In the medical world, when a physician, a scientist, a
hospital, a drug company or a panel of experts issues a report, the games
begin. If one agrees with the statement
or benefits from it, then the report is heralded as breakthrough
brilliance. If, however, the report
suggests a new medical pathway that diminishes your relevance or reimbursement,
then the report and its authors are regarded as misguided. Yes, I am generalizing somewhat here, but you
get the point.
As readers of this blog know, I am a conservative medical
practitioner. I do not mean conservative
as in supporting the NRA, prayer in public schools, self-deportation of illegal
aliens (or should I say ‘undocumented residents?), ‘clean coal’ and lower taxes
for millionaires and billionaires.
Conservative physicians describe those who are extremely judicious with
regard to medical treatment and diagnostic testing. We don’t lurch to treat or test unless a high
threshold of necessity and effectiveness is crossed. Before ordering a medical test, two questions should be considered.
Will the results of the test under consideration potentially
change the medical management of the patient?
Is the change in medical management referenced above in the
patient’s best interests?
Gallstones
Let me illustrate why the 2nd question above is so
critical. For example, assume a surgeon
orders an ultrasound on a patient with abdominal pain to determine if
gallstones are present. This test seems
reasonable as the result of the test may change the medical management of the
patient – the point raised in question 1.
So far, so good. If gallstones
are present, then the surgeon removes the gallbladder. But, if this is not the correct treatment
(because the pain is not caused by gallstones), then the principle in question
2 has been violated. In this example,
the physician feels that the ultrasound
test was needed as it led to gallbladder removal. He feels that the test changed the
management of the patient – which it did – but it led him down the wrong
path. So, the test was not reasonable and should not have been ordered in the first place.
I make this point as for years during medical training and
afterwards, I have been told and have read that tests should only be done if
they might change medical advice. This
is true but not the whole story. Left
out of this medical maxim is the more important point that the new medical
advice must advance the patient’s medical interest.
An oncologist may recommend a CAT scan because if new cancer
is found, then new treatment will be prescribed. Does this strategy pass the two question test
I have raised here? Sometimes yes, and
sometimes no.
Is there anyone out there who doesn’t believe that we are
testing and treating patients excessively?
This same two-question strategy can be applied to a medical
commentary blog to assess its worth.
Does the blog potentially change your point of view?
Is this new viewpoint enriching you?
As always, readers’ views are earnestly solicited.
As an R. N. and a patient, I don't stay with a "liberal" physician who orders tests willy-nilly. There can such a thing as too conservative, however, when a test result, in light of my age, showed clearly that I had a parathyroid adenoma, but instead I was praised for having such a nice, high calcium level! I had it for over 5 years before my newer physician picked it up. He is wisely conservative, but also willing to look at symptoms outside of his field of cardiology when said symptoms aren't in alignment with his specialty. I also happen to feel much more comfortable with a politically conservative physician, as I feel that I can trust him far more than one who is stuck on Obamacare, which is a disaster.
ReplyDeleteBarbara, if I had a category on this blog entitled, Comments Quality, yours would be entered. Well stated. Visit often.
ReplyDeleteI've had several doctors that are too conservative also and they've hurt me worse than the liberal ones.
ReplyDeleteIts the liberal ones who did cover all the bases that helped me to find an answer.
Now to just get the docs to treat the problem.
Randy
Aw, thanks, doc! You made my day! :-) I follow your blog on Bloglovin' and quote you freely!
ReplyDeleteDr Kirsch, in your opinion as a gastroenterologist, are surgeons too ready to perform lap chole for biliary dyskinesia (i.e. low gallbladder EF on HIDA scan)? Do you believe that a more "conservative" approach to biliary dyskinesia is warranted, or that too many lap choles are being done for this indication?
ReplyDeleteWhile I do not offer any specific medical advice on this blog, in general, biliary dyskinesia is a tricky issue that is not easily defined. There is no single and satisfying answer on how to approach it. Biliary endoscopists are generally the most knowledgeable on this issue and should be part of the conversation.
ReplyDeleteDr Kirsch, I actually asked my question regarding biliary dyskinesia because I am a general surgeon and am frustrated by the ubiquitous "abdominal pain/GI distress + low gallbladder EF" consult. Even after reviewing the literature, I am often unclear how to proceed. The patients all seem to want their gallbladders out ASAP because someone convinced them that they would feel so much better so soon -- I end up being the bad guy that tries to slow down the wagon train.
ReplyDelete@anonymous general surgeon, your dilemma is not quite a quagmire. If the cholecystectomy does not make sense, help the patient understand the folly of going through an unnecessary procedure. "Would you want to undergo surgery, with it's risks, if there is only a 5% or less chance that it will help"? I'm sure that you are aware that there is often a placebo effect after gallbladder (GB) removal when the GB was not responsible for the pain. If patients or their MD's insist on donating a perfectly health GB, then you might gently advise a 2nd opinion with an 'expert' at your local medical mecca. I assure you that you will not be a hero if the patient continues to have pain after an operation where there were hopes for a cure. Moreover, if there is a surgical complication, then would you be comfortable that the surgical indications were solid?
ReplyDelete