Thursday, September 20, 2007

The Problem with Health Policy Initiatives

A. The Old Days
A patient walks into the emergency room, complaining of a weak arm and hand for four days.

A careful history is taken to determine the distribution, timing, precipitating and palliating factors, and severity of the weakness. The patient notes that buttoning clothes and picking up objects with their left hand has become increasingly difficult. A carefully performed physical examination discloses mild swelling and tenderness of the metacarpophalangeal joints, hyperreflexia of the biceps and brachioradialis muscles on the left arm. Pin prick, temperature sensation, and propioception are reduced in the digits of the left hand. Pronator drift is noted of the left hand. Flexion and extension of the biceps muscle on the left is reduced. A disorder of the central nervous system is suspected, a careful conversation is had with the patient to explain the symptoms and diagnostic process. A CT scan is ordered and later documents a 3 cm radiolucent mass in the right motor cortex. Doctor returns to patient and explains the findings. A neurosurgery consultation is requested. Total time: 2.5 hours.

B. The New Days
A patient walks into the emergency room, complaining of a weak arm and hand for four days.

A CT is ordered and patient is wheeled to scanner. CT documents a 3 cm radiolucent mass in the right motor cortex. Doctor sees findings, calls neurosurgeon. Doctor and neurosurgeon enter room to discuss CT findings with patient. Total time: 25 minutes.

Two tactics, same outcome. Process B ten times as efficient as A. Therefore, process B must be better than A, right?

It depends on which side of the health care debate you're on.

-Wes

6 comments:

Alison Cummins said...

Ooh, careful with your math! Only six times more efficient.

DrWes said...

Alison-
Duly noted. If one rounds to one significant digit, I guess I could say I was close enough.

shadowfax said...

Only more efficient when you consider that there were 25 other CT scans ordered that were negative. (largely done for defensive reasons, partially because the ER doc does not have an hour to spend interviewing and examining every patient s/he sees.)

Time efficient? Maybe. Efficiant use of resources? You be the judge.

Nurse K said...

It's been 4 days--could have been done outpatient as long as the symptoms are not changing. The only reason for the quick CT scan is lytics. If you're in my ER, the neurosurgeon would order the MRI before they see the patient.

Anonymous said...

In medical school, a favorite attending of mine joked that in the ER ABC's are no longer about Airways, Breathing, and Circulation but stand for "Admit, Begin, CAT-Scan".

Sadly, you're not going to change the latter. ER Medicine is CAT Scan medicine. Anything that has a pain threshold of higher than 3/10 gets intensive radiological imaging.

Chris said...

So the differential Dx stuff I'm currently learning in gross anatomy is no longer used, wink wink;)