Monday, July 21, 2008

Unnecessary Tests

Recently, I was asked to examine a patient who was scheduled for an emergency amputation of her leg because of gangrene. I went over her chart and discovered that one of the junior residents had seen her the night before and had requested two consults: 1) A cardiology consult because the patient was complaining of unstable angina (chest pain at rest). and 2) A vascular surgery consult because of a history of CVA (cerebral vascular accident aka - stroke). I cancelled the consults because they were unnecessary. The patient had bypass surgery 4 months prior. The most recent echocardiogram showed that the patient suffers from congestive heart failure. Even if a workup were done, no surgeon in his right mind would do bypass surgery on a patient with an active infection. The same goes for the CVA. Since the stroke the neurological status of the patient has been stable. Again, even if vascular surgery were indicated, this is not the time.
Bossman, the chief of anesthesiology, raked me over the coals for cancelling the consults saying that it was irresponsible. I told him that consultants opinions would change nothing in the anesthetic management of this patient and were, therefore, superfluous. Having painted himself in a corner, Bossman nonetheless found a pretext to delay surgery. The patients's hemoglobin was 9.7, just a hair below the threshold of 10 for a cardiac patient. The patient would have to receive a unit of blood and wait another day.
The next day, I ran into the resident who requested the consults. In an attempt to educate and not just criticize, I asked him why he asked for the consults. His reply made me see red. It is the reply of the imbecile, of the doctor who is afraid to think and make decisions, and it drives me to distraction: "To spread around the responsibility". To be fair, it is not all his fault, he learned this "defensive medicine" posture from Bossman.
I told him that even if he really believes in that philosophy, he should never actually say it out loud, it's just plain embarrasing. I proceeded to impart two pearls of wisdom that I believe are universal:
1) If you ask the consultant a stupid question, you will, invariably, get a stupid answer. Don't just ask for a "cardiology consult". One must ask the consult a specific (and hopefully intelligent) question. For example, "Does this patient need further workup and/or intervention for her chest pain?"
2) You better have a damn good justification for delaying surgery if the delay endangers the patient. In this case, delaying the amputation exposed the patient to another day of infection that could have developed into full blown sepsis with septic shock. This complication can be fatal. This is not speculation, this is experience. We've all anesthetized patients with septic shock, it's challenging to say the least. Had such a complication occurred, the first question the judge will ask is: "What did you gain from the consults that justified delaying surgery and endangering the patient".
The fear of "missing" something exists. In this era of defensive medicine and zealous over-litigation, it is in the back of all our minds. No physician wants to miss a diagnosis that might endanger the patient and/or expose us to a lawsuit. But if we order every and any test under the sun are we really serving our patients well?
I believe in this guiding principle: Any investigation, whether a consultation or a blood test should be done only if the results will affect patient management. Not only is an unnecessary test a waste of money, it may even endanger the patient.
P.S. - The patient had surgery with no complications.


Anonymous said...

What a frustrating experience. But did you really delay an emergency case to receive a unit of blood? At my hospital, the vascular surgeons would have been doing the case, and would have arranged to wheel the patient into the OR as soon as the blood was hung, or possibly sooner. Maybe Israeli hospitals run differently?

Unknown said...

It was an orthopedic case actually. The problem here was one of ego. This is NOT the usual modus operandi in Israeli hospitals.

concernedjewgirl said...

It appears that Doctors and Police officers are stuck in the same boat...Dammed if you do and dammed if you don't.

Lioness said...

Oh blimey, that's so irresponsible! Actually, that's criminal, they effectively placed her life in danger, the woman could have died! It makes my blood boil, everyone's navel first, patient last. And what sort of an idiot actually says those words out loud?? And egos have no place at all where lives and health are at risk. ARGHHH!

(I'll be such a fuming professional won't I. I dread it.)

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