I Didn't Practice Evidence-Based Medicine Today

[flashl]

Reuters

FROM BLOG: Dr. Wes - News and opinion on health care issues from the perspective of an internist, cardiologist and cardiac electrophysiologist.

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.

...

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.

[Barack_America]

1. And saved thousands of dollars in the process, but...

Opened him/herself up to a potential lawsuit.

That's medicine today, folks.

[DU9598]

3. How so?

If you really think that there are successful medical negligence suits still possible in America, then I need to find out what you are smoking. Seriously, if there is a legitimate medical negligence claim you can be sure that the republican dominated appeals courts will take away the monetary judgment.

[Barack_America]

5. Saying "lawsuit" doesn't assume success.

For example, the doctor noted peripheral neuropathy and didn't work it up. If this guy ends up with an amputation due to untreated peripheral neuropathy and subsequent infection, the doctor could find him/herself sued. True the patient's primary care physician and the admitting general medicine team should have picked this up, but still. Even if the lawsuit is unsuccessful (though it would probably be settled), it's still noted by the doctor's malpractice insurance company and uses court time (i.e. costs money).

And who would you side with then? The doctor, who was focused on treating the cardiac issue at hand and not wasting money on other workups? Or the patient, who was diagnosed with something that was not worked up and could have future consequences?

If we're going to demand a healthcare system that covers all, this is an issue we're really going to have to wrestle with (the "do I waste money working everything up to save my ass vs. focus on the issue at hand and save the system some $" issue)

It would be interesting to know whether the doctor noted that peripheral neuropathy finding in the patient's chart. My guess would be "no".

[Fire_Medic_Dave]

10. I have a retired doctor friend that does malpractice consultation.

He tells the lawyers which cases have clear malpractice, they rarely have to sue, the insurance companies settle quickly. If they do have to sue they are successful about 80% of the time.

David

[gblady]

4. did you read the assessment of the patient....

the intervention seems quite reasonable given the health status.

[Barack_America]

6. I did...

And yes, the patient would most likely not live long enough for that peripheral neuropathy to become a serious issue.

But would you note that finding (without subsequent workup) in the patient's chart?

[godai]

2. But there's $$ in all that testing!

I saw a news story yesterday about dentists doing screening for diabetes, cholesterol and C reactive protein etc. Of course, the dentist suggesting this has a business to manage these tests. Occasional screening, maybe as part of an annual physical, can be useful but diet and exercise are the 'cures' for a lot of these medical issues.

[postulater]

7. "I just practiced medicine."

And what was that? What DID you do?

I guess it's a cliffhanger waiting until the next blog entry.

Can hardly wait.

[Warpy]

8. I've been uninsured for 20 years

and I've had to remind docs that practicing empirical medicine is the best way to go with me. If their best first guess as a diagnostician turns out to be wrong, then there would have been little outlay lost. Fortunately, most docs I've run across have been fine diagnosticians. I've just reminded them that technology to confirm their diagnosis hasn't been necessary.

When they see me, they have to realize that dealing with the problem at hand is the best policy because I can't afford having them touch all medical bases to find problems I don't know I have.

The above patient was a train wreck and he's probably going to be dead in a few short months. The best policy was to treat what was making him most uncomfortable in the least invasive manner. Looking at long term issues would have been futile.

[Orrex]

9. They should invest him in a slow-growth B-Share mutual fund, while they're at it

In just eight short years he can get out without paying a fee.