Friday, July 25, 2008

I Didn't Practice Evidence-Based Medicine Today

He was 70 with critical aortic stenosis and ejection fraction of 10%, coronary artery disease and history of 5-vessel bypass in 2001, a history of Stage D colon cancer with lung mets resected 18 months ago, obesity, diabetes mellitus, chronic renal insufficiency and was recently extubated after a failed aortic valvuloplasty. He later developed a wide complex tachycardia at 150 beats per minute for which I was asked to consult. The SVT looked just like his underlying left bundle branch block and would start and stop – usually with a PAC. He was administered 2.5mg metoprolol intravenously and loaded with Amiodarone. His SVT became a non-issue thereafter.

But I didn’t check his HbA1c.

I didn’t check his LDL lipid level.

I didn’t do a diabetic fundoscopic exam.

I didn’t refer him to a neurologist for his mild peripheral neuropathy.

I didn’t get him an evaluation of his footwear.

I didn’t give him an implantable defibrillator or biventricular pacemaker.

I didn’t do universal weight screening.

Instead, I just practiced medicine.

I wonder what my PQRI measure score sheet will look like? I probably won't get my 1.5% bonus from Medicare, I guess. * Sigh *

Too bad there’s no box on that scoresheet for how much money careful judgment could save our healthcare system.



The Happy Hospitalist said...

I agree completely.

J Craig MD said...

Better defined as the "art" of medicine, the art which is not taught to extenders.

R. W. Donnell said...


Jonathan Dee said...

Well said!

"Careful judgement" is the prerogative of the insurance companies, not the physicians.

Clinical Medicine said...

I guess this is CSBM (Common Sense based medicine), or GFBM (Gut feeling based medicine
I totally agree

Anonymous said...

My experience as an old "detailman" litterally living in doctor's offices,medical schools, hospitals, pharmacies, nursing homes, and clinics for 35 years, has given me a special appreiciation for clinicians who have the ability to practice medicine on this level. I never failed to be impressed when I saw them in action. It is the difference between "paint by the numbers" and a master artist.

Elizabeth said...

As a 4th year medical student, not far from the days when I will be making similar decisions for my patients, I applaud you for noting the absurdity of some of the things we do in medicine. So often I see someone in the unit who is elderly, has esrd, stage 4 cancer (pick your favorite), alzheimers, and someone has the nerve to call a cardiology consult for a heart block... talk about rearranging the deck chairs on the Titanic.

I think that because of there being so many "guidelines" we have to follow, we have begun to practice "Cover Your A** Medicine".

Anonymous said...

Hey Doc, probably the best way to describe in the grand rounds your actions is PBM (patient-based medicine). Have a nice sunday.
Dr. DJ