I came home for lunch and my wife was reading my CMAJ and showed me this article. I was a little taken back.
Certainly when one is blogging, if you are going to have fun and have a blog that people might actually read, it is necessary to criticize and make fun of individuals and institutions. That is why I remain semi-anonymous and use nick-names. For example I call the institution where I used to work, "The Centre of Excellence". Just about every university town has a "Centre of Excellence". I trained at one.
The article gives the example of an ER resident who vents his frustrations at patients, staff and life on his blog resulting in disciplinary action. It is of course a hypothetical case. This made me wonder for a second why it seems that emergency doctors have so many blogs but then I realized that next to proctologists ER docs have the most interesting and funny cases.
Now a while back I indulged in some gossip about a local physician. Some people might consider this a breach of patient confidentiality and while somebody did in fact breach doctor-patient confidentiality, it was not me. Trust me, I am usually the last person to hear juicy rumours. Also I have never established any doctor patient relationship with the individual. This is extreme rationalization I know, but when the blog police show up, that will be my defence.
I should mention that over the years I have given anaesthetics to or treated my clinic, famous athletes, politicians and other notables. I never even tell me wife who I did (at least not anymore
Thursday, July 31, 2008
Not enough information
I am a consultant. This means my job is to help other doctors with their patients. I am a little baffled by why other doctors perceive me as smarter than them in a least a very small way.
As a part-time chronic pain doctor, all my patients come to me by a referral.
Some chronic pain patients are very simple. I can take a history and examine them, come to a diagnosis and suggest or initiate treatment.
Most chronic pain patients are more complex. They have had a lot of procedures, medical trials and investigations. To properly assess this, I need to know what they have tried, for how long and in what dose. For example 100mg of gabapentin is a lot different than 3600 mg of gabapentin.
About a year ago, I saw a patient who had moved to town from another community. He had been getting injections with Botox from another doctor and wanted this continued as it seemed to have been working. He was however very vague about where or how much possibly due to a head injury or PTSD. Unfortunately the consult did not have much more than his name and healthcare number. A lot of times I can figure out what to do without my information. This patient wasn't one of those times.
Anyway I took the initiative to call the other doctor up and either discuss the patient or get the file.
This doctor as it turned out has the receptionist we all hate. She answered the phone, "Dr. X's office can you hold" and before I could reply, I was on hold. I put my phone on speaker and killed time for 10 minutes before I hung up and dialed again. The same thing happened. The third time I was ready and was able to interrupt her. I told her who I was, that I would like to talk to her doctor, that I knew she was busy and that I could give him a number to call at his convenience (GPs can actually bill the healthcare system for such phone calls). She just said, "well we're busy" and put me on hold again.
I therefore gave up trying to talk to this doctor or for that matter his receptionist. I dictated a letter and I asked for a copy of his records on this patient. I had told the patient that when I got the letter I would call him in for treatment.
Months passed. Every once in a while, usually while somebody else had me on hold, I would think about the case.
I came in this morning and found a handwritten note from the patient asking why several months later I had still not treated him. Apparently he had showed up the evening before in very bad humour and hassled the receptionist about why I hadn't seen him.
Any in a few weeks I will try to muddle my way thru a very unhappy patient.
Now in the 15 or so years that I have been seeing patients, this lack of documentation has been a major problem for me. When I worked at of CofE we actually designed a form where we asked for more information and would not book the patient until we had received the information. The thing is, most doctors offices have fax machines now; it is a simple matter to fax the rel event documents. It would take a secretary less than a minute. I know this because I frequently fax stuff myself (I thought it was neat when I learned to use a fax 10 years ago).
Almost worse than the family doctors are specialists who refuse to send you a copy of their consults when the family doctor either hasn't or can't send you a copy. Next to them are the family doctors who copy their entire chart so I have to sift thru the pap smear results to find the MRI report. Hospitals now seem to put their records on micro-film after about two years and actually ask you to come down and look for the records on the little micro-film viewer.
The monthly newsletter our friendly college puts out actually has a letters section. About a year ago, a family doctor actually wrote a letter to complain about the bad specialists who were demanding he send them information so that they could actually do a proper assessment on the patients he sent them. Now I would have thought that this would merit a public written tongue lashing from the registrar but it was in fact just published without comment.
(I should note that I did after I posted this (after I sent off an angry letter to the FP copied to the college) that I got an appologetic letter from the FP along with the info requested.)
As a part-time chronic pain doctor, all my patients come to me by a referral.
Some chronic pain patients are very simple. I can take a history and examine them, come to a diagnosis and suggest or initiate treatment.
Most chronic pain patients are more complex. They have had a lot of procedures, medical trials and investigations. To properly assess this, I need to know what they have tried, for how long and in what dose. For example 100mg of gabapentin is a lot different than 3600 mg of gabapentin.
About a year ago, I saw a patient who had moved to town from another community. He had been getting injections with Botox from another doctor and wanted this continued as it seemed to have been working. He was however very vague about where or how much possibly due to a head injury or PTSD. Unfortunately the consult did not have much more than his name and healthcare number. A lot of times I can figure out what to do without my information. This patient wasn't one of those times.
Anyway I took the initiative to call the other doctor up and either discuss the patient or get the file.
This doctor as it turned out has the receptionist we all hate. She answered the phone, "Dr. X's office can you hold" and before I could reply, I was on hold. I put my phone on speaker and killed time for 10 minutes before I hung up and dialed again. The same thing happened. The third time I was ready and was able to interrupt her. I told her who I was, that I would like to talk to her doctor, that I knew she was busy and that I could give him a number to call at his convenience (GPs can actually bill the healthcare system for such phone calls). She just said, "well we're busy" and put me on hold again.
I therefore gave up trying to talk to this doctor or for that matter his receptionist. I dictated a letter and I asked for a copy of his records on this patient. I had told the patient that when I got the letter I would call him in for treatment.
Months passed. Every once in a while, usually while somebody else had me on hold, I would think about the case.
I came in this morning and found a handwritten note from the patient asking why several months later I had still not treated him. Apparently he had showed up the evening before in very bad humour and hassled the receptionist about why I hadn't seen him.
Any in a few weeks I will try to muddle my way thru a very unhappy patient.
Now in the 15 or so years that I have been seeing patients, this lack of documentation has been a major problem for me. When I worked at of CofE we actually designed a form where we asked for more information and would not book the patient until we had received the information. The thing is, most doctors offices have fax machines now; it is a simple matter to fax the rel event documents. It would take a secretary less than a minute. I know this because I frequently fax stuff myself (I thought it was neat when I learned to use a fax 10 years ago).
Almost worse than the family doctors are specialists who refuse to send you a copy of their consults when the family doctor either hasn't or can't send you a copy. Next to them are the family doctors who copy their entire chart so I have to sift thru the pap smear results to find the MRI report. Hospitals now seem to put their records on micro-film after about two years and actually ask you to come down and look for the records on the little micro-film viewer.
The monthly newsletter our friendly college puts out actually has a letters section. About a year ago, a family doctor actually wrote a letter to complain about the bad specialists who were demanding he send them information so that they could actually do a proper assessment on the patients he sent them. Now I would have thought that this would merit a public written tongue lashing from the registrar but it was in fact just published without comment.
(I should note that I did after I posted this (after I sent off an angry letter to the FP copied to the college) that I got an appologetic letter from the FP along with the info requested.)
Monday, July 14, 2008
Bugs and Drugs
I have spent the last few days doing largely orthopaedic "emergencies". While this is good mindless work, it has entailed administering multiple doses of Ancef.
When I first started out in medicine, the dose of Ancef was 500 mg. Now 1 g is the routine dose, 2 g is more common and 3 g no longer surprises me. Nobody seems to comment on this dose inflation.
While published data suggests that if Ancef is to work , it must be administered 2 hours early, normal practice is for it to be administered by the anaesthesiologist in the OR at the beginning of the case. This is a practical matter as most patients have their IV started in the OR; even patients however who have been in hospital for several days on IV fluids are sent to down to have their first dose of Ancef given "just in time". This means that Ancef is usually administered at an inopportune time at the beginning of the case, when you are trying to give other drugs watching the blood pressure on induction, moving and positioning the patient etc. It is hard to predict in which patients the surgeon wants Ancef, some of them just assume you will give it and get mad when you haven't correctly read their mind. Not infrequently the surgeon doesn't want Ancef until after he has taken cultures (you are supposed to figure this out too!) Quite frequently I find the little mini-bag in the chart in the middle of case well after the tourniquet is up or I find that the nurse has placed it in an inconspicuous spot on my table.
Other surgeons just ask, "Can the patient have some antibiotics?". While I am quite pleased that they think highly enough of my bacteriologic and pharmacological knowledge to chose what antibiotic they want, I usually ask, "Any particular antibiotic?"
Anyway you get the impression that I find giving Ancef to be distasteful.
Part of the whole issue for me is the cognitive dissonance of the whole issue. I don't remember much from medical school but I do remember something about microbiology and the action of antibiotics. I also took a course in population genetics as an undergraduate.
The bacteria that is giving or is going to give you an infection is actually a heterogeneous group of individuals. This means that every little cocci or bacilli has a different degree of susceptibility to antibiotics. The weaker ones may succumb to one dose, some may require 10 days or more. Now if a patient gets only one dose of antibiotic as quite a few of these patients do, this means that the weaker bacteria are killed off leaving a population of slightly more strong bacteria. This well known with tuberculosis where incomplete treatment of TB has lead to drug resistant strains. The same thing is of course happening to our garden variety bacteria as well.
Another thing, as I found out when I had to buy Ancef for a medical mission (who better to buy Ancef than an anaesthesiologist) Ancef cost $7.00 for 1 g. That is by the way for generic Ancef. So what $7, not even 2 lattes. Remember when Propofol came out? It cost $8 a bottle. Do you remember the hassle we had to go thru to get the bean counters in pharmacy to let us use it, the rationing, the special populations. In fairness to pharmacy they have cracked down on the use of some of the more expensive antibiotics.
Which brings me to a case I did on the weekend amongst all the ortho cases.
This case was debridment of an infected ankle in a patient with Methicillin Resistant Staph Aureus (MRSA). When one of those patient known to have MRSA comes to the OR, the whole OR springs to an even higher level of paranoia and irrationality. The patient comes down from the floor gowned, hatted and masked and is whisked an OR that has been stripped of all it's equipment except what is absolutely necessary. This means aside from the anaesthetic machine, all your equipment is also not in the room. You have to figure out what what you might need, and bring it into the room with you, otherwise you have to ask someone outside the door to pass in the syringes or drugs you need. Having usually no idea what the surgeon is doing or for how long, the case usually involves me repeated going back and forth between the head of the bed and the door to ask for stuff.
Afterwards, the room is closed for cleaning and the patient is parked in a far corner of the recovery room.
All this makes some sense. Nobody wants innocent bystanders in the hospital infected with MRSA, or VRE or even C Diff.
Except quite often a couple of days later, you will inevitably run into the same patient, sitting outside smoking, having walked from his room, into elevator (touching door handles and elevator buttons on the way) and thru the lobby in a cloud of MRSA. Nobody seems to care.
Now a significant number of these patients originally acquired their infection in a hospital. And where do you think these supercharged bacteria originated. Could it be the single doses of Ancef? Am I the only person who has made the connection.
On another tangent, we frequently see in the press estimates of numbers of patient who have died as a consequence of infection with one of these bad bugs like MRSA, VRE or C. Diff. All these are of course the consequence of promiscuous use of antibiotics. Now as a consequence of working at the CofE which among other things is a cesspool of nasty bacteria I probably carry all three of these bugs plus several other nasty ones. But I feel fine.
No doubt many elderly patients or younger patients with significant medical conditions succumb to these bugs. This is however rarely the sole cause of their demise, it was just the final straw that pushed them over the edge. In most cases we are talking of maybe a few weeks taken off their lives. (A nephrologist where I trained always said, nobody dies of renal failure; he was quite right, if you keep dialyzing them you can keep their numbers correct every 2 days until they die of complications of renal failure or of dialysis or even from VRE, MRSA or C. Diff. A fine distinction)
Now occasionally healthy people do succumb to nasty infections like "flesh eating disease" or meningococemia. These are however bugs that are largely sensitive to antibiotics if you can get them in soon enough and in the correct doses.
When I first started out in medicine, the dose of Ancef was 500 mg. Now 1 g is the routine dose, 2 g is more common and 3 g no longer surprises me. Nobody seems to comment on this dose inflation.
While published data suggests that if Ancef is to work , it must be administered 2 hours early, normal practice is for it to be administered by the anaesthesiologist in the OR at the beginning of the case. This is a practical matter as most patients have their IV started in the OR; even patients however who have been in hospital for several days on IV fluids are sent to down to have their first dose of Ancef given "just in time". This means that Ancef is usually administered at an inopportune time at the beginning of the case, when you are trying to give other drugs watching the blood pressure on induction, moving and positioning the patient etc. It is hard to predict in which patients the surgeon wants Ancef, some of them just assume you will give it and get mad when you haven't correctly read their mind. Not infrequently the surgeon doesn't want Ancef until after he has taken cultures (you are supposed to figure this out too!) Quite frequently I find the little mini-bag in the chart in the middle of case well after the tourniquet is up or I find that the nurse has placed it in an inconspicuous spot on my table.
Other surgeons just ask, "Can the patient have some antibiotics?". While I am quite pleased that they think highly enough of my bacteriologic and pharmacological knowledge to chose what antibiotic they want, I usually ask, "Any particular antibiotic?"
Anyway you get the impression that I find giving Ancef to be distasteful.
Part of the whole issue for me is the cognitive dissonance of the whole issue. I don't remember much from medical school but I do remember something about microbiology and the action of antibiotics. I also took a course in population genetics as an undergraduate.
The bacteria that is giving or is going to give you an infection is actually a heterogeneous group of individuals. This means that every little cocci or bacilli has a different degree of susceptibility to antibiotics. The weaker ones may succumb to one dose, some may require 10 days or more. Now if a patient gets only one dose of antibiotic as quite a few of these patients do, this means that the weaker bacteria are killed off leaving a population of slightly more strong bacteria. This well known with tuberculosis where incomplete treatment of TB has lead to drug resistant strains. The same thing is of course happening to our garden variety bacteria as well.
Another thing, as I found out when I had to buy Ancef for a medical mission (who better to buy Ancef than an anaesthesiologist) Ancef cost $7.00 for 1 g. That is by the way for generic Ancef. So what $7, not even 2 lattes. Remember when Propofol came out? It cost $8 a bottle. Do you remember the hassle we had to go thru to get the bean counters in pharmacy to let us use it, the rationing, the special populations. In fairness to pharmacy they have cracked down on the use of some of the more expensive antibiotics.
Which brings me to a case I did on the weekend amongst all the ortho cases.
This case was debridment of an infected ankle in a patient with Methicillin Resistant Staph Aureus (MRSA). When one of those patient known to have MRSA comes to the OR, the whole OR springs to an even higher level of paranoia and irrationality. The patient comes down from the floor gowned, hatted and masked and is whisked an OR that has been stripped of all it's equipment except what is absolutely necessary. This means aside from the anaesthetic machine, all your equipment is also not in the room. You have to figure out what what you might need, and bring it into the room with you, otherwise you have to ask someone outside the door to pass in the syringes or drugs you need. Having usually no idea what the surgeon is doing or for how long, the case usually involves me repeated going back and forth between the head of the bed and the door to ask for stuff.
Afterwards, the room is closed for cleaning and the patient is parked in a far corner of the recovery room.
All this makes some sense. Nobody wants innocent bystanders in the hospital infected with MRSA, or VRE or even C Diff.
Except quite often a couple of days later, you will inevitably run into the same patient, sitting outside smoking, having walked from his room, into elevator (touching door handles and elevator buttons on the way) and thru the lobby in a cloud of MRSA. Nobody seems to care.
Now a significant number of these patients originally acquired their infection in a hospital. And where do you think these supercharged bacteria originated. Could it be the single doses of Ancef? Am I the only person who has made the connection.
On another tangent, we frequently see in the press estimates of numbers of patient who have died as a consequence of infection with one of these bad bugs like MRSA, VRE or C. Diff. All these are of course the consequence of promiscuous use of antibiotics. Now as a consequence of working at the CofE which among other things is a cesspool of nasty bacteria I probably carry all three of these bugs plus several other nasty ones. But I feel fine.
No doubt many elderly patients or younger patients with significant medical conditions succumb to these bugs. This is however rarely the sole cause of their demise, it was just the final straw that pushed them over the edge. In most cases we are talking of maybe a few weeks taken off their lives. (A nephrologist where I trained always said, nobody dies of renal failure; he was quite right, if you keep dialyzing them you can keep their numbers correct every 2 days until they die of complications of renal failure or of dialysis or even from VRE, MRSA or C. Diff. A fine distinction)
Now occasionally healthy people do succumb to nasty infections like "flesh eating disease" or meningococemia. These are however bugs that are largely sensitive to antibiotics if you can get them in soon enough and in the correct doses.
Wednesday, July 2, 2008
Lab Work
I wish I had learned more in medical school.
I did learn, what should have been a very valuable lesson, quite early on during the laboratory medicine part of our pathology course. What I was taught was:
Don't order any investigation where the result (positive or negative) will have no influence on the management of the patient.
With that knowledge in hand out I went into the world.
I learned another thing along the way.
If after talking to and examining the patient, you have not the foggiest what could be wrong, no lab test is going to help you.
Now if you read this blog, you will know that collecting blood for the lab was one of my most favourite parts of internship. Through sheer stupidity I actually used elective time to do orthopaedics thinking I would actually learn something useful. Now on ortho, every admitted patient (and back then there was very little day surgery and no same day admission) whether he was 19 or 90 got a laboratory panel of 24 tests known as the SMAC. This required 5 tubes of blood to be collected. So on my first or second day, I asked the resident, "why do we do so many tests on apparently healthy patients?". He looked me in the eye and said, "Anaesthesia wants them". Naturally all these patients were admitted after 1500 when the lab blood collection went home, which left the blood collection to the interns.
Of course "normal" results are in fact the range that 95% of healthy assymptomatic patients fall into. This means that 5% of otherwise normal patients will have an abnormal result to a test. If you order 24 tests, there is an absolute certainty that at least one will be abnormal. These abnormal tests have to followed up on which of course means more blood work.
Now did "Anaesthesia" really want them. Apparently not as I learned a few years later when I read the guidelines for routine lab work. Here are the current ones:
Now I was able to find these in about 30 seconds because I know where to look for them. If I had googled pre-operative blood work it is little more complicated but by simply looking up the guidelines of your national anaes. society, it should be quite easy. Or you could ask your anaesthesia department.
But why do I even give a shit?
1. I pay taxes
Most healthcare is publicly funded in Canada. A significant amount is publicly funded in the US. I want my tax dollars spend on treating patients not on lab work! As an aside, much of the blood work in my province is done by a private company. Do you thing they have any interest in reducing lab work?
2. Healthcare is a zero sum game
Even in the US, there is a finite amount of money that can be spent on healthcare. That means money spent in one area is money that will not be spent in other areas. Every dollar spent on unnecessary lab work is a dollar that could be spent on something useful like chronic pain.
3. It holds up things.
How often has your day in the OR been disrupted by a cancellation or postponement due to an abnomral lab test that shouldn't have been ordered that has absolutely no bearing on the patient's ability to tolerate surgery. Just the same, you have to cancel the case, or wait while the test is repeated or the necessary follow-up tests are done. Many years ago I saw a patient who had been cancelled a month ago because of an abnormal gamma GT that someone had ordered pre-op. It was elevated so she was cancelled, went for the million dollar work-up which was of course normal and was re-booked. Of course somebody ordered the gamma GT again which was still elevated. Remembering from my time in family practice that this test is a marker for alcohol abuse (or use?) I asked her if perhaps she might have had a glass of wine the night before her testing and lo and behold she said yes. I put her to sleep and she survived despite her abnormal lab test.
4. It delays necessary lab work.
A classic example is the PT/PTT. Nobody would deny the benefit of these tests in following response to anti-coagulant therapy. There are also important in the management of an evolving coagulopathy or in monitoring whether a patient has been off his anti-coagulants long enought to do surgery or stick a needle in. Except...when you order the stat PT/PTT you really need, it is going to be queued up behind all the "baseline" PT/PTTs that have been ordered. Therefore you are going to get back your PT/PTT long after you have already bit the bullet and given the FFP your patient may or may not have needed.
5. Nobody looks at it or does anything about it
Sadly, that is the case. We order all this stuff and it gets filed in the chart and nobody looks at it. This includes abnormal lab work which frequently isn't followed up on. Chest X-rays are the classic which are often ordered pre-op and reported on post-op. As I found out as a resident, actually going to X-ray and looking at the CXR is no help. The one and only time I tried that, the tech at the film library laughed at me. Actually at our hospital, CXRs are available on-line now if I could just find the time to fill out the stupid form, make up a password etc. EKGs of course go off to be reported by the cardiologist which means they sit on someone's desk until look after the surgery.
6. Surgeons actually think lab work is a substitute for a proper history and physical.
The last time I cancelled somebody as medically unfit, the surgeon's whine was, "But I ordered a cardiogram". Further people think that lab work is a static thing, like the fact that the patient's K was normal on admission, means his K is still normal after he's been vomitting for 3 days.
7. Politicians know we order too much lab work and use it as a stick to beat us on the head when we complain about lack of funding in other areas. "The ER is full of patients waiting to be admitted?. That's because you doctors order too many blood tests".
8. It leads to more unnecessary testing and interventions
I have a personal story here. My first born was born at term after an uneventful labour and was normal size for gestation. Despite this somebody decided he needed to have a blood glucose done. It was something like 3.0 which would be low for an adult but normal for a full-term neonate (because of this episode the normal range for neonates of 2.5-3.5 which of course I had to know for my recently completed written exams has stayed in my mind). Of course the lab reported that number as low using the adult range, so the first thing the nurses did was to feed him some glucose and water. This meant when my wife woke up a few hours later with swollen boobs, our son didn't want to feed. It also meant he got an extra heel prick the next day to see if his blood glucose was still "abnormal".
I did learn, what should have been a very valuable lesson, quite early on during the laboratory medicine part of our pathology course. What I was taught was:
Don't order any investigation where the result (positive or negative) will have no influence on the management of the patient.
With that knowledge in hand out I went into the world.
I learned another thing along the way.
If after talking to and examining the patient, you have not the foggiest what could be wrong, no lab test is going to help you.
Now if you read this blog, you will know that collecting blood for the lab was one of my most favourite parts of internship. Through sheer stupidity I actually used elective time to do orthopaedics thinking I would actually learn something useful. Now on ortho, every admitted patient (and back then there was very little day surgery and no same day admission) whether he was 19 or 90 got a laboratory panel of 24 tests known as the SMAC. This required 5 tubes of blood to be collected. So on my first or second day, I asked the resident, "why do we do so many tests on apparently healthy patients?". He looked me in the eye and said, "Anaesthesia wants them". Naturally all these patients were admitted after 1500 when the lab blood collection went home, which left the blood collection to the interns.
Of course "normal" results are in fact the range that 95% of healthy assymptomatic patients fall into. This means that 5% of otherwise normal patients will have an abnormal result to a test. If you order 24 tests, there is an absolute certainty that at least one will be abnormal. These abnormal tests have to followed up on which of course means more blood work.
Now did "Anaesthesia" really want them. Apparently not as I learned a few years later when I read the guidelines for routine lab work. Here are the current ones:
Now I was able to find these in about 30 seconds because I know where to look for them. If I had googled pre-operative blood work it is little more complicated but by simply looking up the guidelines of your national anaes. society, it should be quite easy. Or you could ask your anaesthesia department.
But why do I even give a shit?
1. I pay taxes
Most healthcare is publicly funded in Canada. A significant amount is publicly funded in the US. I want my tax dollars spend on treating patients not on lab work! As an aside, much of the blood work in my province is done by a private company. Do you thing they have any interest in reducing lab work?
2. Healthcare is a zero sum game
Even in the US, there is a finite amount of money that can be spent on healthcare. That means money spent in one area is money that will not be spent in other areas. Every dollar spent on unnecessary lab work is a dollar that could be spent on something useful like chronic pain.
3. It holds up things.
How often has your day in the OR been disrupted by a cancellation or postponement due to an abnomral lab test that shouldn't have been ordered that has absolutely no bearing on the patient's ability to tolerate surgery. Just the same, you have to cancel the case, or wait while the test is repeated or the necessary follow-up tests are done. Many years ago I saw a patient who had been cancelled a month ago because of an abnormal gamma GT that someone had ordered pre-op. It was elevated so she was cancelled, went for the million dollar work-up which was of course normal and was re-booked. Of course somebody ordered the gamma GT again which was still elevated. Remembering from my time in family practice that this test is a marker for alcohol abuse (or use?) I asked her if perhaps she might have had a glass of wine the night before her testing and lo and behold she said yes. I put her to sleep and she survived despite her abnormal lab test.
4. It delays necessary lab work.
A classic example is the PT/PTT. Nobody would deny the benefit of these tests in following response to anti-coagulant therapy. There are also important in the management of an evolving coagulopathy or in monitoring whether a patient has been off his anti-coagulants long enought to do surgery or stick a needle in. Except...when you order the stat PT/PTT you really need, it is going to be queued up behind all the "baseline" PT/PTTs that have been ordered. Therefore you are going to get back your PT/PTT long after you have already bit the bullet and given the FFP your patient may or may not have needed.
5. Nobody looks at it or does anything about it
Sadly, that is the case. We order all this stuff and it gets filed in the chart and nobody looks at it. This includes abnormal lab work which frequently isn't followed up on. Chest X-rays are the classic which are often ordered pre-op and reported on post-op. As I found out as a resident, actually going to X-ray and looking at the CXR is no help. The one and only time I tried that, the tech at the film library laughed at me. Actually at our hospital, CXRs are available on-line now if I could just find the time to fill out the stupid form, make up a password etc. EKGs of course go off to be reported by the cardiologist which means they sit on someone's desk until look after the surgery.
6. Surgeons actually think lab work is a substitute for a proper history and physical.
The last time I cancelled somebody as medically unfit, the surgeon's whine was, "But I ordered a cardiogram". Further people think that lab work is a static thing, like the fact that the patient's K was normal on admission, means his K is still normal after he's been vomitting for 3 days.
7. Politicians know we order too much lab work and use it as a stick to beat us on the head when we complain about lack of funding in other areas. "The ER is full of patients waiting to be admitted?. That's because you doctors order too many blood tests".
8. It leads to more unnecessary testing and interventions
I have a personal story here. My first born was born at term after an uneventful labour and was normal size for gestation. Despite this somebody decided he needed to have a blood glucose done. It was something like 3.0 which would be low for an adult but normal for a full-term neonate (because of this episode the normal range for neonates of 2.5-3.5 which of course I had to know for my recently completed written exams has stayed in my mind). Of course the lab reported that number as low using the adult range, so the first thing the nurses did was to feed him some glucose and water. This meant when my wife woke up a few hours later with swollen boobs, our son didn't want to feed. It also meant he got an extra heel prick the next day to see if his blood glucose was still "abnormal".
Only so much niceness to go around
I was explaining to somebody in the non-medical field about how much abuse we received as students, interns and residents from more senior doctors. (I didn't tell her how much abuse I still get as a senior doctor). She said something like, "But I thought all doctors had to be nice!". So I explained the facts of life to her.
Early on in my career I noticed that the doctors whose patients loved them all had one thing in common. Without exception they treated students, junior doctors, nurses and whoever else got in their way like shit. Now there were also doctors that were great to work with. Surprise, surprise they weren't popular with the patients. Some of them were actually not very nice to their patients which I thought was cool at the time.
I can remember doctors ranting, cursing, swearing in the hallway outside a patient's room usually at something I had done or often not done; rant finished we would go into the room and it would be "How are we today Mrs. Smith".
Fact is we all only have a finite supply of niceness which we can chose to spread around where we want. Unfortunately niceness is not something that can be divided, it is more a quantum amount; you can give it all in one direction or the other.
Another factor that has to be considered is the person's life outside of medicine. So you have three groups to be nice to: patients, co-workers and family. Most of us only have 2 quanta of niceness (some of us only have one). If you find a physician who is nice to both patients and staff, it is only a matter of time before he starts looking for cardboard boxes to move out. I had the pleasure of working with an internist who was both nice to patients and to staff. I was perplexed by this until I heard a couple of years later that he had just divorced his wife.
Early on in my career I noticed that the doctors whose patients loved them all had one thing in common. Without exception they treated students, junior doctors, nurses and whoever else got in their way like shit. Now there were also doctors that were great to work with. Surprise, surprise they weren't popular with the patients. Some of them were actually not very nice to their patients which I thought was cool at the time.
I can remember doctors ranting, cursing, swearing in the hallway outside a patient's room usually at something I had done or often not done; rant finished we would go into the room and it would be "How are we today Mrs. Smith".
Fact is we all only have a finite supply of niceness which we can chose to spread around where we want. Unfortunately niceness is not something that can be divided, it is more a quantum amount; you can give it all in one direction or the other.
Another factor that has to be considered is the person's life outside of medicine. So you have three groups to be nice to: patients, co-workers and family. Most of us only have 2 quanta of niceness (some of us only have one). If you find a physician who is nice to both patients and staff, it is only a matter of time before he starts looking for cardboard boxes to move out. I had the pleasure of working with an internist who was both nice to patients and to staff. I was perplexed by this until I heard a couple of years later that he had just divorced his wife.
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