Diagnosis for Democracy
Insights into the State of Our Union
A Blog by Rob Tenery, MD


July 11, 2011: Shotgun Medicine

By Rob Tenery, MD on July 11, 2011

“It seems as if physicians today are more afraid of leaving out the appropriate test than missing the diagnosis.  A very common practice, not too many years ago, was observation. If the diagnosis was in doubt, the patient was either hospitalized or sent home, but with very specific instructions of what to watch for. At the first sign of change, the physician was to be notified, so the appropriate treatment could be started.

Observation is essentially not done anymore. Today, those same patients are admitted, consulted, SMACed, CTed and scoped through every orifice. If the results are negative, then the whole process is repeated again for fear of missing something.”

The author, 1996.

Dr. Senthil Kumar Sanran, an Associate Professor and surgeon at Madres Medical College in Chennai, India, put it succinctly when he states, “clinical acumen is what elevates a doctor from just good to great.” He goes on to say, “A good doctor treats the disease, while a great doctor treats the patient…those with clinical acumen, ponder, decide and find out the root cause which is diagnosing…unlike the modern day medical pundits who plot in software and derive at a diagnosis.” (1)

Secluded in front of the CRT screen in an alcove just off the nurses’ station, the young physician carefully reviews the results of the numerous laboratory tests, scans and radiographs that he had recently ordered. Several of the tests are equivocal. Pondering his next move, he rubs the back of his neck, cramped from the long hours staring at screens on the different hospital floors where his patients are scattered. He flips to another screen that chronicles his patient’s vital signs and intake and output. With the patient’s chart opened in front of him, he scribbles a new set of orders, then flags the chart for the nurse. Before leaving the floor, he stops by the patient’s room to tell her that he has ordered another barrage of tests.

The young physician is still running over the differential diagnoses in his mind as he heads for another floor.

As a child, I recall making rounds with my father, a general surgeon, as he checked on his post-operative patients at the end of the day. He would pick up the chart, which hung on a hook at the foot of the bed. After a quick review, and a few brief comments from the nurse who usually accompanied him, he would hand her the chart and reach out for the patient’s wrist. As his gentle fingers checked the pulse, he used his other hand to draw back the patient’s sheet, then palpate the abdomen. After repositioning the sheet and a few words of reassurance, he moved on.

The focus of my father’s exam was his patient.

When patients are referred to our medical school located in Dallas, it is often because they need further evaluation and treatment for their medical problem. The history and any prior test results and therapies are usually sent along with them. This is the patients’ ‘last-stop’ in the referral chain of medical expertise. Maybe, there is no answer. But if there is, the accepting physician must find it. Every possibility must be evaluated, even if it takes more, and often repeated, testing. Even that one-of-a-kind disease must not be overlooked. Some might label this a ‘shot-gun’ approach, hitting as wide a target as possible. Most often, it is a ‘plugging-any-leaks’ approach, searching for any detail that might have been missed.

The approach, analogous to casting out a net into open water and seeing what is hauled in, is now creeping into other areas of our profession. Several factors contribute to both an increase and decrease in these more comprehensive workups. Concerns of malpractice play a definite roll. The thought is that missing the proper diagnosis puts the physician in as much jeopardy as selecting the wrong treatment.  Although managed care and the increased use of practice parameters have worked to curtail the widespread use of over-testing, there are still many situations where physicians receive financial benefit from increased utilization.

The most common reasons for over-utilization, however, appear to be two: Unfamiliarity with the patients and an increased number of available diagnostics.

With more utilization of emergency facilities and frequently sicker patients, emergency room physicians, hospitalists and intensivists are thrust into serious situations, often with little or no previous knowledge of the patients and sketchy histories at best. Since time is of an essence, they are forced into making quick decisions. The shotgun approach often gives them the best opportunity for an early diagnosis and a start at the most appropriate treatment.

The problem, as I see it, is this approach can become a habit, to be used not just in true emergencies, but also in non-emergent situations. A bump on the head and the patient gets a skull series and an MRI. A cough and a low-grade fever generates a strep culture and a possible chest x-ray, even then a Z-pack is prescribed for good measure. It’s often easier to order a panel (multiple laboratory screens) than one or two selected blood tests. I can’t remember the last time I saw a white cell count without the hemoglobin, hematocrit, red cell size and platelet count included. The labs encourage this practice, because their automated systems are set up to run panels, besides generating more revenue for these multiple tests.

Whatever happened to observation or ‘gargle with hot salt water,’ until the test results are in? Has watching and waiting become passé or even considered an act of negligence if the latest diagnostics are not performed?

This increased reliance on diagnostics and less attention to the patient’s rudimentary signs and symptoms moves physicians away from their basic skill sets, which if they don’t continue to use, they lose. Then again, maybe, being able to order and evaluate the results of this exploding array of new diagnostics are the skill sets of the ‘new’ generation of physicians.

At a time when the focus is on cost constraints, ‘plotting in the software’ (1) is more costly. More important, it’s a lot less personal.

-------------------------------------------------------------------------------------

REFERENCES:

(1) http://hubpages.com/hub/IS-CLINICAL-ACUMEN-A-DYING-SCIENCE





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