Musings of a Dinosaur

A Family Doctor in solo private practice; I may be going the way of the dinosaur, but I'm not dead yet.

Friday, November 24, 2006

More About Ancillaries

From the comments to "Ancillary My Ass":
I am wondering how ordering these useless tests is different from stealing? Doctors who do these tests think they really need to supplement their income because the insurance companies don't pay enough. Well, the company I work for doesn't pay me enough either. If I had only one 4% raise in the last 2 years - and this is with pretty good evaluation, does it mean I can take somebody's money by convincing them they need to buy something from me that they really don't need just so I can get my income in line with the inflation? And there is a difference between selling people something they don't need and ordering a test: at least with the former nobody believes his/her life will be in danger if they refuse.
How is this different from stealing, eh?

Why, I don't think it is at all!

As for other commenters who pointed out the standard defensive medicine, CYA and "but he found all kinds of things" answers, I still say BULLSHIT.

Medical diagnosis consists of (in order!):
  1. History
  2. Physical
  3. Testing
That is to say, if you've never seen or talked to the patient, you have no way of knowing what tests (if any) that particular patient is going to need. Get your history first; formulate your diagnostic hypotheses, then examine the patient. At that point a competent clinician will have a pretty good handle on some kind of differential diagnosis, and can make a rational decision about what further testing (lab, imaging, PFTs, whatever) is needed to clinch it. Enormous amounts of money, time and energy are wasted when this sequence isn't followed.

One scenario that annoyed the hell out of me was a patient assigned to my HMO panel who called and said that he needed a referral for an MRI of his brain. WTF? It turned out he had had what sounded like a TIA and a neighbor -- who was a retired chief of radiology at a large tertiary care center -- told him he needed to see his friend, the neurologist: chief of neurology at said tertiary care center. When he called for the appointment, he was told he needed to have an MRI before being seen. I eventually managed to get the guy to come in to my office, went through the appropriate workup, got him started on aspirin and controlled his blood pressure, all without an MRI or a referral to the chief of neurology at a big tertiary care center, who had much better things to do with his time than take care of an uncomplicated TIA.

I understand that in today's busy world of medical practice it is considered efficient to have as much as possible completed before seeing a patient. I have no problem with things like vital signs being completed before walking into an exam room. But however you slice it, PFTs are not "vital signs."

Defensive medicine is real, without a doubt. But routine PFTs literally on everyone who walks in the door is not defensive; it's indefensible. As for detecting clinically significant occult conditions on testing before they become apparent either to the patient (in the form of symptoms) or to an astute clinician on physical exam, it doesn't happen nearly as often as often as you might think.

So what's the difference between ordering unnecessary tests and stealing?



At Sat Nov 25, 09:00:00 AM, Blogger MedStudentGod (MSG) said...

I agree that it is akin to stealing. However I feel that this is the case only if certain criteria are met. A doctor housing much of these ancillary tests in their office seems far more prone to ordering unnecessary tests to help pay for this equipment. PFT’s ordered for every cough is not something I would expect seeing in an office that doesn’t house the equipment. In this avenue, I would expect that referrals to specialists would not occur since the physician can now treat for an “abnormal PFT”.

On the flip side, another physician having been sued, or being trained by physicians who've been sued might refer over anything for fear of "being over their head". Yet I feel that the over-testing, requiring a patient visit to another office, would not occur as often in this setting. Instead it seems easier to just refer to a specialist that covers that area – like a Pulmonologist. Unless kickbacks are in place (illegal though they may be) the physician does not profit from this referral.

The climate for primary care doctors, in as much as this medstudent can understand, seems fraught with patients wanting tests or specialists. Unfortunately the idea that a primary care doctor can control a lot of problems *without* extensive testing or referrals is becoming foreign to younger patients.

At Sat Nov 25, 11:18:00 AM, Blogger Medicine Man said...

I agree, and how about primary care physicians training in and using cosmetic procedures to make up for the loss of income in primary care medicine?

At Sat Nov 25, 08:31:00 PM, Anonymous Anonymous said...

I totally disagree. I went to school in Canada, I learned how to do historys and physicals. I stopped doing them after I was sued twice, once for a patient I never even saw. If and when I go back to Canada, my training in H & P's will do me well, but for now, it's bullshit. How will H & P tell me which 30 year old patient out of the thousand I see a year with chest pain will turn out to have a small pulmonary embolism that I'll miss. None. But a D-dimer will. When's the last time I heard of a lawyer asking you what you heard when you auscultated the lungs? Did they ask if you used the bell or the diaphragm. What's bullshit is the American Healthcare system. My take on your comments is that you're not in a raped specialty, like ER or Neurosurgery. Try that on for size, then talk about H & P's. Until then, I wil purposely try to bankrupt the system, till I get out of this country, or they stop letting the lawyers rape us.

At Sat Nov 25, 10:08:00 PM, Blogger Dex said...

Agree with H & P before ordering testing. Some points to consider with respect to testing, from the meagre experience of a lowly intern.

1. You can't make an asymptomatic patient feel better. Exception: screening--

2. In general, clinical suspicion comes before biochemistry comes before radiology comes before pathology. Example: 21 y.o. F, no PMHx, /c F/C & anorexia x 1d, 5x NBNB N/V, RLQ pain, Pelvic/guiac (-)-->Bl Cx, UCx, U/A, Chem7, LFT, GC/Chlam, RPR, PT/PTT, T&C-->EKG, CXR, XR Upright & Decubitus/Supine, CT Abdo /c IV/PO contrast, (+/-) RUQ U/S, (+/-) Pelvic U/S-->OR for tx and final pathologic dx.

3. Don't do a test unless it is going to change your management; alternatively, don't do a procedure unless you can manage the complications. Ex: Only use sedation if advanced airway management is readily available.

4. Incidentalomas are a bad thing. The more testing ordered, the greater the probability of discovering an abnormality that, once documented, must be investigated, however irrelevant to the current clinical problem. Many legal ramifications--ex: lung nodules, liver/kidney/ovarian cysts, slight anemia/hypertension/hyperglycemia/LFT abnormalities.

5. Poor communication/ history taking/ rushed sign out/ lack of PMD involvement leads to needless reinvestigation of stable chronic problems. Very common in patients with diminished capacity/ inability to communicate/ foreign-language speaking only/ lack of social support/ or with poor compliance.

Overall, for common conditions, tests should be ordered mainly to confirm clinical assessment, to rule out rare or atypical presentations, and (unfortunately) to keep the sodomites at the door.

At Sun Nov 26, 07:07:00 AM, Blogger Big Lebowski Store said...

It's stealing unless the patient is actually buying it, and you have not misrepresented the service you are selling. Okay, officer, I'll come quietly. Do I have to wear the white jacket again this time?



At Sun Nov 26, 11:30:00 AM, Blogger #1 Dinosaur said...

Earth to Anonymous: RE 30 y/o with chest pain. HELLO! "Chest pain" = "History" You're right that "Physical" doesn't add much (though it might, if you found grouped vesicles on an erythematous base in a thoracic dermatomal distribution) but please keep in mind that H >> P. You don't order D-dimers on everyone walking in the door, do you? How do you bill for tests on someone who just came to fix the sink?

I cannot believe were actually successfully sued for a patient you never had any interaction with, which is not quite the same as "never saw" (ie: no phone management; never called for an appointment) and that the suit went beyond being named in a shotgun approach. If you didn't have a lawyer on the ball enough to get you dropped quicker than you can say WTF, then my heart (negative cardiac enzymes and all) goes out to you.

Dex: Thanks for right-on treatise about testing. My point(s) exactly!

Flea: But it's such a nice white jacket, and you know it's just for your own protection.

At Sun Nov 26, 12:21:00 PM, Anonymous Anonymous said...

Queries for Dino:
Does herpes have a protective effect with respect to coronary thrombosis? Just because you see vesicles, does it mean that angina/MI is any less probable? I'm not being snarky (this time). We are all taught that blood in the stool of a patient over 40 mandates colonoscopy even if we see big hemorrhoids. Is this any different?

The anon commenter above did not say that he was successfully sued. Being sued, even unsuccessfully, is traumatic- emotionally and financially costly, and it has a negative impact on the way you practice for the rest of your career. One unsuccessful lawsuit cost my insurance co $50K in in legal fees, not to mention >100 hours of my time reviewing charts from several years before, meeting with attorneys, preparing for deposition, only to be dropped from the lawsuit, as 11 of the 13 defendants were, when the case settled with payment by the 2 other defendants. This process took over 2.5 years, and I describe it not because I believe it to be unique, but sadly typical of the way the trial lawyers do business. So, yes, a little chest pain and shortness of breath does have to lead to the d-dimer, if not directly to the CT pulm angio. It's a thousand bucks, with risk of renal injury from the contrast, but it's not my money or nephrons. Thank you trial lawyers.

At Sun Nov 26, 01:52:00 PM, Blogger #1 Dinosaur said...

In an otherwise healthy 30 y/o with chest pain localized to the area of a typical shingles rash, no other suspicious symptoms (this was your first mention of SOB) and no other risks for cardiac disease, yeah, I'd stop there.

As for BRBPR with big fat hemorrhoids at 40, yeah, I tell them, "I'm supposed to tell you that you need colonoscopy" but out here in the post-training "real world" neither of us loses any sleep if he doesn't get around to it for 5-10 years (again, in the absence of other elements on H&P; I just sent over a guy who turns out to have some colitis going on. It isn't always cancer.)

As for a truly frivolous lawsuit changing the way you practice: why should it? If you did nothing wrong, then why change what you do in order to avoid something you have no control over anyway? It's like being rear ended at a stop sign. Traumatic? Of course. What are you going to do differently? Stop driving, or realize that shit happens even if you take every precaution (and get counseling to help you deal with it, if necessary.) And just for the record, I have been sued, went all the way to trial after 7 years, and was found not liable in 1 hr, 15 minutes (which included the jury's lunch.)


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