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.

Anonymous said...

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

Robert W Donnell said...


Anonymous said...

Well said!

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

Anonymous 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