Least Shocking Study ever

[sum dude]

http://well.blogs.nytimes.com/2015/11/04/defensive-medicine-may-lower-malpractice-risks/?_r=0

I am by no means advocating ordering more, it's damned if you do, damned if you don't in our field. What kills me is Legislature seems unwilling (outside of Texas, anyways) to address this, with many clinging to the world is flat/global warming is made up/defensive medicine doesn't exist logic (or wait, maybe it costs $650 Billion a year, who knows?)

Still waiting for the day we consider No-fault in the US (while I drive my kids to school in our magical flying unicorn which bypasses all traffic).

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[The White Coat Investor]

Wow! I would never have guessed malpractice risk would be 5 times lower for the heavy orderers. Not a perfect study, but man, I found it at least a little shocking. I would have thought that all those extra tests didn't actually lower the risk of being sued despite many of us doing it.

 

[Old_Mil]

The reality is that not all disease presents with classic signs and symptoms. Patients lie about their medical history, social history, and symptoms. If you go by history and physical alone it is cheaper, but you are practicing 19th century medicine and will miss a larger percentage of diagnoses than if you test...and everything from missed diagnoses to unavoidable bad outcomes results in lawsuits.

I guess I am surprised that people who order less are only 5x as likely to be sued given the lack of self awareness among patients about their own health. Honestly with some of these people it is like being a veterinarian. "Do you take any medicines?" "I take a red pill in the morning." "Do you know the name, or what it is for?" "No." Seriously? You were sick at one point and you went to a doctor who gave you medicine and you are dutifully taking this with no idea what it is for or even what it is called? A little ownership maybe?

As always, protect your life and license first. Your job isn't to save the system.

 

[erdoc00]

The thing about ordering tests is that every once in a while you'll be humbled by an unexpected result. The bottom line is that many people would be fine if we did nothing. If you simply play the probabilities you can be pretty good about not missing things. But you're playing with fire and taking chances.

I had an obese 30 yo man that had intemittent chest pain for a week and was comfortable with normal vitals except for a slight tachycardia; he ended up having an aortic dissection and I got lucky because I was scanning for a PE because he had a minimally elevated ddimer. I guarantee many of my coworkers wouldve missed this because they often aren't too worried about young people with chest pain and often times rule out "badness" with just a cxr and ekg +/- trop. I've also picked up several posterior CVAs by being liberal with MRIs for vertigo; I've also seen several missed posterior CVAS by colleagues who's line of thinking was "it's more likely peripheral" and sent the pts home. I've also had a positive appendicitis in a young guy with 4 years of intermittent rlq pain and an unimpressive exam; the only reason I scanned him was because his WBC was slightly elevated at 11.x and he specifically was worried about appendicitis because he read about it online.

Everyone is entitled to practice how they want. I figure though that by the making the decision to come to the ER, pts want everything possible done to evaluate them. I don't care about saving the system money since the system doesn't give a crap about us. And I used to feel bad about the radiation from excessive scans but I've finally come to the point that I didn't create the problem of unrealistic expectations and I'm not going to burn at the hands of some idiot lawyer because I was unlucky and missed something that would've been caught by a scan but where there was no real indication for a scan.

Until we have the ability to use good medical judgement without being penalized for an unexpected miss, I will continue to over test. Not my fault...not my problem.

 

[gman33]

One issue with "over testing" is where do you stop?
I mean from a malpractice standpoint.

Young chest pain with no risk factors. CXR, EKG. Do you get a trop? If you do, full r/o and stress test?
Some med mal guys will say if you start the workup you need to finish it.

Same with vertigo. I see some people getting CT scans and d/c.
We all know the CT scan will probably not show a posterior lesion.
If you are looking for central cause, why didn't you get an MRI?
Would you be better with H&P and d/c if nothing points to central cause?

Based on odds, young people are less likely to have anything serious, but those missed are a disaster from med mal.
I try to do what I think is best for the patient, and I think most patients like when we get tests.
If the patient doesn't want something, I have a conversation and document refusal and capacity.
If i'm really concerned they may get an AMA, which I'm not sure really helps.

I am at the beginning of my career.
I probably order too much stuff.
That may change, it may not.

 

[southerndoc]

Over testing will be significantly reduced in a few years when CMS ties CT utilization rates with pay. Order more CT's than your peers at similar institutions matched for volume and trauma/stroke designation and you'll have your reimbursements decreased.

No, that is not a typo.

 

[LaBusqueda]

Over testing will be significantly reduced in a few years when CMS ties CT utilization rates with pay. Order more CT's than your peers at similar institutions matched for volume and trauma/stroke designation and you'll have your reimbursements decreased.

No, that is not a typo.

I have caught wind of this, but in the "rumor mil" type of conversation. It does seem like a logical albeit dumb progression of CMS but does anyone really know if this is an actual policy decision coming up yet?

 

[Hercules]

I have caught wind of this, but in the "rumor mil" type of conversation. It does seem like a logical albeit dumb progression of CMS but does anyone really know if this is an actual policy decision coming up yet?

Yes this is real with value based modifiers going into effect in 2017. Its not as simple as just CT utilization but it will basically be looking at how cost effective you are. If you get the chance you should try to get your QRUR to take a look at where your group would fall if they applied it now. Now the kicker is that they don't say what that x variable will be with respect to the modifier. See the chart above.

 

[TooMuchResearch]

View attachment 197666

Yes this is real with value based modifiers going into effect in 2017. Its not as simple as just CT utilization but it will basically be looking at how cost effective you are. If you get the chance you should try to get your QRUR to take a look at where your group would fall if they applied it now. Now the kicker is that they don't say what that x variable will be with respect to the modifier. See the chart above.

I was reading the cms information on this a couple weeks ago and maybe was too tired but decided it was way over my residently head.

 

[GeneralVeers]

The 30 yo with aortic dissection had tachycardia. That's always a red flag. Even as a "minimalist" I wouldn't ignore it. Usually I document: "Young healthy male with normal vitals, normal exam, no risk factors for CAD/PE and in no distress". If I can't document all of that, then I probably will do some additional workup on them.

 

[Old_Mil]

Over testing will be significantly reduced in a few years when CMS ties CT utilization rates with pay. Order more CT's than your peers at similar institutions matched for volume and trauma/stroke designation and you'll have your reimbursements decreased.

No, that is not a typo.

Glad you brought this up. I don't know that too many people are aware of it yet. Basically it gives you the job of rationing care while leaving you on the hook for what you miss from a liability perspective.

 

[shoal]

Do you guys ddimer every patient with chest pain and tachycardia without shortness of breath, hypoxia, tachypnea, risk factors, signs or symptoms of dvts?

I find this very challenging as a new attending. I havent been when i think they are low risk and document as such.

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[WilcoWorld]

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[coachB]

Do you guys ddimer every patient with chest pain and tachycardia without shortness of breath, hypoxia, tachypnea, risk factors, signs or symptoms of dvts?

I find this very challenging as a new attending. I havent been when i think they are low risk and document as such.

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Really? Challenging? Would you order a CTA on all of these patients? That is how you should be looking at it. Do you understand basic pre-test and post-test possibilities and the test characteristics of a d-dimer assay? At least it sounds like your current practice is reasonable. Have a reason for ordering a test or explain your reasons for not ordering it D-dimer continues to be one of the most misused tests out there.

 

[shoal007]

Coachb, that is what i am doing. I understand pre test prob. The problem is the patient is not PERC negative therefore i cannot rule out PE to less then CTA false negative rate. I use my gesalt but now out in the community every fricken chest pain has tachycardia in the low 100s which usually resolves prior to dc. But PERC clearly states any episode of tachycardia they cannot be ruled out clinically. If om not going to order a CTA on them if i didnt have a ddimer i dont order the ddimer. But im not sure if this leaves me opeb to litigation

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[southerndoc]

Glad you brought this up. I don't know that too many people are aware of it yet. Basically it gives you the job of rationing care while leaving you on the hook for what you miss from a liability perspective.

Yep, gotta be a perfect doc. Don't order too many, but can't miss anything either (don't want the lawsuits or the complaints). C-suite wants it both ways.

 

[Vandalia]

One issue with "over testing" is where do you stop?
I mean from a malpractice standpoint..

That is the question isn't it?

This is how I view it: Anyone can be sued for any reason. However, I have malpractice insurance, and no one really cares when it comes to looking for a new job if you have been sued or not. And I honestly don't care what a group of around 12 people "so stupid they couldn't think of a way to get out of jury duty" think about my practice of medicine. Could I be hit with an above-coverage-limit suit? Sure. But then again a meteor could come through the wall of my house. (Did you know if a meteor comes through the roof of your house you are covered, but if it comes through the wall you are not? We got drunk one night in college and started reading our renter's insurance policy. Anything can be funny with enough ethanol.)

However, long ago I decided that if I am sued, it will be for doing what I wanted to do. There is one thing worse than being sued for a decision you are completely comfortable with; being sued for doing something you thought was stupid in the first place. Sue me for not ordering a stress-test on a 21 year old with chest soreness (and everything negative) who was hit in the chest with a football? Fine. However, I don't want to be sued for ordering the stress-test in that case. Something I knew was stupid but did simply to make someone else (like a malpractice attorney) happy.