ordering tests

[Lactic Folly]

The nephrologist at our institution gave a talk about how many ER docs order contrast CT abdos on query AAA and send these old timers to nephro inpt ward.

 

Where are you working that this is happening?

For one, a query AAA does not need intravenous contrast.

Secondly, it is a shared responsibility between ER and radiology to ensure that only tests with the proper risk/benefit ratio are done, and radiologists should be the ones protocolling studies, so I am surprised that such scans would be approved when contrast is not needed in the first place.

[Lactic Folly]

Relevant to discussion (I think)

 

http://www.choosingwisely.org/wp-content/uploads/2012/09/Choosing-Wisely-Master-List_LQ1.pdf

 

Yes, this is a good example of what is necessary to move forward - multidisciplinary discussion leading to consensus guidelines.

 

There is a danger in medicine of siloization. It takes open communication and a desire to understand others' points of view in order to really begin to have a grasp of all the factors affecting an issue, and enlist the necessary buy-in for change. Without breaking down these barriers, all you see is people getting more entrenched in their viewpoints.

[NLengr]

Generally, my opinion is that if Rads or IR is blocking a study by saying the patient doesn't need the study MEDICALLY, then they need to see the patient and write a note in the chart.

 

If they are blocking it for a technical reason, because it won't find what you are looking for, or because they think another study is better and want to do that one, than that makes sense.

 

Overall, my division tends to have a good relationship with the rads guys. Some other services (which I rotated through) tended to be much more adversarial, and as a result, they frequently ended up in arguments with rads to get scans.

[Lactic Folly]

Overall, my division tends to have a good relationship with the rads guys. Some other services (which I rotated through) tended to be much more adversarial, and as a result, they frequently ended up in arguments with rads to get scans.

Why do you think the other services were more adversarial - was it part of the culture passed down, or the personalities in the program? Were the studies they were requesting limited in availability, or not as indicated? Did the adversarial approach work? I'm curious.

[Lactic Folly]

Generally, my opinion is that if Rads or IR is blocking a study by saying the patient doesn't need the study MEDICALLY, then they need to see the patient and write a note in the chart.

I was going to do this once, but the patient had already decided they weren't going to wait around for a CT and had already left

[A-Stark]

What speciality are you in Satsuma? If you do a nephro rotation, you'll quickly see how many contrast nephropaths get admitted. The nephrologist at our institution gave a talk about how many ER docs order contrast CT abdos on query AAA and send these old timers to nephro inpt ward.

Tests are not without morbidity and free of charge.

 

Well, I've done nephro twice and I can't recall any patients admitted with proven contract nephopathy. The radiologist I was talking to last night about arranging a CTPE called it a "theoretical" risk.

 

In any case, so far I've found the rads guys at my centre pretty reasonable and approachable. Certainly last night I was able to arrange an after hours scan for a patient in pre-admission clinic in about 10 minutes. I got the verbal report half an hour later. (And it most certainly had contrast.)

 

In emerg (not that that's where I was working), you have to rule out the bad stuff first. For a patient with mildly decreased sats and some other nonspecific findings, we needed to rule out a PE.

[Alastriss]

Emerg doctors over investigating? Usually they're more prone to pass on inadequately worked up consults.

 

All inpatients get too much bloodwork, though.

 

Actually, I've found emerg docs over-investigate otherwise benign conditions and under-investigate more serious things, and yes, inadequately worked up consults are a hall-mark of Emergency Medicine.

[Lactic Folly]

Well, I've done nephro twice and I can't recall any patients admitted with proven contract nephopathy. The radiologist I was talking to last night about arranging a CTPE called it a "theoretical" risk.

 

Yup, the true extent of contrast-induced nephropathy is a bit controversial at present (see the April 2013 issue of Radiology for a few articles on this topic). However, most people will want to err on the side of safety until this is better understood.

[NLengr]

Why do you think the other services were more adversarial - was it part of the culture passed down, or the personalities in the program? Were the studies they were requesting limited in availability, or not as indicated? Did the adversarial approach work? I'm curious.

 

Probably culture and personality play a role. The studies were pretty std., certainly my discipline orders much more complex studies.

 

I think part of it is we are sub specialized. We know our specific scans very well. We know why we do them, how to read them pretty good and when to get them. The rads guys know that when we ask for something, we have a good reason. We also tend to do stuff like ask them if this study or that study would be a better pick and we value their opinion. So they aren't defensive at the start of the conversation.

[Lactic Folly]

Probably culture and personality play a role. The studies were pretty std., certainly my discipline orders much more complex studies.

 

I think part of it is we are sub specialized. We know our specific scans very well. We know why we do them, how to read them pretty good and when to get them. The rads guys know that when we ask for something, we have a good reason. We also tend to do stuff like ask them if this study or that study would be a better pick and we value their opinion. So they aren't defensive at the start of the conversation.

 

I agree very much with all of this. Being able to speak the same language is very beneficial - the challenge is to make this communication a reality in other healthcare interactions. With limited shared knowledge and communication, it's easy to misinterpret requests and questions, leading to conflict, less efficient care, and at worst medical errors.

[Satsuma]

What speciality are you in Satsuma? If you do a nephro rotation, you'll quickly see how many contrast nephropaths get admitted. The nephrologist at our institution gave a talk about how many ER docs order contrast CT abdos on query AAA and send these old timers to nephro inpt ward.

Tests are not without morbidity and free of charge.

 

 

I am in emerg.

 

Please do not generalize your experience with one service at one institution to an entire specialty. Not sure what the point of that talk was and who it was directed to, but I wonder if that nephrologist had any kind of discussion with rads and emerg before presenting this talk? And were there solutions to this problem suggested or just a bunch of complaining. As Lactic Folly already pointed out, radiologists protocol the studies, and I can't see why so many inappropriate scanning procedures would be done at your centre. And I'm not sure why that nephrologist would centre out emerg docs.

 

Please remember that every specialty looks at the same patient and problem slightly differently. And sometimes the practice simply reflects that state of the evidence out there.

 

eg. CT heads - the CCTHRs only apply to a certain percentage of the population in a certain set of circumstances. Since there are no rules for elderly patients, and and due to atrophy are at higher risk of bleeds which can present with minimal neurologic signs initially, then old people get scanned more from their falls. There are no studies to help guide CT scanning in head trauma in old people.

 

Emerg docs are aware of risks associated with imaging procedures and we are well aware of costs. I am not concerned about the radiation risk to a 70 year old. I will do everything I can to avoid a CT scan in a 20 year old. And the docs I practice with would agree.

 

Looking at costs is not just about investigations it is also about department flow. Sure, bloodwork and imaging costs money. But patients sitting in the ER waiting to be dispositioned also costs money. So emerg docs try and find a balance. I can tell you at my stage of training I am expected to see 5-6 patients an hour. When I am staff, that will double. Everything in the emerg is timed, and you see your board go from green, to yellow, to flashing red as patients sit in the department too long. And there are financial consequences to the department when flow constraints set out by the ministry are not met. So if ordering a bunch of tests up front means streamlining the process - that will sometimes be done. And it may mean a patient gets referred to you with an inital work-up and stabilization but not neatly packaged with bow on top.

 

And then there are the demands placed by the referring services. Gen surg won't come down and see that pt with a tender RLQ, fever and + Rovsing without documented appendicitis on CT - though you really think they might not need the radiation. Medicine won't come see your confused old patient with ARF and hyponatremia until you get a CT head and rule out a bleed - what if they could go to neurosurgery. Psych won't come see your psychotic or suicidal patient who is known to them and stopped taking their meds 3 months ago, until you've checked their TSH, done a drug urine screen etc. Even though, it isn't a first presentation and the evidence shows that urine screens are useless, and the result isn't going to change where the patient is going in the end. So we sometimes order things, we don't really want.

 

 

And back to some of the reference about various "rules" - these are not the be all and end all of medical decision making. You still need to use your brain. Patients don't present as classic cases all the time.

 

eg. I had an overweight young pt fall down 3 stairs. And had neck pain. Due to body habitus her plain films were not very good. So I requested a CT cspine. Well you can bet that rads did not want to do it and told me I should go learn about the Canadian cspine rules. That patient had an unstable C3 fracture right through the facets. (arguably they probably didn't have pts with BMIs as high as this pts in the validation study)

 

eg. Recently called to arrange a CT abdo for r/o kidney stone vs appendicitis in a pt with Rt flank pain and 3+ hematuria. In a rather rude manner, I got told I could not ask both these questions, I could only ask one and I needed to decide which question I was asking and that I should be able to tell clinically - so r/o kidney stone it is. And the patient had appendicitis. It is sometimes frustrating when radiologists who do not see patients, tell you what you should be able to tell clinically. This patient had a very sore Rt flank and minimally tender RLQ.

 

I don't go around bashing an entire specialty based on some interactions with some individuals. I recognize that we all have different skills and backgrounds. I would hope we would all be working together to deliver excellent patient care, without being adversarial toward each other.

 

Keeping dialogue open between specialties is important. We can all learn from each other and improve things for the future. No one person and no one specialty has all the answers for one person. People are generally willing to change practice if it can be demonstrated that there is a problem in the first place and that the change improves things. But adversarial blanket statements that are not targeted around a specific issue cannot adequately be discussed or addressed. Furthermore, most physicians aren't going to purposefully do things that will cause patient harm.

[Lactic Folly]

I don't go around bashing an entire specialty based on some interactions with some individuals. I recognize that we all have different skills and backgrounds. I would hope we would all be working together to deliver excellent patient care, without being adversarial toward each other.

 

Keeping dialogue open between specialties is important. We can all learn from each other and improve things for the future. No one person and no one specialty has all the answers for one person. People are generally willing to change practice if it can be demonstrated that there is a problem in the first place and that the change improves things. But adversarial blanket statements that are not targeted around a specific issue cannot adequately be discussed or addressed. Furthermore, most physicians aren't going to purposefully do things that will cause patient harm.

 

Agree with Satsuma. Important points for everyone to keep in mind, especially those just starting out. As NLengr intimated, you'll get better cooperation if you approach people by giving them benefit of the doubt - the adversarial approach is often a self-fulfilling prophecy and makes your life a lot harder than it needs to be.