aka American ER Doc Gone Walkabout 023
Let’s take a single complaint – “sore throat” – and look at a few of the ways that it can be handled.
Let’s say that we’re satisfied with having a good outcome with no further intervention, say 90% of the time. And, another 9% of the time we get a second chance on a “bounceback” to get it right. To do this we might develop a very simple algorithm. Ask the patient if it hurts, and ask if he had a fever. Ask the patient to open his mouth – if he can open it, get a Rapid Antigen Test for strep. If he can’t open it, get a CT scan and call ENT to drain the abscess.
The nice thing about this approach is that almost everybody gets better no matter what we do, so we’ll have a good outcome no matter what. But, Medical Doctors, like a shaman, needs a little theater, so the strep test and antibiotics come under the rubric “Medicine is show business for ugly people” (thanks, Greg Henry). Never mind that our ostensible reason to treat (prevent rheumatic fever) is, and has been for 50 years, a myth (thanks, David Newman). That, if we treat promptly with antibiotics, while shortening the duration of illness by a day, we will raise the one year recurrence rate from 5% to 35% (Pichichero, Ped Infect Dis J, 1987). And, that they’ll get better in a couple days anyway. The businesslike doctor knows that the patients love the theater of the swab, the test, and the antibiotics if “necessary”. Do the patients believe that they’ll have a 90% chance of dying without antibiotics? Great research project for somebody. And, if the patient can’t open his mouth, we go to even stronger magic of a CT scan and specialty referral – it’s the grand finale to a mystery movie.
I would propose that everyone would love this “pathway”: the patients get examined and treated quickly, they get enough magic to be sure of modern medicine, the doctor can see lots of patients quickly and make a lot of money in the American fee for service system, radiologists get lots of “positive” (even if trivial) studies. And, rare and life threatening diseases are indeed rare enough that a truly bad outcome will come to each Doctor only once every couple years (and, he’ll be protected because he followed the “pathway” – I think the “following orders” argument has been prominent for about 65 years, so it’s time tested). And, the “suits” love it because 90% of people had a good outcome and a quick visit – thus providing good Press-Ganey satisfaction scores. And, the really bad outcomes are rare enough that they’ll probably not get one of the satisfaction surveys – and will be so miserable that they can’t fill in the answer form. The docs look like heroes, and get their bonuses (we’re talking American system here).
Scene 1, in ER: MD: “Does it hurt, are you in terrible pain – 11 on our 10 point scale? Oh dear, I think we better get a test – the best that modern medicine has to offer.
Scene 2, at Home opening the mail, 5 days later: Oh look, dear, that nice hospital asked us to rate the Doctor on this nice little survey. Let’s give him a 5 out of 5, he was so quick that he must have been smart, and that test predicted exactly what would happen: I did get better in a couple of days. (alternate ending: Honey, the test predicted exactly what would happen, I got better after just a few days of penicillin).
The approach above is likely to improve departmental throughput, patient satisfaction, and departmental and physician income – at a very small cost in adverse outcomes.
It eliminates all those time consuming questions and parts of the exam (I’m sure that I will get only a smattering here, and no, I don’t ask all these questions of each person with a sore throat): can you swallow your own spit, are you hoarse, can you bend your neck, have you been giving indiscriminate blowjobs, have you been bitten by a bat and now even the sight of water gives you horrible throat spasms, did you feel tired and rundown for the past week before the sore throat, do you have facial pain and purulent rhinorrhea with the sore throat, did you step on a nail or shoot up smack with a dirty needle and now you can’t open your mouth at all? Do you have pallor, petechiae, trismus, adenopathy all over your body, a large swelling in your pharynx, true trismus, a big spleen, a penile drip, stridor, encephalopathy, a cup full of drool, etc. Is there really any reason to implicitly or explicitly know the pros and cons of treating strep, or knowing about other bacterial causes of pharyngitis like Fusobacterium necrophorum or Arcanobacterium haemolyticum? Or gonococcus? Or being aware of the initial presentation of HIV or leukemia as sore throat? Or separating out EBV from other viral sore throats? Or identifying the secondary sore throat that goes with sinusitis?
And, although the individual experienced ER doc can go through this quickly, in academia, to walk (or even run) a junior doctor through all this takes a lot of time. But, if we don’t push the junior doctors to learn the extensive differential of a simple sore throat, a few years from now, all ER Docs will be triage docs.
All these other disease presenting as sore throat are rare, and statistically can be ignored. And almost all your patients will be happy with the quick care instead of wasting time on this rare stuff.
Why do I even bring this up? Well, we are being faced more with a conflict between efficiency and throughput, and our role as patient advocates, and as teachers of our less experienced colleagues. In some settings, there appears to be a rebalancing of the relative weights of the various roles.
So, let’s ask ourselves: “What is professionalism?” And, how can a simple clinical pathway – like how to diagnose and treat a sore throat – have anything to do with professionalism?
First, lets forget the paid vs unpaid distinction (as in athletes).
As professionals (the learned type) we have special knowledge and skills that can contribute important benefits to society when used to that end. We, as professionals, get some special autonomy and privileges. We are both allowed and expected to have special collegial relationships – that is a privilege, but a responsibility to share knowledge both with peers and with younger colleagues. And, most important to this blog: we are expected to put the interest of the client ahead of our own interests.
Particularly in the learned professions (that’s us, Mates), there is quite a significant asymmetry in that the healer is likely to know much more about a given disease than his patient. The healer can increase his own prestige and income by taking advantage of that asymmetry (just a few more tests that I can provide for a reasonable fee – even though the diagnosis is clinically obvious), but from a moral view he should rather use that asymmetry of knowledge for the patient’s benefit (I know that you’d just like a cheap prescription of penicillin for that sore throat, and a quick discharge, but those little spots on you nose – let’s just see what your platelet count is), even when the patient’s stated objective (quickly, please) is different from the learned practitioner’s objective (accurate, please).
Take a look at this slideshow for a very nice detailed view of the specifics of medical professionalism by Ghaiath Hussein:
The situation gets Dilbertesque when the various components of professionalism conflict. There’s the “Whatever the client wants” and let’s keep him happy. There’s the professional collegiality and teamwork (we need a unified voice to make this highly efficient program and pathway work). There’s the responsibility of the learned professional to both use his knowledge for the patient (let’s not accept the easy answer, but go a little further even if it takes some more time and isn’t very efficient) and to (taking time out of the efficiency demand) pass on the knowledge to his younger colleagues (he stepped on a nail, and now we can’t pry his mouth open – what might be the diagnosis besides conversion reaction?). And, Hussein goes on to talk about the unprofessional parts of the professions, including abuse of power, arrogance, etc.
For those of us facing multiple competing demands, perhaps it would be wise to recall that, as professionals, we do have responsibilities to our patients – all of them, not just the next patient who might demand a lot of time and care, but to our future patients who might be waiting and waiting and waiting, and to our future patients who will be ours vicariously through our trainees – trainees who depend upon us for guidance, wither superficially or in depth.
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