Call Me Old School
I have had the privilege to teach medical and graduate students about critical appraisal of the medical literature, health technology assessment, health economics and health policy, amongst other topics.
The standard approach is to understand the patient's “chief complaint” and then conduct a focused history and physical. After this a decision is made on the most probable diagnosis which is usually rank ordered in a “differential diagnosis” list. Then diagnostic and other tests are ordered to better confirm the primary diagnosis. I usually hear snickers during part of this lecture, especially when discussing the diagnostic test steps. The snickers are usually related to a generic example I present related to management of emergency patients with “abdominal pain NYD” (not yet diagnosed).
Based on feedback from the medical students, who have had emergency or surgery clinical rotations, the scenario is as follows: a patient is in emergency and emergency staff interview and examine the patient to the point of concluding that the patient needs a surgical consult. General surgery is consulted and they relay to emergency “get a CT abdomen and then we will see the patient”. The surgery team who order the CT have not necessarily directly interviewed or examined the patient prior to the CT. The information going to the physician who is interpreting the CT (i.e. a radiologist) may be minimal (e.g. abdominal pain NYD) and may not provide essential information (e.g. what part of the abdomen is hurting, what type of pain the patient has, how long it has been going on etc.) to assist the radiologist in their image interpretation. The radiologist may not necessarily have access to the emergency staff findings but this is changing, in the positive direction, with advent of electronic medical systems.
One may ask: “Why doesn’t the radiologist interview and examine the patient?”.
The answer is simple: they read a large volume of studies, many of which are urgent and time sensitive, and direct clinical assessment and patient management are not, in most cases, within their primary scope of practice.
This is all to say that patients benefit most if the information relayed to the radiologist contains pertinent past history, what the chief complaint is and what are the essential findings on history and physical examination. Incidental findings on the CT need to be interpreted based on the provided history and if such is lacking the importance of such findings is uncertain and may lead to additional unnecessary tests and time spent in the health care system.
I understand that getting the CT ahead of time is efficient and may move patients more quickly through the system but this is it still out of sequence. System efficiencies should be shaped by what is in the best interest of patients versus ER and admission wait times/statistics. In my opinion “abdominal pain NYD” does not cut it, is “bad medicine”, and does not meet the prevailing “justification” criteria for ordering a CT scan.
Although I may be like “tilting at windmills” I will continue to teach “after you do a thorough history and physical you should be fairly certain what your differential diagnosis is, THEN you order tests to confirm your impression – NOT the other way around.
Call me old school.
Dr. Demeter is a Public Health researcher with particular interests in health policy and health economics. By investigating and reporting on stories like the above he hopes to create a dialogue on health care in MB and to increase awareness of issues which positively, or negatively impact, Manitobans. Feedback and comments are welcomed directly at firstname.lastname@example.org or through his blog at https://www.codeblue.me.