medicare Patients

This cross-sectional study evaluates differences in diagnostic imaging ordering patterns for Medicare patients seen in emergency departments by nonphysician practitioners vs physicians.

jamanetwork.com

 

[VeitVat]

seriously, as a rad, it's killing me. The list is evergrowing and having to read these essentially negative ct abd/pel on call kills me. Or am I just being dramatic and needs to STFU and just do my job?

or dont get me started on these CTA chest/CT abd/pel combos that gets ordered. Sweet baby jesus.

For the love of god, stop ordering so many exams.

Inshallah

I feel your pain. In *general* orders from attendings in er tend to be reasonable. But the lower down the totem pole you go, the more common the unnecessary testing.

From senior residents down to 1st years the percentage of bs increases.

Orders from a triage RN/NP/etc are 4/5 bull poop and a waste of resources. Seriously, no advanced testing orders should be written by anyone other than a physician.

 

[BoardingDoc]

I feel your pain. In *general* orders from attendings in er tend to be reasonable. But the lower down the totem pole you go, the more common the unnecessary testing.

From senior residents down to 1st years the percentage of bs increases.

Orders from a triage nukes are 4/5 bull poop and a waste of resources. Seriously, no advanced testing orders should be written by anyone other than a physician.

I'm surprised that's even a thing where you work. We have protocol orders that a triage RN can enter but thats things like "ekg, trop, CXR" for chest pain. There is no order set which contains CT/US/MRI

 

[turkeyjerky]

Ugh, felt kinda bad about my shift last night. Ordered something like 4 CT a/ps, all negative (well one showed gallstones, which I had figured clinically but he had a mild leukocytosis and I wanted some formal imaging showing no actual -itis). All kinda old people, nonspecific pain, pretty benign exams but w/ some combo of anxiety/weirdness/concerning comorbidities or mild wbc counts. I kept on thinking, "okay, this has to be the one. One of these patient has to have something going on"

 

[RustedFox]

Ugh, felt kinda bad about my shift last night. Ordered something like 4 CT a/ps, all negative (well one showed gallstones, which I had figured clinically but he had a mild leukocytosis and I wanted some formal imaging showing no actual -itis). All kinda old people, nonspecific pain, pretty benign exams but w/ some combo of anxiety/weirdness/concerning comorbidities or mild wbc counts. I kept on thinking, "okay, this has to be the one. One of these patient has to have something going on"

Right there. That's enough.

 

[maxxor]

Ugh, felt kinda bad about my shift last night. Ordered something like 4 CT a/ps, all negative (well one showed gallstones, which I had figured clinically but he had a mild leukocytosis and I wanted some formal imaging showing no actual -itis). All kinda old people, nonspecific pain, pretty benign exams but w/ some combo of anxiety/weirdness/concerning comorbidities or mild wbc counts. I kept on thinking, "okay, this has to be the one. One of these patient has to have something going on"

Don't feel bad. We forget about the case 10 minutes later when we are cursing because we have to call someone for a critical finding.

 

[TooMuchResearch]

Ugh, felt kinda bad about my shift last night. Ordered something like 4 CT a/ps, all negative (well one showed gallstones, which I had figured clinically but he had a mild leukocytosis and I wanted some formal imaging showing no actual -itis). All kinda old people, nonspecific pain, pretty benign exams but w/ some combo of anxiety/weirdness/concerning comorbidities or mild wbc counts. I kept on thinking, "okay, this has to be the one. One of these patient has to have something going on"

It's okay, you're probably due for a shift in which even your low probability studies show actual pathology.

 

[GonnaBeADoc2222]

I feel your pain. In *general* orders from attendings in er tend to be reasonable. But the lower down the totem pole you go, the more common the unnecessary testing.

From senior residents down to 1st years the percentage of bs increases.

Orders from a triage RN/NP/etc are 4/5 bull poop and a waste of resources. Seriously, no advanced testing orders should be written by anyone other than a physician.

Sounds good. I don't want any of your residents reading studies or calling me. Only attendings.

 

[Neopolymath]

You guys invented real life x-ray vision PLUS a way to make a s* *t-ton of money by looking at pictures without having to interact with humanity. You should be jumping up and down for joy, popping champagne bottles, celebrating that the plan workout, NOT complaining because the plan worked too good.


"Up in the hot tub, poppin' bubbly...
...I don't wanna be a player no more
I'm not a player, I just crush a lot" - Big Pun, Still Not A Player

As a resident I view it as practice when the same person orders CTAs on everyone that are always negative. I came into medicine pre-jaded so I don't think my view as an attending will change. As an attending they will just be boat fund money instead of practice and speed building. No beef with the ED aside from a few people that order the incorrect type exam over and over despite education. The bottom line is that the patients are the problem (hence radiology).

 

[doctalaughs]

I feel your pain. In *general* orders from attendings in er tend to be reasonable. But the lower down the totem pole you go, the more common the unnecessary testing.

From senior residents down to 1st years the percentage of bs increases.

Orders from a triage RN/NP/etc are 4/5 bull poop and a waste of resources. Seriously, no advanced testing orders should be written by anyone other than a physician.

Same thing in derm. Malignant : non-malignant pathology for biopsies with board certified dermatologists tends to be about 1:4 whereas for extenders 1:10.

They cost the practices less, but the system not so much. And the patients are stuck with the costs (and the scars).

 

[collegestud2013]

When I cover the ER, I don't complain about what the ER is ordering. That's like hating on your colleagues, man. They can't control what comes in the door any more than we can control what pops on the list.

Instead, I complain when the volume is too high to do a good job and that whoever is making radiology staffing decisions is cheaping out on patient care and contributing to burnout.

Multimillion ER radiology malpractice verdicts are getting more common. I remember when the missed lung cancer chest X-ray was $16 million in MA; now we have this $75 million one hanging in the air.

Everyone is citing high EM malpractice risk as a reason for ordering tests that are not really indicated if going by guidelines, or admitting patients that probably could be reasonably discharged. In reality, according to this study EM malpractice risk is similar to that as the average physician when compared to other specialties (Malpractice Risk According to Physician Specialty); it's the surgical specialties that have the highest malpractice risk. Also, studies have shown that the probability of losing personal assets in a malpractice lawsuit (ie someone successfully sues above your malpractice insurance coverage limits), while not zero, is extremely rare and probably almost as low as winning the lottery.

 

[maxxor]

Everyone is citing high EM malpractice risk as a reason for ordering tests that are not really indicated if going by guidelines, or admitting patients that probably could be reasonably discharged. In reality, according to this study EM malpractice risk is similar to that as the average physician when compared to other specialties (Malpractice Risk According to Physician Specialty); it's the surgical specialties that have the highest malpractice risk. Also, studies have shown that the probability of losing personal assets in a malpractice lawsuit (ie someone successfully sues above your malpractice insurance coverage limits), while not zero, is extremely rare and probably almost as low as winning the lottery.

My contention is that the work environment has changed drastically for hospital associated specialties, such as ER, hospitalist, and radiology, to the point where safe practice may or may not be possible given staffing shortages.

I think comparing malpractice rates pre-covid vs post-covid will be interesting in the coming years.

Surgeons and more "elective" specialties have arguably more control over their patient volumes and are less affected by these changes.

 

[bravotwozero]

It isn’t just malpractice, there’s also the issue of patient satisfaction scores…

 

[Dred Pirate]

Were they??

I mean, AngryBird and I would joust with regularity.

If you read the posts, Lafleur and I even agreed to the donnybrook beforehand like two hockey players observing "the code".

Guy get booted, and here I am defending him.

I think the mods get off on a power trip of booted random anonymous people on a message board - I get it is a volunteer thankless job- but seriously, just let people be people - it isn't like this is twitter and millions of people are using this. As long as you don't give out bad medical advice, just let people express their opinions.

 

[NYEMMED]

Everyone is citing high EM malpractice risk as a reason for ordering tests that are not really indicated if going by guidelines, or admitting patients that probably could be reasonably discharged. In reality, according to this study EM malpractice risk is similar to that as the average physician when compared to other specialties (Malpractice Risk According to Physician Specialty); it's the surgical specialties that have the highest malpractice risk. Also, studies have shown that the probability of losing personal assets in a malpractice lawsuit (ie someone successfully sues above your malpractice insurance coverage limits), while not zero, is extremely rare and probably almost as low as winning the lottery.

I would rather not spend 5-7 years of my life in a lawsuit over ordering or not ordering a CT. Until the government gives tort reform, Defensive medicine will continue.

 

[Neopolymath]

The people (patients) have chosen *drumroll* and they have chosen radiation!

 

[southerndoc]

It isn’t just malpractice, there’s also the issue of patient satisfaction scores…

You fail to mention how it's not just patient satisfaction scores, but how performance on those scores can be tied to both compensation as well as job security.

The testing is multifactorial. I can spend 10 minutes educating someone why they don't need a CT of their head for their trivial traumatic injury, and by doing so I delay seeing the next patient and then I have 2 patients ticked off (the one who I "refused" to order a CT on and the patient who has to wait to be seen as if 10 minutes is going to kill them for their ingrown toenail)... or I can just simply tell them they don't meet criteria, and if they seem hesitant in the least bit, just order the CT and move on.