Triage RN: “What brings you in Ma’am?”

Mrs Aphlebulous: “My back pain! I’ve had it for years and I can’t take it any more!”

Triage RN: “Did you take your medications?”

Mrs Aphlebulous: “No! The only thing that works is if you give it to me IV, and tell the doctor I’ll need a central line since my veins are all gone!”

So on the heels of the post from two days ago entitled “stupid crap”, comes this follow-up. Insurance companies are always accused by physicians of denying necessary procedures and care. Now related to the post from before one could argue that a lot of these tests should not be approved since so much stuff is completely worthless and simply performed for mental masturbatory reasons. However on the flipside there are some things that are so blatantly, obviously necessary that it defies reason that insurance companies would deny them. Take for example arguing about an air ambulance transport of the patient with massive intraperitoneal bleeding following blunt trauma. Quibbling over the flight transport time of 15 minutes versus 45 minutes by car is ridiculous considering how unstable patients such as these are. I realize flying a helicopter is extraordinarily expensive and do agree that just because a helicopter is there does not mean you need to use it for a transport. This does not apply to critically ill patients who need to be sent to a facility that can properly treat them. After all this is what helicopters are intended to do. Instead of spending time arguing about this sort of transport spend your time denying all of the other ridiculous garbage that will probably be ordered on the patient after he’s been hospitalized for two weeks because somebody finds out that he has a history of rheumatoid arthritis.

So, I without really realizing it have become a crusader against stupid, wasteful, and unnecessary medical testing. I see it every day and I can’t help it. It just drives me nuts. So much of what we do as physicians is completely worthless or at least excessive. One can argue about defensive medicine – and yes, I agree that is a good part of it. Especially when it comes to ordering things that specifically rule stuff out that is dangerous or life threatening – like CT’s of the chest when a 50 year old guy presents with upper back pain to rule out dissection. But then there is everything else. Much of it I believe is done because we just want to investigate EVERYTHING. I mean, it may just be because we are intellectually curious – not just because we are worried about missing something really bad. We just want every little thing explained. This could entail ordering esoteric blood tests just to check for something really rare. Or calling a rhematology consult to see someone with chronic RA and new atypical symptoms. ENT consult for ear pain, etc.

There is a time and a place for this – usually it should be done over time as an outpatient. Especially if the symptoms are not likely anything really serious (like possible cancer, etc), there is no rush to investigate everything. No need to CT or MRI every little ache and pain. CERTAINLY this stuff should not be done as an in patient or in the ER. This time is reserved for dealing with serious, more acute issues. All the mental medical masturbation can wait until the patient is discharged. You don’t need an Echo, EEG, CT, MRI, and EMG just because the patient has some symptoms that might be answered by doing them – UNLESS missing it would seriously endanger the patient in the short term. Otherwise, just let the PMD deal with it the week after they go home.

I see this kind a crap all the time. I read what my colleagues have ordered and scratch my head. I see the workups people have gotten in the hospital – and for what? I am baffled by the stupid crap people order and the ridiculous consults people get. I get furious when my nurses order dumb garbage on a patient before I have gotten a chance to see them. I swear I spend half my shift d/c’ing orders that were ordered by the nurse. It doesn’t help though that many of my colleagues just go along with it – and even encourage it to speed things up. I would argue it often doesn’t! Once something have been ordered and can’t be cancelled, you have to wait for the result since you have to address it if it is abnormal – even if it has no bearing on what is acutely wrong with the patient.

It’s a huge waste of money. A huge waste of health care dollars. It sets up unrealistic expectations in patient who now demand every test all the time. We’re blowing through cash like there’s no tomorrow. We have to put some curbs on this kind of wanton wasteful behavior. I hate proposing restrictions on what we can do and what we can order – but it’s come to pass. We need to really explain WHY we are ordering something – because half the time I bet the answer is “well, I just want to know what is going on”.