winkleweizen

7+ Year Member
Apr 10, 2011
801
45
Status
Attending Physician
Have any of you guys started withholding abx? I've wanted to, but it's just not common practice where I'm from and Id be the odd one out.
 
D

da8s0859q

Have any of you guys started withholding abx? I've wanted to, but it's just not common practice where I'm from and Id be the odd one out.
I am aware that there is (some varying quality) evidence to argue for rest, fluids, judicious diet, symptomatic management, etc., for uncomplicated diverticulitis without oral antibiotics if truly uncomplicated.

That said, I would not do this. Nope.

"Doctor, Mr. Jones was seen in your emergency department for intractable nausea, vomiting, and pain, and he ultimately had a repeat CT scan which showed perforated colon which required surgery. As you know, he had a long, complicated hospital stay afterward. Can you tell us why you decided to not prescribe antibiotics -- a common mainstay of treatment in most places -- when you diagnosed him with diverticulitis earlier that week?"

Would it had perforated regardless of what you did? Maybe. Can you prove it either way in the face of current routine care which I would argue approaches "standard"? Good luck.
 

WildcatS11

10+ Year Member
Jul 17, 2009
111
121
Status
Resident [Any Field]
Have any of you guys started withholding abx? I've wanted to, but it's just not common practice where I'm from and Id be the odd one out.
"Never be the first person or the last person to adopt a new treatment/strategy/procedure/etc" is a good rule to live by. This seems to be pretty early on. Like the poster above, not really standard of care yet.
 

gro2001

SOCMOB
10+ Year Member
Jul 4, 2006
1,055
806
the desert
Status
Attending Physician
You have to stick with whatever the culture is at your institution. If you feel strongly about this issue, you should work on an institutional level to make the change. Options could be to reach out to your chairman to get him on board. Then at a departmental meeting, present the research you think is compelling enough to change practice. Then, if your chair and departmental colleagues are on board, you have to reach some sort of understanding with the other stakeholders (IM and surgery folks, maybe some of the PCPs in the community). Just going rogue and doing something no one else in your community agrees with or has even heard of will get people (MDs) pissed and make the patients feel they got subpar care from you when they hear from their PCP: "The ER did WHAT?!"
 
  • Like
Reactions: Makati2008

emergentmd

10+ Year Member
Jul 6, 2008
1,473
1,612
Status
Attending Physician
Have any of you guys started withholding abx? I've wanted to, but it's just not common practice where I'm from and Id be the odd one out.
I don't care what evidence says. I do not change my practice unless something is universally accepted and practiced. Its great being a pioneer but not when there is a bad outcome. If you don't treat uncomplicated diverticulitis, you will get 2 bad outcomes

1. Pt talks to family or does an internet search and complains to admin that you are a bad doc.
2. Pt comes back with a Perf tic, has a colectomy, ostomy or even worse death. Good luck pulling up "good reasearch articles"
 

goodoldalky

Member
10+ Year Member
Jul 6, 2006
555
369
Status
Attending Physician
If you want to try to cut back on abx usage, there is a lot lower hanging fruit than this. Like, colds.
 
OP
W

winkleweizen

7+ Year Member
Apr 10, 2011
801
45
Status
Attending Physician
If you want to try to cut back on abx usage, there is a lot lower hanging fruit than this. Like, colds.
Hopefully most people aren't prescribing them for colds or at least are making an effort not to
 

gman33

Moderator Emeritus
10+ Year Member
Aug 18, 2007
2,188
496
Status
Attending Physician
I'm not quite there with no abx for a ct proven diverticulitis.

I do believe the evidence is decent that there is no benefit, but if they have complications, you are going to be on the hook.

I have however become less likely to get a ct if that's what I think is going on. No ct,
No proof, no abx.

I'm also more likely to send tics home, since I don't believe the hospitalization and iv abx will add anything to their care.
 

Arcan57

Junior Member
15+ Year Member
Nov 21, 2003
2,860
1,301
Visit site
Status
Attending Physician
I'm not quite there with no abx for a ct proven diverticulitis.

I do believe the evidence is decent that there is no benefit, but if they have complications, you are going to be on the hook.

I have however become less likely to get a ct if that's what I think is going on. No ct,
No proof, no abx.

I'm also more likely to send tics home, since I don't believe the hospitalization and iv abx will add anything to their care.
And your peer review is fine when they bounce back with complications after a documented tender abdomen?
 

Psai

This space for lease
Removed
5+ Year Member
Jan 2, 2014
11,519
23,501
ヽ(´ー`)ノ
Status
Resident [Any Field]
Hopefully most people aren't prescribing them for colds or at least are making an effort not to
I know a pcp who sends antibiotics with his patients when they go on vacation as a just in case they don't feel good
Patients love him though
 

BoardingDoc

Don't worry. I've got my towel.
7+ Year Member
Feb 23, 2010
1,325
1,896
Status
Attending Physician
  • Like
Reactions: Makati2008

Arcan57

Junior Member
15+ Year Member
Nov 21, 2003
2,860
1,301
Visit site
Status
Attending Physician
Well, yeah. This one is pretty clear. Outpatient treatment of diverticulitis is common.
"Doing something" doesn't prevent complications, and can create some if done wrong.
Outpt treatment that doesn't include abx? Your hospital's peer review committee must have a different make up from mine. Most are medicine subspecialists that only remember things outside their field at a med student level and the rest are surgeons that vividly remember every single soft admit they've ever taken and are incredulous whenever anything bounces back because they think we admit everyone.
 

WilcoWorld

Senior Member
10+ Year Member
Nov 2, 2004
3,032
1,803
Status
This is an opportunity for shared decision making. Same with tamsulosin in renal colic, discharging low risk CP, etc. I know what the literature says, but many of my consultants (with whom the patient will follow up) don't. If I employ shared decision making and discuss the risks and benefits in the ED, when the Urologist says "The ED didn't give you Flomax!" the patient can say "well, they told me it didn't help most people, and I was afraid of getting lightheaded and falling". Unilaterally deciding to implement the latest EM Rap-endorsed development is asking for a lot of Monday morning emails.

Personally, I'm still rx'ing ABX for diverticulitis most of the time. We work in an interventionist-minded society. I'll advocate for a wiser approach at faculty meeting and interdepartmental conferences, trying to get a new policy on the books. But when I'm treating Sally Individual on Saturday night, I go by the book (the best, most up to date, book we have, but still by the book).
 
Last edited:

Dr.McNinja

Nobel War Prize Winner
Moderator
10+ Year Member
Aug 2, 2006
10,288
6,961
Texas
Status
Attending Physician
Outpt treatment that doesn't include abx? Your hospital's peer review committee must have a different make up from mine. Most are medicine subspecialists that only remember things outside their field at a med student level and the rest are surgeons that vividly remember every single soft admit they've ever taken and are incredulous whenever anything bounces back because they think we admit everyone.
Oh, you weren't clear about the Abx or no Abx.
But yeah, you're right about your (and my) colleagues. So I do shared decision making with the patient, and yes, if it came to it, I have plenty of literature to back up my viewpoint. I've been called to peer review for giving TXA, and they threatened to do it for not giving tPA one time. I would rather practice good medicine than make other people happy. They don't have to look at themselves in the mirror at night.
 
  • Like
Reactions: winkleweizen

emergentmd

10+ Year Member
Jul 6, 2008
1,473
1,612
Status
Attending Physician
Your choice is give abx and everyone is happy (5 min) vs not giving in 95% of URI and having 1/3 of those pts thinking you suck, complain, or get worse then get abx (15 min trying to educate)

I will let you decide your practice. You do realize that people who are actually educatable will not go to the ED for URIs. Those that comes want abx.

Thats like a mcdonalds cashier telling 75% of the customers that they don't need fast food b/c thats the vast majority of their customers. I never go to mcdonalds and if I was FAT, I would appreciate someone not selling me a big mac. But those that shows up to Mcdonalds are uneducatable. No different than the ED.

My sanity/well being is of utmost importance to me.
 

Arcan57

Junior Member
15+ Year Member
Nov 21, 2003
2,860
1,301
Visit site
Status
Attending Physician
Your choice is give abx and everyone is happy (5 min) vs not giving in 95% of URI and having 1/3 of those pts thinking you suck, complain, or get worse then get abx (15 min trying to educate)

I will let you decide your practice. You do realize that people who are actually educatable will not go to the ED for URIs. Those that comes want abx.

Thats like a mcdonalds cashier telling 75% of the customers that they don't need fast food b/c thats the vast majority of their customers. I never go to mcdonalds and if I was FAT, I would appreciate someone not selling me a big mac. But those that shows up to Mcdonalds are uneducatable. No different than the ED.

My sanity/well being is of utmost importance to me.
Would be nice to expect more than a McDonald's cashier attitude towards the patient.
 

Daiphon

Semper Ubi Sub Ubi
15+ Year Member
Nov 6, 2003
989
259
The Windy City
Status
Attending Physician
Would be nice to expect more than a McDonald's cashier attitude towards the patient.
Would be nice to expect more than a McDonald's customer attitude *from* the patient.

Semper Brunneis Pallium
 

Arcan57

Junior Member
15+ Year Member
Nov 21, 2003
2,860
1,301
Visit site
Status
Attending Physician
Would be nice to expect more than a McDonald's customer attitude *from* the patient.

Semper Brunneis Pallium
It would, although the McDonald's cashier is getting a lot less money out of the transaction and the McDonald's customer is paying a lot less than the patient. The idea that 1/3 of patients get pissed about not getting abx for a URI or that it takes 15 min to explain why you're not giving them is BS, though. If you want to make tons of money off them coming back every 3-5 days until their cough resolves you could definitely template something like:
1) Visit 2 - CXR (which will be neg), change from azithro/ amox to augmentin or omnicef, tessalon perrles
2) Visit 3 - add steroids, +/- albuterol inhaler
3) Visit 4- repeat CXR, change inhaler to nebulizer, add on narcotic cough medication
4) Visit 5- loudly complain to everyone how stupid the patient is and how frustrated you are that the keep coming back when there's nothing you can do for them. Collect $200 copay while bemoaning the idiocy of the public.
 

e30ftw

peace
7+ Year Member
Feb 23, 2012
485
383
Status
Attending Physician
Agree with the above sentiment to practice within standard of care at your facility. If you are a frequently published academician with millions in NIH funding and sit on committees etc, fine, deviate as your peer review allows. For the vast majority of community docs, we will practice within the "standard of care" of our respective facilities, which for uncomplicated diverticulitis means abx.

Regarding the URI/abx scenarios in adults, I attempt to make the patient happy as well as provide education. I tell them their history/exam/vs point towards a viral syndrome, antibiotics are unlikely to be beneficial, and that there are potential side effects to all medications. If the patient strongly wants a zpack/amox I write the Rx without resistance then instruct them not to fill unless symptoms persist > 7 days and to see their pcp. The only time I make exception is in pediatric patients with a clear viral source and no other indication for abx. In which case I cannot justify the side effects of unnecessary abx in a pediatric patient who lacks medical decision making capacity to satisfy the psychological needs of their parent.
 

GeneralVeers

Stable Genius
10+ Year Member
Mar 19, 2005
5,470
3,136
Las Vegas
Status
Attending Physician
Patients love being told they have an "infection" and love it even more when you tell them the cause, in this case "diverticulitis". They love it even more when you give them a treatment: "antibiotics" and they get better.
 
  • Like
Reactions: Angry Birds and exi

Janders

Senior Member
15+ Year Member
May 23, 2002
669
333
38
BOSTON
Status
Honestly, I find 80% of people are just fine being told their URI is viral and that we have a long list of things that might help their symptoms, but it is very likely abx will only-->
cost them money
give them a rash
give them a yeast infection
make them prone to MRSA and CDIFF
Get them better in six days, instead of half-a-dozen days.

So suggest symptomatic relief, if needed Rx an albuterol inhaler or Ibuprofen 600mg, or cough-med-which-isn't-better-than-honey-but-looks-like-medicine. And if they work a hateful, difficulty job give them a work note for 1-2 days.

And frankly 10% of patients probably do deserve abx (big smokers, symptoms >1 week, etc).

Which leaves about 10% who will potentially piss-and-moan. I haven't found these people create enough racket with admin and press gainey to worry about. Abx stewardship is a topic of interest, and responsible prescribing with occasionally irritated patients is A-OK.


I find the diverticulitis question very different, vis-a-vis our current knowledge base and practice standards. Maybe in 15 years we'll be typing what I wrote above about Cipro/Flagyl for divertic...
 

WilcoWorld

Senior Member
10+ Year Member
Nov 2, 2004
3,032
1,803
Status
Honestly, I find 80% of people are just fine being told their URI is viral and that we have a long list of things that might help their symptoms, but it is very likely abx will only-->
cost them money
give them a rash
give them a yeast infection
make them prone to MRSA and CDIFF
Get them better in six days, instead of half-a-dozen days.

So suggest symptomatic relief, if needed Rx an albuterol inhaler or Ibuprofen 600mg, or cough-med-which-isn't-better-than-honey-but-looks-like-medicine. And if they work a hateful, difficulty job give them a work note for 1-2 days.

And frankly 10% of patients probably do deserve abx (big smokers, symptoms >1 week, etc).

Which leaves about 10% who will potentially piss-and-moan. I haven't found these people create enough racket with admin and press gainey to worry about. Abx stewardship is a topic of interest, and responsible prescribing with occasionally irritated patients is A-OK.


I find the diverticulitis question very different, vis-a-vis our current knowledge base and practice standards. Maybe in 15 years we'll be typing what I wrote above about Cipro/Flagyl for divertic...

I often start my URI encounters by saying something like "I reviewed your chart and I see that you've got a really bad cough. I want to ask you some questions and do an exam so we can see if you need antibiotics, or if it's the sort of thing that antibiotics won't help." This doesn't work for everyone, but I've found that acknowledging the gorilla in the room at the beginning helps a lot of patients accept the no ABX discharge at the end.
 
  • Like
Reactions: hundreddaysoff

VA Hopeful Dr

Senior Member
15+ Year Member
Jul 28, 2004
20,351
26,071
Status
Attending Physician
I often start my URI encounters by saying something like "I reviewed your chart and I see that you've got a really bad cough. I want to ask you some questions and do an exam so we can see if you need antibiotics, or if it's the sort of thing that antibiotics won't help." This doesn't work for everyone, but I've found that acknowledging the gorilla in the room at the beginning helps a lot of patients accept the no ABX discharge at the end.
Truthfully, I get much less irritated with EM docs giving out antibiotics more freely than I do with us PCP types - y'all don't have an established relationship, they can't get back in touch with you in 2-3 days if they aren't any better, and are likely already ticked off being in the ED in the first place. Plus, in terms of sheer numbers your prescribing is a drop in the bucket compared to ours.
 

gro2001

SOCMOB
10+ Year Member
Jul 4, 2006
1,055
806
the desert
Status
Attending Physician
I am a little less angsty about patients demanding antibiotics for the URI or being upset when they are denied than I used to be. I realized a couple of things:

1) There is some benefit. We (physicians) tend to parrot that there is no benefit, but actually there is some mild benefit to giving antibiotics for undifferentiated URI. It's only about a day of symptoms, but for some people that's a day of misery and lost income. Yeah, we know that the benefit is outweighed by the risks, but ignoring that there is actually a benefit doesn't help understand the patients perspective.

2) My patients are different. They aren't like the ones in the studies because the smoke more, are sicker, and have less access to a PCP. A lot of the studies that the systematic reviews are based on have excluded these people.

3) The system sucks. There isn't an easy or cheap way for a lot of people to come back in case your plan of "lets wait and see, I'm sure you will get better" doesn't work. Its time consuming and expensive to see a doctor and they can't exactly follow up with you for a question. Even a lot of PCPs aren't available to answer questions by phone or email. You need to make another appointment and come back and pay another copay to get the prescription in case you are still coughing 2 weeks later. Yeah, a lot of the ER docs have the attitude of "oh whatever, they will just come back to the ER, no one pays their bills anyway", but having been uninsured and ill recently, I can tell you that that's BS. A complete degenerate who doesn't pay any bill might come back every day, but lots of people who really should come back because the initial treatment plan didn't work, don't due to fear of another huge bill.
 

emergentmd

10+ Year Member
Jul 6, 2008
1,473
1,612
Status
Attending Physician
EM docs are different. I get one shot to treat pts. Thus I tend to order more, prescribe more.

If I were to see the pt in 2 dys in the ED if not better, I likely would forgo abx. But I get one shot, thus I usually take out a bigger shotgun than more PCPs.

Sorry but that is FACT. There is a reason all 60+ belly pain almost always gets a CT in the ED while most don't in their PCP office. So those who judge my overprescribing abx should look themselves in the mirror when they order more labs, imaging than really is necessary.
 

Apollyon

Screw the GST
Lifetime Donor
15+ Year Member
Nov 24, 2002
20,339
5,121
SCREW IT!
If I were to see the pt in 2 dys in the ED if not better, I likely would forgo abx.
If you saw the pt 2 days later, and they were not better, you would NOT give antibiotics? That is what you are saying. That seems to go against (my) common sense.

Then again, the guy above who says, "if I think it's maybe diverticulitis, I don't get a CT", that, to me, is some severe degree of confirmation bias, or anchoring bias, or just plain crazy. If I was the guy with a perf or abscess in my belly, and the doc who saw me didn't image or write abx, and I ended up with a colostomy or ileostomy, man, I'd be calling the first piece of **** ambulance chaser I could find.
 
Nov 24, 2015
102
116
Status
Resident [Any Field]
Shared decision making is a GREAT thing. I can frame things pretty well if I dont want to scan a 70 year old with fibro with belly pain.
 

dpmd

Relaxing
10+ Year Member
Sep 14, 2006
20,702
31,400
Lazytown
Status
Attending Physician
If you saw the pt 2 days later, and they were not better, you would NOT give antibiotics? That is what you are saying. That seems to go against (my) common sense.

Then again, the guy above who says, "if I think it's maybe diverticulitis, I don't get a CT", that, to me, is some severe degree of confirmation bias, or anchoring bias, or just plain crazy. If I was the guy with a perf or abscess in my belly, and the doc who saw me didn't image or write abx, and I ended up with a colostomy or ileostomy, man, I'd be calling the first piece of **** ambulance chaser I could find.
I think he is saying that if he knew he could just see the patient again in 2 days if not better he would avoid abx on the initial visit but since he can't he treats them all.
 

gman33

Moderator Emeritus
10+ Year Member
Aug 18, 2007
2,188
496
Status
Attending Physician
If you saw the pt 2 days later, and they were not better, you would NOT give antibiotics? That is what you are saying. That seems to go against (my) common sense.

Then again, the guy above who says, "if I think it's maybe diverticulitis, I don't get a CT", that, to me, is some severe degree of confirmation bias, or anchoring bias, or just plain crazy. If I was the guy with a perf or abscess in my belly, and the doc who saw me didn't image or write abx, and I ended up with a colostomy or ileostomy, man, I'd be calling the first piece of **** ambulance chaser I could find.
What I think is crazy is just getting a ct on every belly pain without knowing what you are looking for.

The patients who I wouldn't scan would be a young healthy person with a benign exam and story.

Bad exam, worse symptoms, old or other risks, scan and all the other stuff.

I'm just saying I don't hunt down this diagnosis with every vague belly pain.

It's like the doc who looks for pe in every lame cp story. They won't miss many but I don't think their patients are being well served.
 
  • Like
Reactions: thegenius

WildcatS11

10+ Year Member
Jul 17, 2009
111
121
Status
Resident [Any Field]
What I think is crazy is just getting a ct on every belly pain without knowing what you are looking for.

The patients who I wouldn't scan would be a young healthy person with a benign exam and story.

Bad exam, worse symptoms, old or other risks, scan and all the other stuff.

I'm just saying I don't hunt down this diagnosis with every vague belly pain.

It's like the doc who looks for pe in every lame cp story. They won't miss many but I don't think their patients are being well served.
It depends on what miss rate you are personally comfortable with. It also depends where you practice.
 

Apollyon

Screw the GST
Lifetime Donor
15+ Year Member
Nov 24, 2002
20,339
5,121
SCREW IT!
What I think is crazy is just getting a ct on every belly pain without knowing what you are looking for.

The patients who I wouldn't scan would be a young healthy person with a benign exam and story.

Bad exam, worse symptoms, old or other risks, scan and all the other stuff.

I'm just saying I don't hunt down this diagnosis with every vague belly pain.

It's like the doc who looks for pe in every lame cp story. They won't miss many but I don't think their patients are being well served.
But that's not what you said.

I'm not quite there with no abx for a ct proven diverticulitis.

I do believe the evidence is decent that there is no benefit, but if they have complications, you are going to be on the hook.

I have however become less likely to get a ct if that's what I think is going on. No ct,
No proof, no abx.


I'm also more likely to send tics home, since I don't believe the hospitalization and iv abx will add anything to their care.
How many 28 y/o diverticulitis puts have you seen? When someone says "diverticulitis", my first thought is a 60 year old. I just can't get my head around "no CT, no proof, no antibiotics", even after you say, just before, that you will be on the hook for complications. So, you have a pt with LLQ pain, fever, and diarrhea, and you don't CT? (That's a deliberately provocative absurdity.) You don't consider admission? Call me over cautious, or you cavalier, but, either you are not being SO cavalier, or you are, and that sounds pretty scary to me.

In the first post, you were 2 or 3 SDs off the median, but, following, you seem to hew back to the middle.
 

dpmd

Relaxing
10+ Year Member
Sep 14, 2006
20,702
31,400
Lazytown
Status
Attending Physician
How many 28 y/o diverticulitis puts have you seen? When someone says "diverticulitis", my first thought is a 60 year old. I just can't get my head around "no CT, no proof, no antibiotics", even after you say, just before, that you will be on the hook for complications. So, you have a pt with LLQ pain, fever, and diarrhea, and you don't CT? (That's a deliberately provocative absurdity.) You don't consider admission? Call me over cautious, or you cavalier, but, either you are not being SO cavalier, or you are, and that sounds pretty scary to me.

In the first post, you were 2 or 3 SDs off the median, but, following, you seem to hew back to the middle.
I have been involved with several patients where this happened (although it was usually their PCP that did it) although they did usually get antibiotics, not that that prevented them coming back with complicated disease and needing to see me (surgeon).
 

Apollyon

Screw the GST
Lifetime Donor
15+ Year Member
Nov 24, 2002
20,339
5,121
SCREW IT!
I have been involved with several patients where this happened (although it was usually their PCP that did it) although they did usually get antibiotics, not that that prevented them coming back with complicated disease and needing to see me (surgeon).
All the PCPs I've ever known do much less imaging (and there's that "fallacy of anecdote" again) then we do in the ED. Virtually all of what I post, unless otherwise specified, is EM-specific.
 

Dr.McNinja

Nobel War Prize Winner
Moderator
10+ Year Member
Aug 2, 2006
10,288
6,961
Texas
Status
Attending Physician
How many 28 y/o diverticulitis puts have you seen? When someone says "diverticulitis", my first thought is a 60 year old. I just can't get my head around "no CT, no proof, no antibiotics", even after you say, just before, that you will be on the hook for complications. So, you have a pt with LLQ pain, fever, and diarrhea, and you don't CT? (That's a deliberately provocative absurdity.) You don't consider admission? Call me over cautious, or you cavalier, but, either you are not being SO cavalier, or you are, and that sounds pretty scary to me.
Uh, there's a lot of enteritis where I live. If their abdomen isn't surgical, then they don't need the CT on the first visit. Similar to kidney stones. I know that I'm an outlier for not thinking the 24 year old with history of stones needs her 20th CT in my EMR, not counting the ones at other hospitals.
 
  • Like
Reactions: gman33

emergentmd

10+ Year Member
Jul 6, 2008
1,473
1,612
Status
Attending Physician
If the system actually rewards good medicine rather than punishing it, I would love to do the right thing. But you are swimming up the stream if you don't play the game.

Admin and the medical society can care less about good medicine. When is the last time I got a pat on the back when I practiced quality medicine? almost never. All they care about is metriccs, patient sats, and nice yelp comments.

When I don't give pain meds or abx, I get complaints. When I give abx, I never get complaints. Guess what I am going to do?
I accuse pts of drug seeking when they have a pharm sheet a mile long and seen 10 different docs with 50 narc scripts in the past year. I sure dont get a compliment. I get a board complaint I have to waste my time defending. While my fellow partners are candy men and never have to deal with this crap. Guess which path is easier.

I get more headaches "doing the right thing"

I am not bitter at all, just being frank. And I would say I order less tests than my fellow docs. I actually use common sense and not shot gun every patients although i get less RVUs.
 

Psai

This space for lease
Removed
5+ Year Member
Jan 2, 2014
11,519
23,501
ヽ(´ー`)ノ
Status
Resident [Any Field]
I don't think I've met a 70 year old belly pain that I didn't want to scan.
I have. Ay ay ay but walking around normally, on cell phone until i come in and magically in distress, unremarkable story, pan positive ros, normal vitals, benign belly. This is scott weingart, with the emcrit podcast, saying bye bye.
 
Last edited:

goodoldalky

Member
10+ Year Member
Jul 6, 2006
555
369
Status
Attending Physician
If the system actually rewards good medicine rather than punishing it, I would love to do the right thing. But you are swimming up the stream if you don't play the game.

Admin and the medical society can care less about good medicine. When is the last time I got a pat on the back when I practiced quality medicine? almost never. All they care about is metriccs, patient sats, and nice yelp comments.

When I don't give pain meds or abx, I get complaints. When I give abx, I never get complaints. Guess what I am going to do?
I accuse pts of drug seeking when they have a pharm sheet a mile long and seen 10 different docs with 50 narc scripts in the past year. I sure dont get a compliment. I get a board complaint I have to waste my time defending. While my fellow partners are candy men and never have to deal with this crap. Guess which path is easier.

I get more headaches "doing the right thing"

I am not bitter at all, just being frank. And I would say I order less tests than my fellow docs. I actually use common sense and not shot gun every patients although i get less RVUs.
It seems like the most important thing to you in the practice of medicine is what is easiest for you.
 

GeneralVeers

Stable Genius
10+ Year Member
Mar 19, 2005
5,470
3,136
Las Vegas
Status
Attending Physician
It seems like the most important thing to you in the practice of medicine is what is easiest for you.
"Easiest" means not spending 30 minutes trying to convince and unconvinceable mother that we aren't giving antibiotics. "Easiest" means not having to take uncompensated time to write responses to complaint investigations. "Easiest" is not having to educate the hospitalists and primary care docs on evidence-based medicine. "Easiest" is not having to worry about getting fired for doing good medicine.
 

goodoldalky

Member
10+ Year Member
Jul 6, 2006
555
369
Status
Attending Physician
"Easiest" is not having to worry about getting fired for doing good medicine.
Do y'all really have to write responses to complaints about not writing antibiotics for colds? You get fired if you practice EBM to the chagrin of some PCP? What is wrong with your medical directors and who do you work for?

Maybe this is unique but we get these baseless nonsense complaints as regularly as anyone, I imagine. And they are given the attention they deserve (minimal) while not firing anyone, nor requiring some sort of written response.
 

GeneralVeers

Stable Genius
10+ Year Member
Mar 19, 2005
5,470
3,136
Las Vegas
Status
Attending Physician
Do y'all really have to write responses to complaints about not writing antibiotics for colds? You get fired if you practice EBM to the chagrin of some PCP? What is wrong with your medical directors and who do you work for?

Maybe this is unique but we get these baseless nonsense complaints as regularly as anyone, I imagine. And they are given the attention they deserve (minimal) while not firing anyone, nor requiring some sort of written response.
Every complaint at some hospitals I've worked for gets "investigated" regardless of the legitimacy. The customer is always right, and I typically have to give my director or admin a written response as to why I didn't give narcs, antibiotics, admit a patient or do a test.

Additionally any PCP or medical staff member can refer my case to be reviewed by the peer-review committee. I then have to spend time writing a response, regardless of whether or not anything incorrect was done.

Administrators generally don't like squeaky wheels. Get too many complaints, and they will encourage your group to get rid of you. Because the CMGs are all run by spineless idiots that are afraid of losing contracts, they won't put up too much of a fight against admin on your behalf.

Therefore it's best to stay below the radar and avoid complaints even if it means doing the wrong thing.
 

WildcatS11

10+ Year Member
Jul 17, 2009
111
121
Status
Resident [Any Field]
Every complaint at some hospitals I've worked for gets "investigated" regardless of the legitimacy. The customer is always right, and I typically have to give my director or admin a written response as to why I didn't give narcs, antibiotics, admit a patient or do a test.

Additionally any PCP or medical staff member can refer my case to be reviewed by the peer-review committee. I then have to spend time writing a response, regardless of whether or not anything incorrect was done.

Administrators generally don't like squeaky wheels. Get too many complaints, and they will encourage your group to get rid of you. Because the CMGs are all run by spineless idiots that are afraid of losing contracts, they won't put up too much of a fight against admin on your behalf.

Therefore it's best to stay below the radar and avoid complaints even if it means doing the wrong thing.
It's funny. I'm still a resident. But I've heard so many people complain (both IRL and on here) about the groups losing contracts at hospitals. You would think they would encourage their CMG leaders to do almost anything to protect a contract. It seems there is no winning?