Doing Less

My only incentive to do less for a patient is because it’s the right thing to do.

A common example is upper abdominal pain most likely from severe gastritis or acid reflux. Patients just can’t believe that their stomach hurts that badly from something like that. They often have a history of acid reflux, but this episode feels different to them. It is lasting longer than usual or is more severe.

There are not many actual disasters that cause pain in the left upper abdomen. We consider them all. Rarely, upper abdominal pain is from a cardiac issue given the right patient characteristics and risk factors, but a cardiac problem that is truly an emergency often comes with other symptoms. Constipation or some other pain from the GI tract can cause pain anywhere in the abdomen. Actual bowel disasters like a bowel obstruction or perforation usually cause a lot of pain. Rarely, a lower lobe pneumonia can cause pain that seems to be in the upper abdomen. A splenic artery occlusion or aneurysm is a rare cause of upper abdominal pain. A ruptured peptic ulcer certainly causes pain. Gallbladder problems are usually in the right upper abdomen or midline but sometimes cause pain on the left. Pancreatitis can cause upper abdominal pain. (There are more things, but those are some of the most common.)

The problem in the ER is that there is no definitive test for gastritis and acid reflux. CTs don’t show gastritis or acid reflux. They rarely show a gastric ulcer. The diagnosis is based on the clinical presentation and excluding other causes of pain. It seems that more and more, patients are not happy with a presumptive diagnosis. Most of them want a CT scan despite the time, the IV, the risk of giving IV contrast (which is low but not zero), and the dose of radiation from a CT scan (also low, but not zero).

Without the CT, I might miss one of those rare things. But ordering a CT scan for young patients is not good medicine. Older patients have a much higher risk of having all kinds of more serious diagnoses, so abdominal CT scans in the elderly make sense almost 100% of the time. Young people with no medical problems besides prior acid reflux don’t need CTs.

Convincing patients of this is hard. It often takes multiple conversations as I explain what is likely going on and the lack of benefit of a CT scan. This takes time that I don’t always have.

I’m not incentivized to do less. In fact, I’m incentivized to do more.

My liability is higher if I don’t do a CT scan. The chance of missing something is small but real. But that’s also true of every patient I see in the ER. The less I do, the more I need to justify it with good clinical decision making. I have to be able to articulate all the reasons why I think something is going on that I can’t actually prove.

The cost to the patient will be higher, but most patients are not concerned about that. The system can charge more for the visit due to the added complexity of doing a CT scan. Every hospital system wants/needs to make money, so Big Medicine is fine with a CT even if not entirely necessary.

The long-term risk of radiation and potential cancer risk down the road won’t be blamed on me. There are too many factors at play that 20 years from now, an oncologist will diagnose cancer and suggest to the patient that it was my fault for ordering a CT scan—even if the patient gets CT scans monthly for their chronic abdominal pain. Obviously, that many CT scans is terrible medicine, but I can only control my part of the interaction with the patient in front of me and what they are telling me about their symptoms.

Not doing what the patient wants can lead to patient complaints and decreased satisfaction—even though there are studies showing worse outcomes for patients who get to pick and choose what gets done. More is certainly not always better. I don’t need to make my life more complicated by having to respond to a patient complaint that gets sent to my medical director and the ER/hospital.

I’ve been having conversations with patients for 20 years, and I do my very best to explain what we are doing and why. I routinely sit down and review all the patient results at the end of a visit. We review labs in detail and what they mean. We look at any images that have been done and what the results mean.

Convincing patients they don’t need something is one of the hardest things to communicate. Again, without 100% certainty—which I don’t have—many patients will not be satisfied. And this takes time. Most of the time, I don’t have time. The ER is usually busy, so having a very long, detailed conversation and having to do it multiple times does not benefit the rest of the patients waiting to be seen. I do my best to give each patient the time and attention they deserve. But at some point, I have to move on. If multiple conversations are not effective, I’ll just order the CT.

Liability goes down. (Good for the system and me.)

Billing goes up. (Good for the system, bad for the patient, no change for me.)

Patient complaints go down. (Good for me.)

Patient satisfaction goes up. (Good for me, not proven good for the patient.)

My satisfaction goes down. (Bad for me.)

My time is freed up. (Good for other patients.)