Archive for the ‘epidemiology and statistics’ Category

Stupid Crap

Monday, May 7th, 2012

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”.

The “Bolus”

Tuesday, January 10th, 2012

No, I don’t mean the 1 am impacted esophageal food bolus, the bane of the the Gastroenterologist’s existence.  I mean the patient bolus.  There is nothing worse than when a boatload of people arrive in the ER at once.  It doesn’t matter if they are sick or not (even a whole bunch of relatively simple and quick patients can screw you). when 10-12 people arrive in one hour, you are instantly overwhelmed. You could be chugging along, dispo-ing 2 patients or more per hour per provider and then, WHAM, you’re done.  It’s even worse when you get a mix of walk-in’s and ambulances.  Even if your ER is fully staffed and on the top of it’s game, you are going to see a rise in the wait times to be triaged, roomed, and to see and doctor. End of story. You can’t be expected to just suddenly see 5 people at once.  You go into a different, damage control mode and just try to see the sicker ones and then whittle away at the pack.

Metrics get worse, patient satisfaction scores plunge, left without being seens go through the roof. That’s life.  Patients, the public, private doctors, and administrators have to realize that.  Eventually you’ll catch up – if you get 2 hours where no one shows up. Not likely in this day and age.


How Far To Go?

Thursday, December 15th, 2011

Recently the NTSB (National Transportation Safety Board) recommended that there be a ban on the ALL electronic devices while driving a car. This includes (for the first time) all phones – including when you are using a hands free device or a built in blue tooth. This was brought about by the increase in accidents attributed to “distracted” driving.   “Distracted” defined by people focusing on something else while driving – including a phone conversation even if they are not holding the phone in their hand. Presumably the mind is occupied with the conversation and thus can’t perform as well on the task of driving the car safely.

I agree IN CONCEPT with this.  Of course if you are distracted, you are not going to pay attention to the road as much.   Trying to drive while texting or surfing the internet obviously stupid and dangerous.  However,  could you imagine a race car driver trying to do anything other than drive? He or she would be off the road in a flash!  So I guess they want us to be like race car drivers and not have our focus distracted from the road at all.   If race car drivers drove at legal road speeds, there would never be any crashes.

Now here is where the problem comes.  Yes, we get distracted by talking on the phone. But we also get distracted by the music we are listening to. We might want to switch stations.  We might want to look down and the satellite radio and see what the name of the song is.  We also get distracted by screaming children in the back seat. We get distracted by trying to drink our coffee and not spill it all over. We get distracted when something slides off the seat and ends up on the floor at our feet.  Hell, we get distracted by having a conversation with the person sitting in the passenger seat!  Shall we ban all these things? I mean, obviously, if you don’t talk at all to anyone, don’t have your kids – or just ignore them 100%, and if you never listen to music or eat, you are going to be able to focus more on driving.  Just like a race car driver who has none of these distractions.

It’s just like the recent recommendation of the AAP (American Academy of Pediatricians) that all children and toddlers ride in rear facing seats until they are 2 years old – regardless of their size or their misery in having to face the seat and not be able to interact with their parents who are up front.   This is because it is safer to ride facing backwards if you get in an accident.  Duh.  Of course it is!  It is also much safer for ADULTS to ride in rear facing seats!  It’s also safer that they are restrained with 4 point harnesses (like in kids’ seats).

Thus to be safe, we should build cars with all rear facing seats except for the driver and he or she cannot interact with anything else in the car either by listening to them, talking, or dealing with anything that happens while you are driving.  Your hands must remain affixed to the steering wheel and your eyes glued to the road in front of you (you can’t look to the side to see the name of the street you are passing or the name of the store you are trying to find).  If you want to ask a question to the passenger, you have to pull over and put the car in park.

That would be great wouldn’t it?