Pressure on EPs to diagnose everything muddies the truth: Patients are worried, not sick
When I listen to CME online or go to a conference, I am endlessly impressed by the knowledge and clinical acumen of my colleagues. We as a specialty are excellent at teasing out obscure diagnoses and finding hidden pathologies.
“Well, Sharon, it was a fascinating case. But I managed to identify the small star-shaped hematoma on his fifth finger, which is obviously pathognomonic for fulminant digital thrombo-sepsis syndrome, a rare but devastating diagnosis we should all be able to identify.”
We look and test, fret and consult, and in the end uncover things that in decades past would have ended with this conversation: “Sorry about your dad. I think he just had hardening of the arteries. Is there a funeral home we can call?”
These days we save lives better than ever. It is truly amazing. And yet....
What we don't seem to do so well is not test and not treat. What we don't do well is recognize how many of our patients are just worried, have unexpressed subtexts for their visits, or simply have unpleasant but non-life-threatening conditions. What we do poorly is walk into rooms and say, “I'm sorry you feel badly. You can go home now.”
Not Always a Diagnosis
We live with constant, intense vigilance from a combination of fear of litigation, love of the chase, and a deep need for validation. We have come to believe that being a physician is synonymous with making a diagnosis, the cooler the better.
Sadly, we also live with constant, intense (and worsening) crowding that makes it difficult for too many patients who need care to get it in a timely manner. And a consequence of our surfeit of caution is that our patients are billed enormous amounts of money and our hospitals lose money that isn't reimbursed. Then they close, in which case nobody gets care there anymore. Especially difficult for those with fulminant digital thrombo-sepsis syndrome!
Anyone who has worked in an ED in the past few years and hasn't managed to buy the winning Powerball ticket or who didn't spend money like a doctor and can actually retire knows that it's pretty bad out there. We have to find a way to do things more efficiently and sustainably.
I do understand the fears of litigation, and we've all banged our heads against the wall about this for years. I don't have any new ideas on that front. But managing these difficult times mean we need to embrace the fact that so many—so very many—patients (how shall I phrase this?) just aren't sick.
Back to the House
We know this in our hearts, in our little doctor hearts. We know that a family with colds is pretty much a family with colds whatever the actual etiology. We know that Ricky Bobby has had 15 negative cardiac workups, and while this could be the big one, it probably isn't. We could reasonably look at many of our high utilizers and see that they have had CT angio after CT angio, lab after lab, ad infinitum with no diagnosis of anything dangerous, and that it's OK to reassure them, do the minimum, and send them back to the house, as we say in the South.
It's not a failure if we do less. It means we're actually using our tired brains and expensive educations to make reasonable decisions. It means we're subjecting our patients to the “doctor scanner” as soon as we walk in the room. And we're actually treating the greater system and the sicker patients and saving the less sick from costly, unnecessary tests and medications, which aren't without their own dangers and consequences.
There's more, however, than what we do as individuals. The system as a whole needs to be more honest. I suggest daily, hospital-driven public service announcements about crowding, capacity, and available resources. Don't have labor and delivery? Make it clear to the public and to EMS in particular.
Hospitals sometimes have signs that tell people about short wait times. More honesty about long ones would help. The public health system should also explain more clearly what people should do with their concerns. The United Kingdom has signs that tell people what constitutes an appropriate visit to Accident and Emergency. Granted, that's unlikely in a system driven by profit, but it would be helpful to everyone here. Clearly, we need more and better primary care and urgent care where the disposition isn't so often, “Your swabs are negative, here's your Zithromax, now off to the ED with you!”
Our system is circling the drain right now. We need all of the surge capacity we can get. But we will have none as long as we live with the delusion that all of our patients are in imminent danger. Far better for everyone—and for those we serve—to take a breath and realize that in many cases doing less may save more lives in actual danger.
In the process, we might just keep the system on life support long enough for things to get better.
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Dr. Leappractices emergency medicine in rural South Carolina, and is the author of the column, Life and Limb (https://edwinleap.substack.com) and a blog (http://edwinleap.com). Follow him on Twitter@edwin_leap, and read his past EMN columns athttp://bit.ly/EMN-Emergistan.