We are the “Real” Doctors Reply

Recently, I got a letter from a patient who had come into the ER with chest pain a few nights earlier. The care was great, she said. The $5,000 bill she received was not.  And the real kicker? We never figured out the cause of her pain.

That night, we did for her what ER doctors are trained to do: We “ruled out” lots of causes of chest pain: heart attack, blood clot in the lungs, a tear in the aorta. That involved a full workup and lots of expensive tests. What we didn’t do was provide her with a diagnosis.

“Follow up with your PCP,” we told her – as if it were perfectly OK for her to leave the ER without knowing what caused her symptoms, and as if her primary care doctor, two weeks later, would somehow have a better chance of figuring it all out. But it’s not just that we passed the buck, like people sometimes do when they’re in a rush. The implication was damning of our entire specialty: we’re just ER docs; leave it to the “real” doctors to make a diagnosis.

That paradigm has to change. Emergency physicians ARE real doctors. It’s time we started acting like them.

Truth be told, it’s not entirely our fault. As ER doctors, we’ve been trained this way for a generation – to do workups, to rule out life threats. This was all one could hope for when ERs were poorly staffed and could barely manage to triage the most acute patients. And at a time when most ER doctors were not specialty-trained or board certified, it’s no wonder many of them felt a certain inferiority complex. But these days, ER’s are staffed with fully trained emergency medicine specialists; we can do better, and our patients expect it.

That’s why the madness – the unnecessary testing, the unnecessary anxiety – has to stop. It’s expensive, it’s making our patients crazy and it’s not good medicine.

I saw a woman the other night with chronic headaches.  The ER doctors had ordered a CAT scan of her head “just to be sure.” Unfortunately, the scan showed an irregularity in a certain area of the brain – could it be a tumor? So they ordered a more sophisticated scan, this time an MRI, which showed that the area in question was actually perfectly fine. Good news!

But that’s not the end of the story, because the MRI turned up another finding – this time a blood vessel near the base of the skull that was probably just a normal variant, but the radiologist couldn’t rule out a small aneurysm.  So the ER called in a specialist who recommended more invasive testing with catheters and intravenous dye.

But ER doctors ARE specialists. We are meant to specialize in figuring out whether symptoms – like headache – represent an emergency or something else. So we went back and took the patient’s history.

She had been having headaches since her teenage years. They were worse during periods of stress or when she hadn’t been sleeping. They usually improved with over-the-counter medicine and a healthy does of rest. Once in a while, she’d end up in the ER (like on that night) where she’d get a shot and feel better.

She had migraine headaches. The tiny aneurysm on the MRI – if it was even real – was purely incidental. It was not causing her headaches and it was not likely to cause any problems down the road.

Sometimes ER doctors are so fixated on ruling things out, that we are prepared to do test upon test, leading patients down the garden path to more anxiety and more medical bills. Real doctors take a history and try to figure out what’s wrong with their patient. There’s no reason doctors in the ER can’t do that too.



A Stressful Complaint Reply

Yesterday I took care of a patient with back pain.

If you’ve ever worked in an emergency room, or an urgent care (where I happened to have been working yesterday), you’re probably not surprised. Back pain is one of the most common “chief complaints” that patients go to the doctor for.

Doctors and nurses often roll their eyes when patients walk in with back pain, the assumption being that most “normal people” would have just taken two Advil, put on a heating pad, and sucked it up. So the patient presenting with back pain is either a wimp, a drug seeker, or some other miscreant trying to make our lives difficult. Of course, even miscreants can have real medical problems, so doctors set about trying to “rule out” the more ominous causes of back pain, even as they strategize to send patients out with some cocktail of anti-inflammatories, muscle relaxants, and pain medication, to keep them from coming back anytime soon.

The patient I saw yesterday was different. This was a 22 year-old woman, in excellent health, who took the day off from work, not because she couldn’t “suck it up”, but because she was legitimately concerned that something was wrong with her back.  She was an avid runner, averaging 5 to 6 miles a day, who was finding that over the past week or so her workouts were getting too painful to continue. It had gotten to the point where even a casual jog was causing severe pain in her lower back. She didn’t fit the mold of your average back-pain sufferer: she wasn’t overweight or sedentary; she was young and athletic.

Mechanical back pain is exceedingly common in our species. It’s been theorized that the anatomy of the human spine has never quite accommodated to our upright bipedal stance, let alone the contortions we put ourselves through, sitting in cubicles or in automobiles for long stretches. The weak links in our spinal anatomy are the discs that provide cushion and flexibility between our bony vertebrae, and the paraspinal muscles that support the spinal column on either side. As such, the two most common causes of mechanical back pain are disc herniations and paraspinal muscle strains. Not infrequently the two conditions overlap. The good news here, is that in most cases these conditions resolve on their own with time.

Of course not all causes of back pain are so benign. Doctors are trained to look for “red flags” in patients with back pain: a history of fever or weight loss, raising concern for an occult infection or malignancy; signs of neurologic dysfunction – weakness, numbness, loss of bowel or bladder function – suggesting impingement of the spinal cord or its major nerve branches; major trauma, or even minor trauma in an older person with osteoporosis, where the vertebrae themselves, normally the stalwarts of the spinal anatomy, become at risk for fracture.

Over the years, doctors have distilled this knowledge into “decision rules,” to help decide which patients require a more extensive back-pain “work-up.” In our age of ever increasing reliance on technology, it’s not uncommon for a patient to ask their doctor for  x-rays or an MRI to figure out what’s wrong with their back. Not only are such tests expensive and usually unnecessary, but the results can often be misleading. So doctors have rules that tell us that if the patient is, say, under the age of 65, has not suffered major trauma, and does not have any progressive neurologic signs or symptoms, then imaging of the spine is unwarranted.

The young woman I saw at urgent care yesterday didn’t meet any of these criteria. She just had pain and wanted to know what was going on. But there was something unusual about her. For one thing, she didn’t strike me as “wimpy.” In spite of her pain, she had tried to continue her daily exercise regime, and only stopped when it became unbearable. And the location of her pain was very specific: right in the middle of her back, at the level of her lowest lumbar vertebra. Could she be suffering from a compression fracture, the result of chronic stress on her vertebrae from the incessant pounding of Nikes on concrete?

These were the thoughts running through my head as I logged onto the computerized order entry system to request x-rays of this patient’s lumbar spine. In order to obtain the films, I had to navigate through a series of “decision-support” questions trying to steer me away from any sort of imaging, because this patient didn’t meet standard criteria. Thankfully, even the most sophisticated decision-support systems still allow some room for clinical judgment. On the other hand, too many “discretional” imaging studies, and a doctor can face consequences, ranging from peer review to financial penalties.

I happen to take pride in ordering as few tests as needed, and so it was with some satisfaction that I read the radiology report an hour later, pointing out a wedge compression of the L5 vertebra – precisely the type of fracture I had been concerned for. Was this an earth shattering diagnosis? Maybe not. If I had failed to consider the diagnosis of a stress fracture and not ordered the x-rays, would there have been irreparable harm done? I doubt it. After all, if the young woman had gone on running she would continue to have pain, and eventually SOMEBODY would have made the diagnosis – one hopes.

So why is this story important? Well, certainly for this particular patient, it helped to be able to validate her concern, provide a definitive diagnosis, and recommend the right course of treatment (in her case, mostly rest). For me, personally, the story validated the importance of taking a thorough history and never underestimating one’s clinical judgment.

But there’s also this message: Patients don’t always follow the rules. In an era of cost-containment and quality metrics, let’s not delude ourselves into thinking that any rule, or algorithm, or decision-support tool can come close to replacing the patient-centered approach doctors should aspire to. If your doctor sees you as merely a “chief complaint,” with items to be plugged into a formula or “red flags” to be on the look-out for, it’s probably time to find a new doctor.

And be especially wary of the eye-rolling!