Follow up to What Would You Do?
I order the scan.
Most people are reasonable, but inevitably you run into those who are not, like this mom who has in her head what is best for her child and is not the least bit interested in my opinion on the matter despite the fact that of the two of us I’m the one who’s the doctor for crying out loud. I could take the time to continue to argue with her at the expense of all the other patients in the department, eventually boot her out of the ER, take a hit on our patient satisfaction surveys, have an unflattering letter about me sent to administration, or I could order the scan. Easy.
Plus, you just never know in this business — while it’s exceedingly unlikely that this kid has any sort of serious head injury it’s not zero and if you happen to be wrong about the child that you refused to scan despite his mother pleading for one (with an unwitnessed fall and tender soft tissue swelling no less), well, you have no recourse and are going to get absolutely nailed in court or with a huge settlement.
What is the risk of cancer from a CAT scan? Nobody really knows the answer to that question — a lot of the data is extrapolated from atomic bomb survivors who were thought to receive equivalent amounts of radiation — but it looks as though for any given patient, even a child, it is minute. I’m not excited about exposing anyone to radiation but for this single patient encounter it’s probably ok. To scan every kid who bonked his head without any sort of selection process would be a problem.
I thought it was interesting that most of the commenters were against scanning, but the two I know to be ER docs were both in favor of pulling the trigger on the CT.
April 10, 2008 at 1:58 am
Half of pediatrics is treating the parents.
April 10, 2008 at 7:12 am
Allow me to play devil’s advocate for a moment. You state that,
“To scan every kid who bonked his head without any sort of selection process would be a problem”
What then is the selection process? Your judgment as a clinician already was against scanning- you said the risks outweighed the benefits. Does your medical judgment get overruled by the squeaky wheel parent? (10/10): Yes
What if all the kids with bonked heads have similar parents? Then I’d have to scan them all. But most parents are reasonable.
Since, “you never know in this business…” Why isn’t EVERY one with the potential for occult injury thusly scanned? Some docs probably do this, there is not any real disincentive to do so, but it is not ethical (social justice as it pertains to medical ethics) and so I don’t scan them all and just keep my fingers crossed that the one’s I don’t end up ok.
I am not naive, I realize that we live in a very litigious society, but I’m wondering about the role of physicians when clinical judgment is swayed by fear of legal action and Monday morning quarterbacking.
By the way I am only a lowly medical student and do not mean to second-guess your call, by any means. I have enjoyed reading your blog for some time now and offer my thoughts only in the interest of the debate. It’s never too early to start thinking about this stuff. Thanks for taking the time to comment.
April 10, 2008 at 8:11 am
Vince says: “I’m wondering about the role of physicians when clinical judgment is swayed by fear of legal action and Monday morning quarterbacking.”
Vince, EVERYTHING that is done in medicine is done out of fear of legal action. Next time you are on rotation, just stop for a minute every time you fill out paperwork, look at paperwork filled out by others, wonder why a certain lab test was ordered, wonder why so much linen is being used, etc. It doesn’t take long in this job to realize that there is next to nothing that we do that we could not do just as safely and effectively for a whole lot cheaper if we weren’t so scared of the lawyers.
-Braden-
20 out of 10 Blog
April 10, 2008 at 8:17 am
There really is such a thing as “parental concern” in medicine. After all, even if the parents are annoying and won’t listen to reason, they know their kid better than you do. It’s a valid reason to order the scan. Now, if it was something that is not even close to being indicated (the full body MRI comes to mind), you just take the complaint letter.
April 10, 2008 at 8:47 am
Braden,
I don’t disagree, for the most part. Perhaps I should clarify, what I meant to say was: I wonder about what the role of the physician SHOULD be. By capitulating to requests/demands of an under-informed patient don’t we subjugate sound medical judgment.
Every needless CT, MRI, or Abx prescription written just serves to elevate the “standard of care” to defensive medicine. Can that be good for anyone?
Vince, if I see ten people with bronchitis, I’ll tell all ten of them that an antibiotic won’t get them better any faster. Nine of them will say fine, the tenth will put up a fight because the reason he came to the ER was for an antibiotic script and he didn’t just waste four hours of his life in the waiting room to not get one. Why fight with this guy? He gets a script for amoxicillin and everyone goes about their business.
You gotta choose your battles, and these are not the ones worth fighting.
April 10, 2008 at 10:49 am
After I thought about it for a bit I figured, yea, just get the scan so she’ll shut up.
I’m one of those stubborn people who doesn’t like to be told what to do by a patient (or the patient’s parent)…I’m learnin’ though.
April 10, 2008 at 10:49 am
Oh, and I’m glad your back!
Thanks
April 10, 2008 at 10:49 am
Vince,
It is good for the lawyers. Whom do you think you work for, anyway?
The administrators could worry about the opinion of a replaceable doctor or about a lawyer who might be very expensive to deal with.
The validity of these concerns is not important to the administrators – they decide what matters.
Then there is the adoration of the Press Ganey score, treating viral infections with antibiotics, registering the patient before allowing treatment, JCAHO, HIPAA, . . . . Do you really think that this is done with the patient’s well being in mind?
It is all about the perceived risk being reduced to zero – not the real risk, which is often increased by the “protections from risk.”
Didn’t we just have this conversation elsewhere?
April 10, 2008 at 11:18 am
No one else has asked, so I figure I will. Did the CT scan show anything or were you right in your initial assesment?
This is just a made up scenario from multiple previous similar experiences. Knock on wood, I have never said no scan, relented, and then have one come back with a cracked skull or head bleed. That would not be fun.
April 10, 2008 at 12:06 pm
im glad to see your blog…
April 10, 2008 at 1:19 pm
Rogue Medic,
If we insist on a perceived risk going to zero then dare I say Physicians will be overqualified and superfluous . We would be much better suited to have, dare I say, paramedics manning the ERs, blindly following “protocol”. Much cheaper since we will be spinning the CT 24/7. [wink]
April 10, 2008 at 1:45 pm
sorry about the 2 “dare I say” phrases- cut and paste error.
April 10, 2008 at 4:20 pm
Vince,
You are a daring guy, perhaps even doubly so. Maybe redundancy is your style.
You know that there are some doctors who, in spite of never attending law school, will give legal advice. They would not take it well if someone were to give medical advice without attending medical school, but where would we be without silliness.
One hospital, that has employed both of us, does not let its emergency response team treat anyone in the hospital until after they are registered. So, if you are visiting a patient, code, and expect CPR – you won’t get it from anyone following hospital policy.
Is this good risk management?
The hospital lawyers think so. Not being a lawyer myself, I still think that, as far as convincing the jury that this is embarrassing and expensive, this would fall into the category of a piece of cake.
April 10, 2008 at 4:21 pm
Well, guess I’m too old. I have never given a patient “what they want” unless I felt it was indicated. yes, there have been complaints, and my administration has backed me up since my “approval” rating is still > 99%.
So, you spent $$$, + radiation exposure, ’cause mom wanted it.
If you can live with that, so be it.
April 10, 2008 at 5:49 pm
He already said he wouldn’t do a test that was absolutely not indicated (like a full body MRI, for example). But a CT head in a kid who had an unwitnessed fall with a bump on their head is more in the gray area.
If you override Mom in every questionable situation, then eventually you’re going to get burned. Good luck telling the jury how “not indicated” the study was.
April 13, 2008 at 1:02 am
Nice discussion.
Just FYI, I too have ordered the same CT scan, many times. It’s good risk management. When you are unable to establish that trust and collaboration with parents then the risk of litigation in the case of that rare unexpected outcome goes up by ten-fold.
I have in a few cases wound up inducing a CT scan by talking too much about head bleeds and getting reasonable parents really scared! I’m more careful with my words now.
GruntDoc blogged about this phenomenon the other day — that patients come in with a set of expectations and woe unto the provider who fails to meet them. There are times to plant your flag and fight it out to the death when patients’ requests are not reasonable, but there are also times when you try to defer a request but compromise if you have to. This is a clear compromise case.
Cheers,
SF
April 13, 2008 at 5:31 pm
FWIW
I wouldn’t have ordered the scan; but then in my ED, I wouldn’t have got the scan – the radiologists wouldn’t have o.k’d it. If mum v. worried, I would ahve admitted for obs; right or wrong that’s the way we have to practice in the UK
April 16, 2008 at 5:45 pm
Ah yes. CYA medicine. I will back up every decision I make with EBM, not CYA. I agree with DrShroom. Admit if necessary, rather than expose a developing brain to radiation.
But then, this is the USA where we run scared of lawsuits. I don’t
June 1, 2008 at 4:03 pm
“…you have no recourse and are going to get absolutely nailed in court or with a huge settlement.”
I wouldn’t say that. I’m not specifically a malpractice attorney, but I’d venture to say that the judge would hold you up to the standard of what a reasonable doctor would have done. Given the fact that you fully examined the child, that you fully informed the mother of the risks and benefits, that the mother was a [rather unreasonable] lay person and was not in a better position to make a decision than you were, and that there were no indicators that the child had something seriously wrong warranting a CAT scan, your reaction of the risks outweighing the benefits was perfectly reasonable. Thyroid cancer is not a reasonable risk to take when faced with a child with a standard small bump on his head who displays no need for a scan.
It may be easy for me to say this because I’m in the legal field, but don’t be scared of the law! It’s there to protect you (even though it may not seem like it). If you do what any reasonable doctor would have done, you won’t get slammed in court if your attorney is not absolutely terrible at her job.
December 19, 2008 at 1:51 am
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