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I ran across this patient problem list the other day. This is completely real, but anonymized to protect the innocent:- Probable occlusive coronary artery disease but fairly asymptomatic. Patient will return for a Persantine Cardiolite.
- Systolic murmurs consistent with mitral insufficiency and aortic sclerosis. She will return for an echocardiogram.
- Labile hypertension. We need to rule out renal artery stenosis. Patient will have a CT angiogram of her renal arteries.
- Historically occluded left carotid. I do not believe it with a lesion in the right. Patient will have a CT angiogram of her carotids.
- Chronic right-sided leg pain. She could have occlusive vascular disease in her lower extremities. We will do the CT angiogram of that as well.
- Ongoing tobacco abuse. I advised her not to smoke. She is not going to quit. She made that very clear to me.
- History of lung cancer. Treated with radiation therapy. No evidence of metastatic disease.
- Dizziness. Probably due to vascular disease. I do not think it is due to any significant arrhythmias. We will place a holter on her to be on the safe side, however.
At least she doesn't have kidney stones or the heartbreak of psoriasis. I'm thinking this little workup on this 80+ year-old patient is going to cost about $15,000+ or whatever Medicare will pay. Let's hope her kidneys hold up with all that iodinated contrast she's about to get.
Now you know how doctors think. Test every twinge, and if the test shows something, order more tests. I wonder why some still carry stethescopes.
3 comments :
"Now you know how doctors think."
Balderdash; coerced doctors have not a single tangible incentive to think otherwise, if you bring yourself to understand a system where ethics are not only not rewarded, but potentially penalized.
Doctors think like everybody else. We just have different influences than everybody else....That means our fear of a malpractice suit might motivate us to spend $5K on a "needless" test. But we're spending Medicare(funny) money not our own, not the patients.
There were times in my practice when I listened to a patients symptoms and had enough of a worry to recommend an expensive test. I would apologize," I'm ordering this almost for my own peace of mind." The patient had these vague symptoms and I wanted to rule out the bad stuff.
But that was rare. More commonly the patient arrived demanding some expensive test I felt might be unnecessary. I spend too much time, and lost too much credibility(read popularity=$) trying to talk them out of it....
Read: "Overtreated" by brownlee.
read:
http://poemd.blogspot.com/2007/02/soldier-for-empire.html
At least the last one is free...
good afternoon - perhaps you may not be getting this post immediately (as it states you may be on a cruise), but to further the discussion on the frequency and costs of tests a fundamental problem (other than the litigiousness of our society) is the relative ignorance of clinicians. Many clinics are ignorant of fundamental evidence based principles and confuse sensitivity/specificity with the markedly more clinically applicable likelihood ratios. Further, most clinicians don't assign pre-test probabilities or understand bayesian theory. In fact, it would help clinicians ifradiologists (given a different malpractice milieu) would report PROBABILITIES of differentials rather than the ubiquitous 'can't rule out' or 'correlate clinically.' That being said, here are posts that further expound on these thoughts. Thanks for your time.
Kolahun
http://kolahun.typepad.com/kolahun/2007/07/when-to-order-a.html
http://kolahun.typepad.com/kolahun/2007/07/a-cost-quiz.html
http://kolahun.typepad.com/kolahun/2007/08/how-does-one-se.html
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