Oct 2003 Table of Contents

IMPROVING PATIENT CARE

Cost-Effectiveness Begins Between Your Ears

Use common sense in observing and assessing patients before you start writing orders.

Fam Pract Manag. 2003 Oct;10(9):65-66.

To become a competent physician, one must assimilate vast numbers of facts, but to deliver high-quality, cost-effective care, a physician must also be able to analyze those facts and data acquired from patients. Medical schools in this country do an excellent job of loading future doctors with information, but they tend to be less effective in teaching clinical judgment and in developing physicians’ ability to focus on what’s important. Physicians typically learn these lessons through seat-of-the-pants experience. Here are some lessons I’ve learned that way – lessons that have helped me meet my patients’ needs while minimizing the amount of money wasted on useless tests and ineffective treatments.

Beware the streetcar accident fallacy

There’s an old story about a collision between a streetcar and an ice wagon that occurred in New York City a century ago. It seems that there were 20 seats in the car and room for perhaps a dozen standees, but 73 people showed up at local hospitals claiming to be passengers who had suffered grievous injury as a result of the motorman’s negligence. They obviously were not all telling the truth.

We see analogous situations today in relation to occupational and motor vehicle mishaps. Some claims of injury are valid but others are not, and each case must be judged on its own merits. The same phenomenon affects the diagnosis of conditions such as the currently fashionable chronic fatigue syndrome. There may indeed be such a disorder, but many chronically tired people don’t have it. Benevolent skepticism is a necessary part of medical practice. You don’t help your patients by treating them for problems they don’t have.

Don’t confuse diagnosis with labeling

Some practitioners, most often mental health professionals, are reluctant to make diagnoses of their patients’ disorders, often because of a well-intentioned desire to avoid value-laden labeling. They fear that professionals may become judgmental and fail to provide first-rate care for persons labeled with socially stigmatized conditions and that patients could become victims of gossip or even lose their jobs if their diagnoses become known.

These concerns are reasonable, but while they may occasionally warrant fudging diagnoses on an encounter form, they do not justify overlooking real problems. Disorders such as depression, alcoholism and panic disorder can be treated, but only after they are defined. Our challenge as physicians is to diagnose accurately while eschewing labeling that could make us undertreat them. We are required to accept imperfection as part of being human and to give patients our best effort without passing judgment.

Always confirm what a patient tells you

“I need treatment for my hypothyroidism/mitral valve prolapse/multiple sclerosis/rheumatoid arthritis/inflammatory bowel disease, doctor.” Patients often ask us to provide ongoing management for diagnoses that reportedly were established elsewhere. Sometimes patients provide accurate information, but occasionally they don’t, and this can lead to inappropriate management. For example, a person may think he or she has inflammatory bowel disease when in fact the previous doctor diagnosed irritable bowel syndrome. Such misunderstandings are common. When in doubt, verify the diagnosis with the appropriate physician or institution.

Distinguish diseases from social problems

Unstable angina is one of the most common discharge diagnoses at our hospital. The usual story is that someone arrives in the emergency department with chest pain that doesn’t go away after nitroglycerine is administered. The patient is admitted to a monitored bed, and serial cardiac enzyme tests are done. When these come back normal, treadmill and/or echocardiographic testing follows. These procedures often show some abnormality, and a diagnosis of coronary artery disease is made even if the objective abnormality is minimal.

These patients often return repeatedly. Some of them develop unmistakable heart disease, but others do not. For many, the symptoms reflect some major life stress. Even in patients with true impairment of coronary circulation, the quality of the patient’s family and social situation has a role in determining the risk of myocardial infarction. Again, taking time to look at and treat the whole patient – doing it right the first time – reduces costs and minimizes morbidity over time.

Don’t mistake lawyers for uncaged gorillas

Medical liability litigation is a real problem in the United States, but the hazards need to be kept in perspective. If you saw a gorilla at the zoo, you wouldn’t reach through the bars and try to pet it, but neither would you run away in panic. The lawsuit threat should stimulate us to practice good medicine and to keep bulletproof records, but it does not justify excessive testing and overtreatment of patients, both of which drive up costs with little benefit.

The evidence indicates that anger is most often what prompts patients to sue. If you really want to stay out of court, build good relationships with your patients. Listen constructively, empathize, treat them with respect and be available (or have an associate available) when things aren’t going well. The pressures of daily practice make this difficult, but it pays off in the long run.

Question research findings

Much of what appears in the literature is sound, but a few whoppers get published from time to time. One of my favorites is a “controlled” study of bed rest for treatment of backache in military recruits.1 Half of the subjects were put to bed in an Army base hospital until they felt better. The others were made to stand for hours at a time watching their peers undergoing basic military training. They were kept on their feet by the drill sergeants, and they may have been subjected to ridicule by their peers out on the drill fields. The bed rest group returned to duty significantly faster than the other subjects. The authors asserted that this demonstrated the value of bed rest for backache, but of course it did nothing of the kind. What it really proved is that backache in young men who are forced to stand on a drill field for hours at a time under humiliating conditions is slow to resolve.

The bottom line? Use that gray stuff between your ears for common sense observation and assessment of your patients before you start writing orders. Clear thinking facilitates both economy and efficiency in clinical care.

Dr. Gillette is a semi-retired family physician living in Poland, Ohio. His medical career includes 15 years in solo practice and 20 years teaching and practicing in family medicine departments and residency programs. He is a former member of the FPM Board of Editors.

Conflicts of interest: none reported.

Send comments to fpmedit@aafp.org.

1. Wiesel SW, Cuckler JM, Deluca F, et al. Acute low-back pain: an objective analysis of conservative therapy. Spine. 1980;5(4): 324–330.

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