Issue 33 / 8 September 2014

I RECENTLY returned from a wonderful trip with an even more wonderful woman who just turned 80.

With her permission, I want to tell you about recent encounters she has had with the health system and what we can learn from them. We might get some clues about cost drivers and priorities, and how to redirect them. I will call her Mrs E.

Late last year, Mrs E was waiting for a bus, having refused a lift home. Bored with waiting, she started to walk to the next stop. Seeing the bus approaching, she made a run for it, tripped on her shoe heel, and fell onto the footpath, hitting the back of her head.

She was not knocked out but had a bleeding laceration on the back of her head and was taken by ambulance to a major teaching hospital, where she was seen by the trauma team. Scans of her head and neck were both normal and she was kept overnight for observation.

Mrs E mentioned to a nurse that there was blood on her pillow. The pillowslip was changed.

Later, she was discharged home, with a mess of coagulated blood and hair on the back of her head —– and no sutures.

A healthy older woman, not taking anticoagulants, who had a mechanical fall and the only injury she sustained wasn’t treated.

Fast forward to the second episode. Mrs E’s younger sister has recently had a stroke. Mrs E develops pain in her neck and is worried she may also be having a stroke. She can’t get in to see her usual GP, so goes to a medical centre.

The doctor orders a neck computed tomography (CT) scan, which shows a goitre, provoking a thyroid scan, which leads to a biopsy. The referring doctor does not know that she previously had radioactive iodine for hyperthyroidism, that is now resolved.

A few tests, time, expense and anxiety, and she is also OK.

The third episode occurs on a holiday Monday, when Mrs E decides to treat herself to a movie. She eats takeaway salad and starts to feel sick while in the movie. By that night, she has vomiting, diarrhoea and severe abdominal pain, leading to another ambulance trip to a teaching hospital emergency department.

Someone thinks she may have cholecystitis, so she is admitted and given antibiotics. She rapidly improves clinically, but her liver function tests are abnormal. Her biliary ultrasound is normal, but more consultations and tests ensue.

The CT cholangiogram shows a possible filling defect. Her history and tests are all consistent with bacterial food poisoning (most likely salmonella), and she is almost back to normal, but a cholecystectomy is discussed even though she has never had biliary colic before or since.

Thankfully, her family encourage the hospital team to leave her alone and let her go. She is back to her normal self in no time, and gets to enjoy an overseas holiday, with fantastic food, symptom-free.

So, what is it that makes clinicians treat the test results and not the patient? Are we so afraid of missing a diagnosis that we miss the patient entirely? Why can’t we investigate sequentially, rather than by a scattergun approach? Are we too pressured to move patients along an assembly line, or have we just lost the skill to manage people as individuals?

This wonderful woman has maintained her good health. She is active, social, watches her diet and has a positive attitude to life.

When she has a symptom, a concern or a problem, what she needs is for the people involved in her medical care to listen, understand and take a patient-based approach — not just conduct a battery of tests. And we need to look closely at her — look at the person she is, not just at her results.

It is part of human dignity to accept risk. Mrs E is not risk-averse, so why are we?

 

Dr Sue Ieraci is a specialist emergency physician with 30 years’ experience in the public hospital system. Her particular interests include policy development and health system design, and she has held roles in medical regulation and management.

13 thoughts on “Sue Ieraci: Testing risk

  1. University of Tasmania says:

    There is plethora of those stories out there and surely we (the profession) must take much of the responsibility for how we have allowed the “investigate everything” approach to be regarded as “good medicine”.

    My normally fit and healthy 87 yr old mum visited her GP with an itchy lesion on her arm. While there he takes her blood pressure (never had history of hypertension) and notices an irregular pulse. ECG shows AF. Off to the cardiologist for Echo and a battery of other tests and put on Beta blocker, Amiodarone, Statin, PPI and Warfarin. Attempted cardioversion but only a few days of sinus rhythm before reverting to AF. Has to make multiple trips to the Pathology “Warafin Clinic” as GP does not do point of care INR. Difficulty stabilising on Warfarin so gets switched to Dabigatran. Told she can’t take any NSAID (her only medication prior to all this) because of the anticoagulants and risk of GI bleed. Paracetamol does nothing for her joint aches and stiffness so mobility suffers. Falls and breaks neck of femur. Confined to hospital bed for 3 days as can’t do surgery until dabigatran wears off. Very slow recovery from surgery and now petrified of further falls and loss of much independence.  Subsequently several short admissions to hospital with “dizzy turns” and more tests.  Life now revolves around visits to GP, cardiologist, general physician, haematologist, orthopaedic surgeon – and dermatologist for the skin lesion. I know this is just an anecdotal case but surely the message is: Don’t go looking for asymptomatic pathology at age 87.

  2. Robert Millar says:

    Sue, I think there are probably a few factors at play here. One of the major ones is that EDs are now under significant political/bureaucratic pressure to achieve time-based KPIs, which has two effects. One is that investigations are much more “front loaded” to reduce waiting time down the track, leading to more tests being done based on less history-taking and examination, leading to false positives or the odd tangential finding. The second is that having excluded the “worst case scenario(s)” there is always something more pressing going on than tying up the less critical details.

    Mrs E may not be risk-averse, but many are. If a patient is seen in ED for abdominal pain, and appropriate care treats her food poisoning, but sometime later she is found to have gallstones, often the ED is criticised for having “missed” the gallstones. This is played out in many scenarios.

    The sequential diagnostic process that you advocate (and I would entirely endorse) would require a different bureaucratic environment which allows clinicians to take the time to gain more insight into their patient, as well as an understanding by patients and those in the health professions that they contribute to a patient journey which has many contributors and evolves over time, rather than discrete episodes where everything should be covered at the “one stop shop”. If we were better collaborators we might feel more comfortable to listen and be a horse whisperer, rather than a zebra hunter.

  3. norman lewis says:

    I refer you to the 2012 book by Leana Wen and Joshua Kosowsky,When Doctors Dont Listen,How to Avoid Misdiagnoses and Unnecessary Tests.

  4. Andrew Wawryk says:

    Although I’m now old enough to be accused of being in the “better in my day” cohort, I sincerely believe I’ve been witnessing a decline in clinical skills, as routine investigations replace clinical expertise.

    One example is the high proportion of recent trainees I have noticed do not have a good hip examination technique.Taken in conjunction with the emergence of universal U./S.screening of babies born breech, it set me wondering.

    I’ve seen studies indicating reduced rates of undiagnosed hip dysplasia with universal screening, but none which indicates significantly more missed diagnoses when best hip examination techniques are universally applied, compared with U>/S.

    I can’t help wonder if the deskilling informs these study results, then further reduces the clinical expertise of the upcoming generation.

    One way to test this concept is to look and see if there’s a clinically asymptomatic group, amongst a universally screened population, with high quality neonatal hip examinations rigorously applied.

    I suspect the result would show we could be saving a lot of money and manpower. This at a time when good medical economics has never been more important. Perhaps this approach could be more broadly applied to other clinical techniques?

  5. Colin O'Shea says:

     Criticism for not diagnosing assymptomatic cholelitiasis should be given its due attention and ignored. We should be aiming to provide clinical care based on best practice, not to stave off inappropriate criticism.

  6. Department of Health Victoria Clinicians Health Channel says:

    One of my favourite aphorisms is:

    “Tests are lies and shadows; truth comes from the patient”.

     

     

  7. Avni Sali says:

    In general doctors are paid better to see more patients per time rather than spend more time with them. It is far quicker and more rewarding  to write out an investigation request rather than talk to patients.

    The worry of legal consequences certainly does not help.  

     

  8. Steve Flecknoe-Brown says:

    Thanks so much for raising this locally, Sue. The American Board of Internal Medicine Foundation’s Choosing Wisely campaign has had a lot to say about unneccesary testing, as has the Australia-based Preventing Overdiagnosis movement.

    The world-wide consensus is that 30% of tests ordered, medications prescribed and surgical procedures performed are either not justified or lack compelling evidence of a benefit. This has recently been the mantra of Don Berwick, the former US Patient Safety and Quality guru who became Administrator of Centers for Medicare and Medicaid. 

    Rob, the time-based KPIs in the Emergency Departments merely reflect good practice. I am sick of hearing them blamed for all sorts of inappropriate behaviours by ED doctors. Ordering a battery of tests at presentation then pursuing the ‘positive’ ones as they come back takes a lot longer than taking a proper history, performing a competent physical examination and formulating a differential diagnosis. Australian medical graduates used to be held in esteem world-wide for their physical diagnostic skills and discipline: it’s time that ED doctors were re-taught clinical medicine.

    If we could eliminate wasteful behaviours like unnecessary test ordering, prescription of medications which lack an evidence base and surgical procedures with dubious outcomes, we would not need to talk about cost restraints, co-payments and the like.

  9. Adrian R. Clifford says:

    Times have changed over the last 50 years when I graduated as a doctor. Today we have all methods of investigation which were not available then. In those days we took a good history examined the patient and came up with a list of provisional diagnoses. We would investigate the most likely of these diagnoses with apropriate tests…Xrays, pathology and microbiology and treat the patient accordingly. What has changed apart from newer investigative tools, is the increased pressure not to make a mistake for fear of legal prosecution.  This over riding pressure has caused over investigation and treatment of minor ailments rather than treating the patient holistically.

  10. Robert Millar says:

    SteveFB, I’m also sick of hearing that the time-based KPIs have altered the practice of Emergency Physicians, but they are the ones telling me how conflicted they feel. Individuals need to be aware of the impact they are having on their thinking and motivations when providing care, and prioritise patient care over the other demands being made of them. The point of Sue’s article seems to be that doctors need to spend more time deciding with the patient what their priorities are, and not practising template-style medicine which has time-restrictions and legal overtones.

    I’m not sure in what area of medicine you practice, but similar behaviour changes were evident when “6-minute medicine” became an issue in general practice due to medicare, and are also evident in various aspects of radiological and surgical practice (and there are probably many I’m not aware of) due to the vagaries of MBS definitions etc.

    When I think of good practice the useful measures seem to be related to patient outcome and satisfaction that their needs have been met. These are not something that time-based KPIs measure, and so to say that they are a reflection of good practice is a nonsense… they reflect a populist political decision that has already been shown to increase mortality where they were first introduced in the UK.

  11. David Henderson says:

    I work in a number of regional hospitals and I agree to some extent with the comments made above about limited history taking.  Whilst many diagnoses may be apparent without detailed histories, a good listen and look at the patient often provide the answers or narrow down the posibilities and determine the need for and the relevance of tests and their results.  Busy emergency departments driven by KPIs and protocols are not good places for practicing good medicine.  Work practices that have registrars admitting patients in the evening and through the night limit good clinical practice.  

    There are a number of dangerous syndromes, including the patient with chest pain that is labelled “atypical” because the troponin is negative,  who is discharged to die of his infarct and the patient with abdominal pain who is not seen by the surgical registrar, because the CT scan is “normal” and or the patient “does not require surgery”.  

    Determining the need for and significance of test results requires clinical skill and an integration of the clinical and investigational findings that is not posssible if the clinical findings are deficient or absent, but it should always be remembered that the practice of good medicine is a skill that is difficult and sometimes impossible to aquire.

    History taking connects the doctor and the person and gives the doctor an insight and a basis for that person to trust the doctor.

     

  12. Michael Moont says:

    I have been trying for years to answer Sue’s question  as to why  we trust the test results and not the patient.  I beieve it is a result of a change in teaching methods in the clincal setting.   It is  no longer politically correct to teach in the manner of Sir Launcelot Spratt, the self confident boss who teaches by putting the intern on the spot with a degree of bullying and causing embarrassment.   Certainly, such teachers could be over the top and it would not be tolerated today but it did have the effect that the intern soon learned that he was obliged to make a clinical decision and there were consequences for being wrong, the most immediate being the scorn of his consultant.   We thus trained doctors to seek the information they needed to justify their diagnoses and the confidence to stand by them under scrutiny.   It seems to me that these days the intern is not even required to be with the consultant on rounds or in theatre — no wonder they are not learning.    

  13. Ulf Steinvorth says:

    Our hospital and ED system is often ‘under-listening’ and instead over-investigating leading to red herrings and more importantly serious errors and omissions by trusting test results more than patients, we all seem to agree on that. Blaming the junior doctors seems incongruous as it happens throughout, blaming the ‘system’ of KPIs, staffing and funding is probably appropriate but will not change anything unless we are prepared to change it.

    This article by an experienced ED staff specialist hits a raw nerve judging by the many informed and passionate responses – maybe it’s time to check the evidence for what we are doing and whether we are getting it right. Maybe putting most of our money into high level hospital care and very little into decent primary care is not the best use of resources?

    Rushing around like the mad hatter trying to fix the disasters once they have occured is a neccessary part of our healthcare system but maybe we can achieve more by making some of these resources available to listening and to personalized medical care inside and outside of the emergency?

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