Evidence. I practice evidence-based medicine. I don't order tests that aren't necessary. I use my clinical judgment. I think about how I'm using resources, and the human costs of false positive results, and I order (on average) about 30% fewer diagnostic tests than my peers. I don't do routine EKGs or chest Xrays (even on smokers) or urinalyses or blood counts. I don't get plain Xrays for back pain. I only order MRIs if I think the patient needs back surgery or joint surgery. "MRIs are road maps for surgeons", I tell my patients.
The evidence is clear that more tests do not make for better outcomes. That doesn't mean I always order the cheapest test. If the CT scan is the right test, I'm not going to order the ultrasound. If my patient needs imaging for a headache, I order the MRI. The wrong test is a false economy.
This is who I am. This is how I was trained. I have good reasons for what I do.
Except....except for the time one of my patients sees a covering provider for back pain, and the covering provider orders what I think was an uncessary Xray, and the Xray finds a fracture.
Which I would have missed.
What if....
What if I'm wrong?
What have I missed over the years?
Maybe I would have ordered it. I wasn't there when she examined him; maybe there was something different about his pain, or the exam. But maybe not. Maybe she's just someone who orders an Xray on everyone with back pain, despite the reams of evidence that such Xrays don't change outcomes. Maybe this was just pure chance.
If I'd seen him and hadn't ordered the Xray, he wouldn't have gotten better with conservative treatment and he would have come back, or called, and eventually we'd have found it. I know that. I don't know why this time, in particular, I am second-guessing myself - not even for something I did, but something I didn't do. Something I wouldn't do if the same patient walked into my office tomorrow with the same complaint.
It's hard to swim upstream, and I've been doing it for 20 years. Sometimes I get tired of holding the line. My brain knows that I've saved hundreds of patients from the anxiety of a false positive, a meaningless abnormal result, with the resulting re-testing and worry and further investigation. It's hard to feel proud of what doesn't happen.
I know that this uncertainty is what drives my colleagues to do more tests. I don't want to go down that road, but tonight I'm struggling to remind myself that I'm on the right path for me. Tonight I'm looking ahead and behind and wondering what if....and I don't like the answers.
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4 comments:
keep holding the line......chance, false positives, false negatives, true positives, true negatives. You need to keep the FP/TN in your frame of reference; you need to clculate your predictive score! Over servicing is as neligent as prctiing with indifference. You do neither. Hang on!!!
Jay, I don't know whether you ever saw any of my blog when I was pregnant with my last child, but it was the pregnancy of false positives. All as a result of utterly unnecessary tests. One of those false positives told me I had a baby with a chromosomal abnormality. It wasn't one I would have terminated on, but someone else might have.
I am bound to die of something undiagnosed because I am reluctant to take stuff to a doctor quickly. But I have to die of something, and better that than spend my life the way that pregnancy was spent. I would much rather my doctor took your approach so that when I do take something to her, it will be treated as required, not to rule out every possible scenario.
Stick to your guns, FWIW, in the absence of omniscience, I at least, reckon yours is the best approach for your patients (if not always for you).
I don't mind being sent for tests if they find something, but most of the time it's money and time poorly spent.
I remember when I had the ulcers. I got sent for all kinds of tests and after two weeks someone ordered an upper and lower GI. That's what showed the ulcer. The drs claimed I didn't have symptoms of ulcers but rather gall bladder so that's the reason they went the way they did. It was frustrating to be so sick and have to show up in all these labs for tests.
This is a really hard point to stick to.
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