Re: Re: Intent - Cardiac Cath? Next!

[Guest guest]

My Friend Jeff is 35 years old. He was running 3-4 miles 3-4 times per week last year. He restarted running last month, but had chest discomfort sternally at levels previously comfortable to him. He sheduled with his primary doctor who ordered a exercise stress test with the group's cardiologist reading the stress test supervised by nurse.

It was " abnormal" you are not going anywhere. I believe he had ST segment sloping in several leads. He was not observed for 10 hours for heart attack, he was taken directly to cath lab for coronary catheter. I talked to him just before(questions racing in my head) just reassured him it would likely be normal (thinking last patient with acute MI didn't get a cath that fast.) Of couse it is the most definitive test, but the pretest probability of someone who knows him is low.

His coronary arteries were completely clear. A week later he has another stress test this time a stress echo. He was told he had LBBB and take a BBlocker.

I just think he was rushed to cath before anyone did any thinking.

Actually, I don’t think those are Ponzi schemes. I proved the numbers to a multispecialty practice I was associated with.

In a group you need to maximize what each individual gets better paid for example a cardiologist gets paid for doing caths, reading echos and stress test; he should not be managing HTN and CHF; that is the work of the internist. Now you can free up the cardiologist to do what he gets high reimbursement and let the internist do the rest. The tricky part is to change the mentality from me getting paid to us getting paid to maximize reimbursement and profit, quite difficult when people don’t think long term. That way the cardiologist, again an example, pays the internist for freeing his time to do the better reimbursed management / procedures.

It works when people behave like a true team and not as selfish doctors which they always do.

But, again, you are right; the solution is not there. As long as the system is geared to reward “treatment†of disease and not “maintenance†of health the cost would continue to spiral with the added burden in pain and suffering.

José

From: Practiceimprovement 1yahoogroups (DOT) com [mailto:Practiceimprovement 1yahoogroups (DOT) com] On Behalf Of l_spikolSent: Friday, February 27, 2009 8:40 AM

To: Practiceimprovement 1yahoogroups (DOT) comSubject: [Practiceimprovemen t1] Re: Intent

Well, this is a very interesting and I think important topic. Clayton Christiansen of Harvard business school has dedicated his professional life to talking about disruptive innovation. Take a look-some of it is worth reading. (I also highly recommend the Harvard business review podcast-)Many on this listserv have responded well to these disruptions innovatin with amazing clinical and operational innovations. The problem has been getting paid adequately which is a continuing struggle. Some have been able to opt out of the current payment system successfully.I am presently working for a hospital system that plays us off against income generated elsewhere. Before you become jealous, I think this is a Ponzi scheme that will eventually fail (cracks are showing up already).I think it's important to continue to do what you have been doing which is thinking of innovations that provide

real value not only to your patients but the system as a whole.I am hoping that President Obama and his administration will discover that reshuffling money within the healthcare schema will not provide the answer, but a system based on strong primary care that is adequately reimbursed will provide the answer. > >> > Playing devil's advocate here...( I do have a second job as> hospitalist)> >> > What if the pymnt system is designed to drive physicians out of> prim care. Maybe society has decided nps/pas are good enough.> >> > Much like

turbotax/tax preparers sub for CPAS now> > legal zoom, stead of lawfirms> > poorly paid/ trsined pilots_ see sullenberger's story> >> > what if thats the reality we have to face> >> > what if THAT is the future? Yes there will always be a market for> premium service. But that may BE the intent rather than an accident?> >> > Sigh!!!!!> >> >> > SANGEETHA> >>

-- If you are a patient please allow up to 24 hours for a reply by email/please note the new email address.Remember that e-mail may not be entirely secure/ MD ph fax impcenter.org

[Guest guest]

SO the really good part of that  KEvin,  would be, if all the parties invovled put this to a conference and went over it. Sit a t a  table  together  and look at strips and each person say how they got the  patietn and what hx they thought hey had and what was on t he strips etc  Mediciine used to be academic now our mtgs a re about  budgets and reimbursmenets and coding and how to, say at our hospitla, since they got someProvider based  rating , which allows th em to paid at astronomical rates- and charge the  cash  payers the same   out of this world rates- they also have to thave state certified  PPD training g and other delaying obscurting bureautcratic processes consuming their tme

 WOuld be really good for all parties involed to talk and think  a bout  could this cath have been prevented  WHat was seen ont he ekg  what  wasmissed and learn sometihng from itSorry  I ami n a really bad mood I think. How dare I suggest thinking and conferecneing

I will hereby keep my hand of the send button for a while:)  Thank god no adverse  effects happend to your friend

My Friend Jeff is 35 years old. He was running 3-4 miles 3-4 times per week last year.  He restarted running last month, but had chest discomfort sternally at levels previously comfortable to him.  He sheduled with his primary doctor who ordered a exercise stress test with the group's cardiologist reading the stress test supervised by nurse. 

 

It was " abnormal "   you are not going anywhere.  I believe he had ST segment sloping in several leads.  He was not observed for 10 hours for heart attack, he was taken directly to cath lab for coronary catheter.  I talked to him just before(questions racing in my head) just reassured him it would likely be normal (thinking last patient with acute MI didn't get a cath that fast.)  Of couse it is the most definitive test, but the pretest probability of someone who knows him is low. 

 

His coronary arteries were completely clear.  A week later he has another stress test this time a stress echo. He was told he had LBBB and take a BBlocker.

 

I just think he was rushed to cath before anyone did any thinking.

 

Actually, I don’t think those are Ponzi schemes.  I proved the numbers to a multispecialty practice I was associated with.

 

In a group you need to maximize what each individual gets better paid for example a cardiologist gets paid for doing caths, reading echos and stress test; he should not be managing HTN and CHF; that is the work of the internist.  Now you can free up the cardiologist to do what he gets high reimbursement and let the internist do the rest.  The tricky part is to change the mentality from me getting paid to us getting paid to maximize reimbursement and profit, quite difficult when people don’t think long term.  That way the cardiologist, again an example, pays the internist for freeing his time to do the better reimbursed management / procedures.

 

It works when people behave like a true team and not as selfish doctors which they always do.

 

But, again, you are right; the solution is not there.  As long as the system is geared to reward “treatment” of disease and not “maintenance” of health the cost would continue to spiral with the added burden in pain and suffering.

 

José

 

From: Practiceimprovement 1yahoogroups (DOT) com [mailto:Practiceimprovement 1yahoogroups (DOT) com] On Behalf Of l_spikol

Sent: Friday, February 27, 2009 8:40 AM

To: Practiceimprovement 1yahoogroups (DOT) comSubject: [Practiceimprovemen t1] Re: Intent

 

Well, this is a very interesting and I think important topic. Clayton Christiansen of Harvard business school has dedicated his professional life to talking about disruptive innovation. Take a look-some of it is worth reading. (I also highly recommend the

Harvard business review podcast-)Many on this listserv have responded well to these disruptions innovatin with amazing clinical and operational innovations. The problem has been getting paid adequately which is a continuing

struggle. Some have been able to opt out of the current payment system successfully.I am presently working for a hospital system that plays us off against income generated elsewhere. Before you become jealous, I

think this is a Ponzi scheme that will eventually fail (cracks are showing up already).I think it's important to continue to do what you have been doing which is thinking of innovations that provide

real value not only to your patients but the system as a whole.I am hoping that President Obama and his administration will discover that reshuffling money within the healthcare schema will not provide the answer, but a system based on strong primary care

that is adequately reimbursed will provide the answer. > >> > Playing devil's advocate here...( I do have a second job as

> hospitalist)> >> > What if the pymnt system is designed to drive physicians out of> prim care. Maybe society has decided nps/pas are good enough.> >> > Much like

turbotax/tax preparers sub for CPAS now> > legal zoom, stead of lawfirms> > poorly paid/ trsined pilots_ see sullenberger's story> >> > what if thats the reality we have to face

> >> > what if THAT is the future? Yes there will always be a market for> premium service. But that may BE the intent rather than an accident?> >> > Sigh!!!!!> >

> >> > SANGEETHA> >>

-- If you are a patient please allow up to 24 hours for a reply by  email/please note the new email address.

Remember  that e-mail may not be entirely secure/    MD        ph   fax impcenter.org

-- If you are a patient please allow up to 24 hours for a reply by  email/please note the new email address.Remember  that e-mail may not be entirely secure/     MD

        ph   fax impcenter.org

[Guest guest]

We had a gentleman in our community a few years ago with exactly

the same story, except that he went into V fib and died during the cath (but he

did have totally clean coronary arteries). 

dts

From:

[mailto: ] On Behalf Of Egly

Sent: Friday, February 27, 2009 8:43 AM

To:

Subject: Re: Re: Intent - Cardiac Cath? Next!

My Friend Jeff is 35 years old. He was running 3-4 miles

3-4 times per week last year. He restarted running last month, but had

chest discomfort sternally at levels previously comfortable to him. He

sheduled with his primary doctor who ordered a exercise stress test with the

group's cardiologist reading the stress test supervised by nurse.

It was " abnormal " you are not going

anywhere. I believe he had ST segment sloping in several leads.

He was not observed for 10 hours for heart attack, he was taken directly to

cath lab for coronary catheter. I talked to him just before(questions

racing in my head) just reassured him it would likely be normal (thinking

last patient with acute MI didn't get a cath that fast.) Of couse it is

the most definitive test, but the pretest probability of someone who knows

him is low.

His coronary arteries were completely clear. A week

later he has another stress test this time a stress echo. He was told he

had LBBB and take a BBlocker.

I just think he was rushed to cath before anyone did any

thinking.

Actually, I don’t think those are Ponzi schemes. I

proved the numbers to a multispecialty practice I was associated with.

In a group you need to maximize what each individual gets

better paid for example a cardiologist gets paid for doing caths, reading

echos and stress test; he should not be managing HTN and CHF; that is the

work of the internist. Now you can free up the cardiologist to do what

he gets high reimbursement and let the internist do the rest. The

tricky part is to change the mentality from me getting paid to us getting

paid to maximize reimbursement and profit, quite difficult when people don’t

think long term. That way the cardiologist, again an example, pays the

internist for freeing his time to do the better reimbursed management / procedures.

It works when people behave like a true team and not as

selfish doctors which they always do.

But, again, you are right; the solution is not there. As

long as the system is geared to reward “treatment†of disease and not

“maintenance†of health the cost would continue to spiral with the added

burden in pain and suffering.

José

From: Practiceimprovement

1yahoogroups (DOT) com [mailto:Practiceimprovement

1yahoogroups (DOT) com] On Behalf Of l_spikol

Sent: Friday, February 27, 2009 8:40 AM

To: Practiceimprovement 1yahoogroups (DOT) com

Subject: [Practiceimprovemen t1] Re: Intent

Well, this is a very interesting

and I think important topic.

Clayton Christiansen of Harvard business school has dedicated his

professional life to talking about disruptive innovation. Take a

look-some of it is worth reading. (I also highly recommend the

Harvard business review podcast-)

Many on this listserv have responded well to these disruptions

innovatin with amazing clinical and operational innovations. The

problem has been getting paid adequately which is a continuing

struggle. Some have been able to opt out of the current payment

system successfully.

I am presently working for a hospital system that plays us off

against income generated elsewhere. Before you become jealous, I

think this is a Ponzi scheme that will eventually fail (cracks are

showing up already).

I think it's important to continue to do what you have been doing

which is thinking of innovations that provide real value not only to

your patients but the system as a whole.

I am hoping that President Obama and his administration will

discover that reshuffling money within the healthcare schema will

not provide the answer, but a system based on strong primary care

that is adequately reimbursed will provide the answer.

> >

> > Playing devil's advocate here...( I do have a second job as

> hospitalist)

> >

> > What if the pymnt system is designed to drive physicians out of

> prim care. Maybe society has decided nps/pas are good enough.

> >

> > Much like turbotax/tax preparers sub for CPAS now

> > legal zoom, stead of lawfirms

> > poorly paid/ trsined pilots_ see sullenberger's story

> >

> > what if thats the reality we have to face

> >

> > what if THAT is the future? Yes there will always be a market for

> premium service. But that may BE the intent rather than an

accident?

> >

> > Sigh!!!!!

> >

> >

> > SANGEETHA

> >

>

--

If you are a patient please allow up to 24 hours for a reply by email/

please note the new email address.

Remember that e-mail may not be entirely secure/

MD

ph fax

impcenter.org

[Guest guest]

I'd say such a test should be considered in context. The potential benefit has to

outweigh the potential risk. Unfortunately, " potential " means that bad

things can still happen. That is the inherent problem with everything, yes

everything, we do in medicine. It's just that, for most questions to consider,

" death " is not high on the list of possibilities.Caths are

fantastically helpful many times, and fantastically awful at others (thankfully less

often than helpful).Tim > > >

> to all> frm HH> >

I think any test which comes with a risk of death is no good.> > H

H> > > > > > >> > > > Playing devil's advocate here...( I

do have a second job as> > > hospitalist)> > > >> > > > What if the pymnt system is designed to drive physicians out

of> > > prim care. Maybe society has decided nps/pas are good

enough.> > > >> > > > Much like turbotax/tax

preparers sub for CPAS now> > > > legal zoom, stead of lawfirms> > > > poorly paid/ trsined pilots_ see sullenberger's story> > > >> > > > what if thats the reality we have to

face> > > >> > > > what if THAT is the future?

Yes there will always be a market> for> > > premium service.

But that may BE the intent rather than an> > accident?> >

> >> > > > Sigh!!!!!> > > >> >

> >> > > > SANGEETHA> > > >> >

>> >> >> >> >> >

--> > If you are a patient please allow up to 24 hours for a reply by> email/> > please note the new email address.> >

Remember that e-mail may not be entirely secure/> >

MD> > > > > > ph fax > > impcenter.org> >> > > > >

------------------------------------> >

[Guest guest]

An interesting part of this topic that has not been overtly mentioned is that a very large part of what drives US medical decision making is the malpractice issue.  We as physicians are rarely, if ever, allowed to be wrong, so we do the most definitive, potentially dangerous intervention with the least likelihood of us being wrong. 

 

Another example of this would be a headache patient in a non IMP type practice.  If you only have 10 minutes, you are more likely to get the MRI/CT of the head because you do not take the time to find out their dog died, their car broke down and they lost their job one week ago.  You just want to make sure they do not have a bleed/tumor/aneurysm.  So now, the patient has a completely normal MRI of the brain, another bill to pay and they still have a headache, but our med malpractice carriers are happy because we " covered ourselves. "   

 

The better I know a person, the better I can care for them without expensive and sometimes dangerous interventions.  Getting to know patients takes time, a relationship built over time, and inherent trust.  My patients must be able to trust my guidance, and I must be able to trust my patients to let me know if symptoms are not following the course I have discussed with them.   

 

I know this is not news to anyone on this list, but I couldn't help but mention it in this context.

 

Durango, CO

I'd say such a test should be considered in context. The potential benefit has to outweigh the potential risk. Unfortunately, " potential " means that bad things can still happen. That is the inherent problem with everything, yes everything, we do in medicine. It's just that, for most questions to consider, " death " is not high on the list of possibilities.

Caths are fantastically helpful many times, and fantastically awful at others (thankfully less often than helpful).Tim > > > > to all> frm HH> > I think any test which comes with a risk of death is no good.

> > H H> > > > > > >> > > > Playing devil's advocate here...( I do have a second job as> > > hospitalist)> > > >> > > > What if the pymnt system is designed to drive physicians out of

> > > prim care. Maybe society has decided nps/pas are good enough.> > > >> > > > Much like turbotax/tax preparers sub for CPAS now> > > > legal zoom, stead of lawfirms

> > > > poorly paid/ trsined pilots_ see sullenberger's story> > > >> > > > what if thats the reality we have to face> > > >> > > > what if THAT is the future? Yes there will always be a market

> for> > > premium service. But that may BE the intent rather than an> > accident?> > > >> > > > Sigh!!!!!> > > >> > > >> > > > SANGEETHA

> > > >> > >> >> >> >> >> > --> > If you are a patient please allow up to 24 hours for a reply by> email/> > please note the new email address.

> > Remember that e-mail may not be entirely secure/> > MD> > > > > > ph fax > > impcenter.org

> >> > > > > ------------------------------------> >

[Guest guest]

,

Great point.  I remember reading a study, while I was a resident

some time ago, that ascribed 30% excess cost directly to fear of malpractice

litigation, no medical reason whatsoever to get the lab, consult or study done;

and that was the late 90’s. 

We tend to forget that we are trained to be, basically, educated

guessers; we shoot for a 95% degree of certainty for the most part.  The sad part is that we don’t get a higher certainty we

all the extra stuff that gets done; even if it looks good on paper.

It is hard to give the appropriate answer to my most hated

question; how can you be 100% sure?, simply I can’t, but on the other hand I am

99.9% sure.

José

From:

[mailto: ] On Behalf Of

Sent: Friday, February 27, 2009 3:14 PM

To:

Subject: Re: Re: Intent - Cardiac Cath? Next!

An interesting part of this topic that has not been overtly

mentioned is that a very large part of what drives US medical decision making

is the malpractice issue. We as physicians are rarely, if ever, allowed

to be wrong, so we do the most definitive, potentially dangerous intervention

with the least likelihood of us being wrong.

Another example of this would be a headache patient in a non

IMP type practice. If you only have 10 minutes, you are more

likely to get the MRI/CT of the head because you do not take the time to

find out their dog died, their car broke down and they lost their job one

week ago. You just want to make sure they do not have a bleed/tumor/aneurysm.

So now, the patient has a completely normal MRI of the brain, another bill to

pay and they still have a headache, but our med malpractice carriers are happy

because we " covered ourselves. "

The better I know a person, the better I can care for them

without expensive and sometimes dangerous interventions. Getting to

know patients takes time, a relationship built over time, and inherent

trust. My patients must be able to trust my guidance, and I must be able

to trust my patients to let me know if symptoms are not following the course I

have discussed with them.

I know this is not news to anyone on this list, but I

couldn't help but mention it in this context.

Durango, CO

I'd say such a test should be considered in

context. The potential benefit has to outweigh the potential risk.

Unfortunately, " potential " means that bad things can still happen.

That is the inherent problem with everything, yes everything, we do in

medicine. It's just that, for most questions to consider, " death " is

not high on the list of possibilities.

Caths are fantastically helpful many times, and fantastically awful at others

(thankfully less often than helpful).

Tim

>

>

>

> to all

> frm HH

>

> I think any test which comes with a risk of death is no good.

>

> H H

>

>

>

> > > >

> > > > Playing devil's advocate here...( I do have a second job as

> > > hospitalist)

> > > >

> > > > What if the pymnt system is designed to drive physicians

out of

> > > prim care. Maybe society has decided nps/pas are good enough.

> > > >

> > > > Much like turbotax/tax preparers sub for CPAS now

> > > > legal zoom, stead of lawfirms

> > > > poorly paid/ trsined pilots_ see sullenberger's story

> > > >

> > > > what if thats the reality we have to face

> > > >

> > > > what if THAT is the future? Yes there will always be a

market

> for

> > > premium service. But that may BE the intent rather than an

> > accident?

> > > >

> > > > Sigh!!!!!

> > > >

> > > >

> > > > SANGEETHA

> > > >

> > >

> >

> >

> >

> >

> > --

> > If you are a patient please allow up to 24 hours for a reply by

> email/

> > please note the new email address.

> > Remember that e-mail may not be entirely secure/

> > MD

> >

> >

> > ph fax

> > impcenter.org

> >

>

>

>

>

> ------------------------------------

>

>

[Guest guest]

Sometimes extensive tests are

ordered/warranted when fast action might be required.  My own example:  my son

came home from school one day in the 1st grade, complaining of

headaches, that he “couldn’t read anymore†and that he couldn’t see any

colors.  I got him in to see one of Steve’s partners (at the time), who was his

pediatrician, the next day.  Rather than thinking “oh, maybe this kid needs

glasses,†Marty rushed to think the worst – brain tumor – and ordered an MRI. 

So off we went to the hospital, 7 year old perfectly behaving for the MRI,

which ended up being completely normal.  We obviously weren’t going to sue our

own partner for malpractice if he had said “see an optometrist first and if

there are still problems in x amount of time, we’ll order an MRI.â€Â  We kick

ourselves that we didn’t take him to an optho first (to save ourselves the cost

of the MRI), but if there had been a tumor, well, obviously there’s no question

that the MRI was the right thing to order.  BTW, glasses completely fixed the

problem, and now he’s a happy 13 year old with contacts.

Pratt

Office Manager

Oak Tree Internal Medicine P.C

Roy Medical Associates, Inc.

From: [mailto: ] On Behalf Of

Sent: Friday, February 27, 2009

12:14 PM

To:

Subject: Re:

Re: Intent - Cardiac Cath? Next!

An interesting part of this topic that has not been overtly mentioned

is that a very large part of what drives US medical decision making is the

malpractice issue. We as physicians are rarely, if ever, allowed to be

wrong, so we do the most definitive, potentially dangerous intervention with

the least likelihood of us being wrong.

Another example of this would be a headache patient in a non IMP type

practice. If you only have 10 minutes, you are more likely to get

the MRI/CT of the head because you do not take the time to find out their dog

died, their car broke down and they lost their job one week ago. You

just want to make sure they do not have a bleed/tumor/aneurysm. So

now, the patient has a completely normal MRI of the brain, another bill to pay

and they still have a headache, but our med malpractice carriers are happy

because we " covered ourselves. "

The better I know a person, the better I can care for them without

expensive and sometimes dangerous interventions. Getting to know

patients takes time, a relationship built over time, and inherent trust.

My patients must be able to trust my guidance, and I must be able to trust my patients

to let me know if symptoms are not following the course I have discussed with

them.

I know this is not news to anyone on this list, but I couldn't help but

mention it in this context.

Durango,

CO

I'd say such a test should be considered in context.

The potential benefit has to outweigh the potential risk. Unfortunately,

" potential " means that bad things can still happen. That is the

inherent problem with everything, yes everything, we do in medicine. It's just

that, for most questions to consider, " death " is not high on the list

of possibilities.

Caths are fantastically helpful many times, and fantastically awful at others

(thankfully less often than helpful).

Tim

>

>

>

> to all

> frm HH

>

> I think any test which comes with a risk of death is no good.

>

> H H

>

>

>

> > > >

> > > > Playing devil's advocate here...( I do have a second job as

> > > hospitalist)

> > > >

> > > > What if the pymnt system is designed to drive physicians

out of

> > > prim care. Maybe society has decided nps/pas are good enough.

> > > >

> > > > Much like turbotax/tax preparers sub for CPAS now

> > > > legal zoom, stead of lawfirms

> > > > poorly paid/ trsined pilots_ see sullenberger's story

> > > >

> > > > what if thats the reality we have to face

> > > >

> > > > what if THAT is the future? Yes there will always be a

market

> for

> > > premium service. But that may BE the intent rather than an

> > accident?

> > > >

> > > > Sigh!!!!!

> > > >

> > > >

> > > > SANGEETHA

> > > >

> > >

> >

> >

> >

> >

> > --

> > If you are a patient please allow up to 24 hours for a reply by

> email/

> > please note the new email address.

> > Remember that e-mail may not be entirely secure/

> > MD

> >

> >

> > ph fax

> > impcenter.org

> >

>

>

>

>

> ------------------------------------

>

>

[Guest guest]

I guess that was part of the 30% I read about.

Don’t kick yourself, it is the job of the pediatrician to figure

that out, not yours as a parent.

José

From:

[mailto: ] On Behalf Of Pratt

Sent: Friday, February 27, 2009 4:13 PM

To:

Subject: RE: Re: Intent - Cardiac Cath? Next!

Sometimes

extensive tests are ordered/warranted when fast action might be required.

My own example: my son came home from school one day in the 1st

grade, complaining of headaches, that he “couldn’t read anymore†and that he

couldn’t see any colors. I got him in to see one of Steve’s partners (at

the time), who was his pediatrician, the next day. Rather than thinking

“oh, maybe this kid needs glasses,†Marty rushed to think the worst – brain

tumor – and ordered an MRI. So off we went to the hospital, 7 year old

perfectly behaving for the MRI, which ended up being completely normal.

We obviously weren’t going to sue our own partner for malpractice if he had

said “see an optometrist first and if there are still problems in x amount of

time, we’ll order an MRI.†We kick ourselves that we didn’t take him to

an optho first (to save ourselves the cost of the MRI), but if there had been a

tumor, well, obviously there’s no question that the MRI was the right thing to

order. BTW, glasses completely fixed the problem, and now he’s a happy 13

year old with contacts.

Pratt

Office Manager

Oak Tree Internal Medicine P.C

Roy Medical Associates, Inc.

From:

[mailto: ] On Behalf Of

Sent: Friday, February 27, 2009 12:14 PM

To:

Subject: Re: Re: Intent - Cardiac Cath? Next!

An

interesting part of this topic that has not been overtly mentioned is that a

very large part of what drives US medical decision making is the malpractice

issue. We as physicians are rarely, if ever, allowed to be wrong, so we

do the most definitive, potentially dangerous intervention with the least

likelihood of us being wrong.

Another

example of this would be a headache patient in a non IMP type practice.

If you only have 10 minutes, you are more likely to get the MRI/CT of the

head because you do not take the time to find out their dog died, their car

broke down and they lost their job one week ago. You just want to

make sure they do not have a bleed/tumor/aneurysm. So now, the patient

has a completely normal MRI of the brain, another bill to pay and they still

have a headache, but our med malpractice carriers are happy because we

" covered ourselves. "

The

better I know a person, the better I can care for them without

expensive and sometimes dangerous interventions. Getting to know

patients takes time, a relationship built over time, and inherent trust.

My patients must be able to trust my guidance, and I must be able to trust my

patients to let me know if symptoms are not following the course I have

discussed with them.

I

know this is not news to anyone on this list, but I couldn't help but mention

it in this context.

Durango,

CO

On

Fri, Feb 27, 2009 at 11:53 AM, Malia, MD wrote:

I'd say such a test should be considered in

context. The potential benefit has to outweigh the potential risk.

Unfortunately, " potential " means that bad things can still happen.

That is the inherent problem with everything, yes everything, we do in

medicine. It's just that, for most questions to consider, " death " is

not high on the list of possibilities.

Caths are fantastically helpful many times, and fantastically awful at others

(thankfully less often than helpful).

Tim

>

>

>

> to all

> frm HH

>

> I think any test which comes with a risk of death is no good.

>

> H H

>

>

>

> > > >

> > > > Playing devil's advocate here...( I do have a second job as

> > > hospitalist)

> > > >

> > > > What if the pymnt system is designed to drive physicians

out of

> > > prim care. Maybe society has decided nps/pas are good enough.

> > > >

> > > > Much like turbotax/tax preparers sub for CPAS now

> > > > legal zoom, stead of lawfirms

> > > > poorly paid/ trsined pilots_ see sullenberger's story

> > > >

> > > > what if thats the reality we have to face

> > > >

> > > > what if THAT is the future? Yes there will always be a

market

> for

> > > premium service. But that may BE the intent rather than an

> > accident?

> > > >

> > > > Sigh!!!!!

> > > >

> > > >

> > > > SANGEETHA

> > > >

> > >

> >

> >

> >

> >

> > --

> > If you are a patient please allow up to 24 hours for a reply by

> email/

> > please note the new email address.

> > Remember that e-mail may not be entirely secure/

> > MD

> >

> >

> > ph fax

> > impcenter.org

> >

>

>

>

>

> ------------------------------------

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>

[Guest guest]

Almost everything we do has a risk of death. There is also a risk that doing nothing, when doing something was an option, can lead a patient swiftly to a funeral home. We are taking life-and-death risks with all of our patients, every day, all day long. This kid is O.K. to go out for the basketball team, probably ... we could be maybe a little more certain if we put him through an E.K.G. and an echocardiogram, but in the absence of warning symptoms, the N.N.T. is huge, so we say: O.K. to go out for sports ... The next kid has a strep throat, or a probably-strep-throat, and we say : here, this Penicillin is probably going to help you -- there is a test to screen for Penicillin allergy, but I have never ordered such a test -- so far, none of my patients has died from anaphylaxis after oral Penicillin, but it could happen. Chest pain is a much more dramatic ballpark, but the truth of the matter is the same, from the T-ball games and the little league, right up to the big leagues. People die. We try to choose the lowest risk which is reasonable. to allfrm HHI think any test which comes with a risk of death is no good.H H> > >> > > Playing devil's advocate here...( I do have a second job as> > hospitalist)> > >> > > What if the pymnt system is designed to drive physicians out of> > prim care. Maybe society has decided nps/pas are good enough.> > >> > > Much like turbotax/tax preparers sub for CPAS now> > > legal zoom, stead of lawfirms> > > poorly paid/ trsined pilots_ see sullenberger's story> > >> > > what if thats the reality we have to face> > >> > > what if THAT is the future? Yes there will always be a market for> > premium service. But that may BE the intent rather than an > accident?> > >> > > Sigh!!!!!> > >> > >> > > SANGEETHA> > >> >> > > > > -- > If you are a patient please allow up to 24 hours for a reply by email/> please note the new email address.> Remember that e-mail may not be entirely secure/> MD> > > ph fax > impcenter.org <http://impcenter.org/>>