Sunday, November 30, 2008

Missing Judgement

A while back, I gave an EKG challenge to the blog-o-sphere to review an EKG of a young man who presented to the Emergency Room for evaluation of shortness of breath and lightheadedness unrelated to exertion. After posting the EKG, I got all kinds of answers for the young man's ailment, but most failed to guess the gist of the exercise: that the EKG was normal.

It is interesting to ponder why.

In medical school, we are trained to develop a differential diagnosis to any and all symptoms before us. Heck, I can remember the pneumonic "VINDICATES" that allowed me to spew forth such great diseases caused by vascular, infectious, neoplastic, degenerative, iatrogenic, congenital, autoimmune, traumatic, endocrine or neurologic ("squash") causes for virtually any unusual finding on a chest x-ray or lab test. It's how we were trained. Think of everything. Don't you dare miss anything, lest you be judged incompetent in the Court of Public Humiliation on rounds with your Chief Resident or Attending. Cover all the bases. Your patient depends on it.

More senior and experienced attendings usually performed the same exercise, albeit at lightning speed. They quickly consulted their vast experiential database to prioritize the most likely diagnosis, leading to a razor-like ability to hone in on the problem and affect proper treatment. Nine time out of ten they were right on, and we stood in awe. Years ago, that was good enough. Attendings were appreciated for their remarkable accuracy but permitted the professional courtesy of occassionally missing a diagnosis. Naturally as residents, we relished the moment when we got it right when the attending didn't: those cases were always presented as "The Case of the Week" conference on Fridays where we rehashed the play-by-play of our diagnostic acumen. It was how we learned.

But with the evolution of the information era, the remarkable improvements in radiologic image quality and test performance, and the speed with which those images and test results are acquired and reported, deductive reasoning and judgement in our Emergency Rooms and offices based on careful history and physical examination has given way to a plethora of testing. God forbid you miss something. Better to shot-gun it rather than limit it. It is far easier to explain a negative test finding than a missed diagnosis. But what about the unexpected findings of, say, a positive troponin from a person with an inflamed toe from gout? Should a cardiologist be consulted? What are the risks to the doctor if there is a heart attack underway?

With the constant drumbeats of "quality" and "safety" echoing in doctors' heads coupled with shortened office visits and overriding liability concerns, a psychology of professional protectionism has come to trump judgement. There simply is no reward for proper judgment in our system, even though there are lots of reasons for false positive troponins. But it is difficult to explain this to a concerned patient and only huge financial and emotional downsides if you're wrong.

So the cardiologist is consulted, the echo obtained, and the nuclear treadmill performed, even as our judgment tells us otherwise.

It's just too risky to do otherwise. After all, it only takes one subpoena.

But as we limit doctors' salaries, drug costs, restrict certain testing (as much as we can), and limit hospital stays as much as we can through policy after policy, we must ask ourselves why we consistently fail to limit liability as the costs continue to spiral ever higher.

Up and up and up.

But limiting liability would require some judgement now, wouldn't it?



Strong One said...

It's almost as if every complaint means that there HAS to be something wrong with me (the patient).

A simple 'this will pass' or 'this is temporary' is NOT good enough.
With the advent of the internet and the over-saturation of mis-diagnosed and altered-reality illnesses, patients these days are almost demanding an illness be there diagnosis.

A wild, wild, world we are living in.

Julie said...

Have just been reading a paper speculating on why health costs are spiraling in Britain and the EU. It mentions a whole lot of factors, but one factor it doesn't mention is liability. Interesting.

Andrew Garland said...

Clearly, the endpoint is to eliminate the doctor's judgment entirely, except to view and record symptoms. Feed the symptoms and test results into a database supported, probability-tree directed, master medical program, and do what it says. Why waste time training doctors, when such a database remembers everything and can only grow larger and more sophisticated over time. Like a bureaucracy in a box, but so much faster and wiser.

The probability-tree can be tuned to meet financial restrictions, giving the most bang for the buck. The outcome of every patient is fed back in, as a continuous multi-variate study. With thousands of inputs and untrackable outputs, it goes beyond the understanding of mere mortals. And, you can't sue a probability tree, especially one supported by the government.

Of course, different people will want to become doctors, and there is the nagging problem of who will operate listening to the guiding voice of a Medical Garmin GPS Navigator (cut here, turn there). Maybe the outcomes will decline a little, in a fair and just way for everyone, but rational, complete, detailed process is more important than outcome. Do we really want a system where you get better care if you pay more (to the doctors)?

(I have to say that this is sarcasm. It can be hard to tell sometimes, looking at proposals for unified, national medical care.)

See also something that I didn't know, but most doctors probably do, Reject Medicare and lose Social Security

The Happy Hospitalist said...

many complaints have a way of disappearing on their own, when given time to do nothing.

Anonymous said...

I see the same thing in my field... I am an airline pilot and have seen our authority whittle away over the years. We have to fight our own dispatchers for additional fuel because years of experience tells us that traffic in the New York area is likely to be heavy and that holding is an assured thing. The dispatchers don't like adding fuel because that adds weight and costs money.

We have to fight with gate agents over the removal of passengers that are obviously intoxicated before they get on the plane. We know from our experience that higher cabin altitudes are going to exacerbate the inebriated condition and it is going to be our problem to deal with, not theirs. Their only concern is that the passengers rights may be violated and they don't want to have to handle any additional paperwork!

Somehow we have lost our ability to stand up and wave the BS flag as today, no one is listening (or no one cares).