On my last shift I ordered roughly 10 CT scans, which unearthed zero pathology. That day I was essentially a TSA officer scanning humans for hidden lawsuits. In retrospect though, I have no idea what I would do different for those same patients today. What corners would I, or should I, have cut?
For unearthing pathology through those CTs, I batted 000. I struck out completely. For doling out reassurance, a sense that I cared, bulletproof charts and big bills, however, I was a slugger… a heavy hitter. Thankfully, nobody tracks our rate of cancers triggered.
A couple of my Pre-R patients have made me think more about radiology as practiced these days. The first is an elderly man who has a swollen leg. He hates hospitals and very much does not want ultrasounds, CT scans or blood test of any kind. He just wants me to take my best guesses and then treat as such. His POA relatives and I periodically exchange texts, and miraculously he keeps on living.
The second patient called me before my last shift. She had abdominal pain. I told her that she would most certainly have a urinalysis done upon entry into any ER. So if she wanted to test her urine first through a home test kit, that could save a step. But just based on her story I told her it was very likely she would have either an ultrasound or CT scan done along with blood tests if she headed to an ER.
Rather than go straight to the hospital, she got the urine test strip from a pharmacy. She tested positive for infection and decided to call me back to reconsider her options. I called in an antibiotic after a lot of conversation, but gave ample precautions about when she should reconsider and head to an ER. 24 hours later she was all better. She saved literally thousands of dollars and a lot of time.
I guess I’m typing all this so readers here understand how different the dynamic is between an ER visit, and talking with your doctors anywhere else. In the ER, I have a short window to see, diagnose, and treat. There’s no time to try this med… then order that lab… then order that scan. Frequently, they all happen at once in hopes of you leaving the ER for home, a floor bed, or another hospital ASAP. It’s a conveyor belt and our “door to dispo” times are tracked closely.
There’s a good chance I’ll never see you again if you leave the ER and get better. If you return during my shift, I may have to look you in the eye later in the day and apologize… and fill out a whole new chart! If you return on a different day, I may hear from a colleague something that starts with: “Remember that patient you saw with XYZ?” Or worse, if I really blow it, our next interaction may be though lawyers in a courtroom. Who needs that? “CT tech… Smoke ’em if you got ’em!”
It’s called defensive medicine. I practice it. And I know I’m not alone, because I’ve been told by some radiology and lab techs they can tell when I’m working based on the LOW number of tests I order.
With Pre-R it’s completely different. I’m able to tell patients what they may expect when walking into an ER, without the pressure of actually delivering that paranoia based care. My patients who choose to head in are less shocked by their experiences. And those who choose to stay home at least feel comforted to know they can call me again if they continue to head south.
It makes me think about how I’d redesign radiology on planet Sammy. I’d do the same thing I’d do with antibiotics. I’d have a radiology vending machine right next to my antibiotics vending machine, with a doctor standing nearby available to answer questions and provide counsel.
The antibiotics machine would have a long list of side effects and local resistance patterns and costs. It would educate about alternative ways to treat common colds, and the differences between viruses and bacteria. No matter your socioeconomic status, nothing would be completely free. (Venezuela has taught me that free causes abuse. Same lesson through plastic straws and cutlery at Starbucks.) The radiology machine would show the costs as well, along with the radiation doses of various studies similar to the attached. Maybe I’d add a “claustrophobia index” to let patients know which tests may cause the most anxiety or discomfort.
I find that patients who want antibiotics or radiology studies ultimately find ways to get them. They learn the right buzzwords and then ER/doctor shop until satisfied. So this doctor would rather play the role of teacher instead of TSA officer.
Doctor Jiffy Lube would be held harmless for bad outcomes, and all questions from patients would ideally come in the shape of: “If this were you or your mother, what would you do?” rather than “What should I do Dr. Who-Never-Makes-Mistakes!? Tell me please!!” Dr. JL would also not be compensated any more or less for types and numbers of antibiotics, nor radiographic studies suggested.
Dream on Sammy.
If I’ve offended anyone here, let me recap. I think I/we do a bad job at choosing who gets scanned and how they’re advised. And our incentives are skewed. Planet Sammy still welcomes suggestions.
PS The following website may lack some precision. Using an image of Ernie rather than Bert, makes me suspect fake news. MEDICAL IMAGING & RADIATION SAFETY