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sese

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There's been a lot in the general news lately about physician groups advocating (or educating the general public) about unnecessary testing or treating. http://www.choosingwisely.org

IM, FM, radiology, ENT, among other groups are involved in formulating their own lists related to their specialty.

Noticed that ACEP is not part of the orgs involved in this.

Some things (like imaging for low back pain without red flags, abx for sinusitis, CT for headache) touch on our domain as well.

What other things that we do in EM are perhaps unnecessary and over-utilized?

Think we in EM should start talking about this as well before other groups tell us what is and isn't needed in the ED setting.
 

Rendar5

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Reducing imaging would be great if we could also limit liability. The american public has made it clear that they want to pay less for their cake and to sue for it too if they don't like the cheaper cake.
 

GeneralVeers

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Reducing imaging would be great if we could also limit liability. The american public has made it clear that they want to pay less for their cake and to sue for it too if they don't like the cheaper cake.

Americans always want MORE imaging when they come in. They think that every cough and cold they get is like a case on House M.D. and expect lots of mood lighting, fancy tests, and dramatic dialogue.

I've gotten in trouble from patient complaints numerous times for not ordering that head CT on the fall-down-go-boom, the chest X-ray on the bronchitis, or the MRI on their back strain they've had for one day.

The biggest single thing we could do to make medical care better, and our lives easier would be to get rid of the "customer service" aspect.
 

Paradise Lost

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Between the liability that we shoulder combined with the heavy emphasis on patient satisfaction, it is much more difficult to decrease low yield testing/treatment. Working in a population where the majority of patients seen have insurance, I find that most non-critical patients come to the Emergency Department with a set of expectations and want us to "do" something or they will be quite unhappy with us. Thus, we generally give in on many demands and get the unnecessary x-ray/blood tests/etc. I've also been amazed at the number of patients demanding uncomfortable procedures such as lumbar punctures because webmd or a "friend" in the medical field told them they have symptoms of meningitis. Even after performing a comprehensive history and physical and less invasive tests and explaining the low utility of the requested test, patients still want it because that is what they came for and their insurance will pay for it. Aargh .:boom:
 

Interpolfanclub

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There is much truth in this thread. I don't want to hear anything about reduced testing and conservation of resources until MDs providing govt mandated emergency care get some legal protection. With regard to pt demanded testing I almost always do it. There's just no real upside to being a wall and refusing. It pisses off the patient, ticks of their PCP if they sent them to the ED, generates pt complaints and if you actually do miss something you look like an idiot. The only tests I'll generally refuse to do are US for DVT or MRI for just about anything that doesn't need it. Those two resources where most people practice are too precious to waste on BS. If I don't think the pt needs an MRI or US I go through in great detail why they don't, what I usually get MRIs for in the ER (can't walk, cancer back pain etc) and the pt usually agrees. I don't think I've ever had anyone storm out after I explain why I think they don't need it. I'll also use my iphone to go through the wells dvt score with them when I think they're zero. And the patient goes, well, I don't have any of that stuff so you're right, I don't need this US. Lately I've noticed everyone with any sort of leg pain thinks they have a clot and their neighbor's brother's cousin's whatever told them to go straight to the ER and get an US. /end rant.
 
D

deleted109597

I probably spent 20 minutes arguing with someone about getting an ultrasound on their husband's leg because they were concerned.
The catch is, they had been diagnosed with a DVT less than 4 weeks ago, and were therapeutic on Coumadin. Nothing I could say would explain to this patient's wife the complete uselessness of the testing. Finally the patient literally said "Shut up, (wife's name), I want to go home, and he's got a point."
I still wonder if I'm going to get a bad press ganey from that one.
 

GeneralVeers

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I probably spent 20 minutes arguing with someone about getting an ultrasound on their husband's leg because they were concerned.
The catch is, they had been diagnosed with a DVT less than 4 weeks ago, and were therapeutic on Coumadin. Nothing I could say would explain to this patient's wife the complete uselessness of the testing. Finally the patient literally said "Shut up, (wife's name), I want to go home, and he's got a point."
I still wonder if I'm going to get a bad press ganey from that one.

This is the kind of situation that gets me. Customer service is not appropriate in the Emergency department. We are not entering into a business transaction with our patients, as many don't pay out of pocket or anything at all. Furthermore patients don't have the ability to understand the tests, or the need for the test.

Imagine if we sold Ferraris. Any old person could walk off the street, demand a "free Ferrari" and our boss (hospital admin and CMS) would tell us to give them the free Ferrari in order to promote good customer service scores, and encourage the customer to come back for even more free Ferraris in the future. It wouldn't matter if they knew how to drive a Ferrari, could afford insurance, or even had a driver's license. We would still have to give it to them. That is our business model. Is it any wonder we are going bankrupt as a country?
 

WilcoWorld

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I truly feel the pain of the above posters, but I would also say that this represents a great (although admittedly a little underhanded) indication for ED Ultrasound. The patients expect a fancy test, but, as you complaints prove, not necessarily the right test. A bedside US (renal/echo/venous duplex, whatever)can go a long way towards satisfying these folks. I've also found that a thorough neuro exam (don't skimp on the weird parts like heel-to-shin, vibratory sensation, rapid alternating movements) can go a long way towards avoiding a head CT.

The MRI for back pain though - I have no tricks for that one (but keep in mind that frequent flyers don't get PG surveys).

To address the original point of decreasing unnecessary utilization:
There are certain conditions where the data is so good that it's rather inexcusable to not try to avoid testing when appropriate:
Pediatric head CT : PECARN
Ankle & Knee : Ottawa
C-Spine : take your pick
Strep : Centor criteria
 

keeping-it-real

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Americans always want MORE imaging when they come in. They think that every cough and cold they get is like a case on House M.D. and expect lots of mood lighting, fancy tests, and dramatic dialogue.

I've gotten in trouble from patient complaints numerous times for not ordering that head CT on the fall-down-go-boom, the chest X-ray on the bronchitis, or the MRI on their back strain they've had for one day.

The biggest single thing we could do to make medical care better, and our lives easier would be to get rid of the "customer service" aspect.

this might be the best post I've read on SDN. anybody in community EM knows exactly how true these statments are.
 

docB

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I probably spent 20 minutes arguing with someone about getting an ultrasound on their husband's leg because they were concerned.
The catch is, they had been diagnosed with a DVT less than 4 weeks ago, and were therapeutic on Coumadin. Nothing I could say would explain to this patient's wife the complete uselessness of the testing. Finally the patient literally said "Shut up, (wife's name), I want to go home, and he's got a point."
I still wonder if I'm going to get a bad press ganey from that one.

It depends on who fills out the survey, the husband or the wife. That's the fact and no amount of BS from the annoying service recovery consultants can change it.
 

GeneralVeers

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It depends on who fills out the survey, the husband or the wife. That's the fact and no amount of BS from the annoying service recovery consultants can change it.

I've given up even looking at my Press-Ganey surveys. Most days I feel as though I'm singlehandedly preventing the department from collapsing. I don't have time to wipe people's bottoms or be a cocktail waitress.
 
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