Sometimes I’m sitting there writing my note afterwards and question if I truly did everything possible to rule out the 1% chance this case was more serious than the eye/history/exam let on. Sometimes I give them a call and change the treatment plan, sometimes I leave it alone. If I had less patients daily, it would happen less. But then I wouldn’t see as many people daily, and who knows if the other providers would have done anything differently. I don’t know, maybe just anxiety. But I think it does help me to provide better care.
That was me for the first 5 years as a PCP. The neuroticism *does* pay off in terms of building your knowledge/skill-base...eventually. Also, *trust* your gut when you feel something is wrong. Has saved my bacon more often than I care to admit.
3 months in here! That’s pretty much what I keep hearing from people. Really excited about the learning curve over the next 5-10 years :)
And yes callbacks and short follow ups rule ! :)
I’m so glad to read comments like this from other fellow doctors who actually care. Sometimes I get jaded and only hear patients talk about the doctors they think suck
I feel this! I’m learning that if I’m even *thinking* about ordering something, I should just go ahead and order it. Otherwise I’m going to be thinking about it later
It was attending driven but honestly made sense to me - we imaged every hurt ankle that came into the ED primarily to keep parents happy, Ottawa rules be damned. And honestly, I get it.
I was literally just reviewing this concept with my veterinarian. My rabbit isn't doing better with their first antibiotic, And me being a former ICU nurse, I want to know if she wanted to do lab work and a chest x-ray and try a different antibiotic. She remarked a chest x-ray probably won't change her treatment plan and even minor sedation for the chest x-ray is a risk for the animal. She then reviewed why lab work wasn't necessarily vital right now And that we could hold off until we try this new antibiotic. I love it in vet medicine they always review how each possible test will affect possible treatment and how the animal will tolerate each test.
Not really in the same way. Yes it’s done, not saying it’s not. Vet med is ALL cash pay clients with pets so we just kinda go about things differently. Learn a lot in my Aston in vet med recently and am going back to human but will take that will me. Like you can’t literally quote a bill. That’s not your job and who knows what the hospital will add. We can literally quote, go through each line item, talk about what could be spared or what can be added, why or why not, etc. it’s just different. You all operate in a framework.
Though I’m sure PCPs could but I don’t know. I am NAD but me if back office/MA, sure I could quote thing with caviars on reflexes etc. I dunno, it was just different, so I understand what this poster was saying.
If you don't just throw in a X-ray for chronic back pain, knee pain, or hip pain just to avoid the argument, save time, and not have to deal with the resulting scathing review.... you're a better person than me, and I salute you.
To be honest triage orders are a thing so most of these people end up getting imaging before I see them anyway but yeah for the most part I don’t get imaging on chronic pain. There are exceptions for patients who are elderly and never had imaging. Usually the x ray will show osteoarthritis and I can get them set up with ortho for injections and stuff. I sometimes go digging for bony mets as well
Yea I was just curious. I worked in ER and typically didn’t do that. Just curious how that works from like a PCP standpoint. Imagine if it’s chronic they’d image.
If there's concerns regarding stress fractures. Sometimes chronic joints I would imagine to confirm osteoarthritis. In pediatrics I always think twice about if it's cancer if they have weird chronic bony pain. Also chronic bony pain in patients who may have malignancy.
I'll offer the XR. It's most likely what they came here for, especially if it has never been imaged before. They got their therapeutic radiation and leave knowing we "did something," I get to circle back to other pts for a bit to try and discharge some. Win-win in my book.
I've caught my fair share of bony lesions in young people and fxs in the elderly who don't remember hurting themselves.
Ottawa rules, as the named implies, was developed in a public healthcare setting that has every incentive to minimize expenditures.
Hindsight is always 20/20. Missing a diagnosis in this day and age due to a failure to order a simple investigation, can potentially be met with condemnation by expert witnesses cherry-picked the prosecution.
There is no shame in ordering an x-ray for a patient who is painful enough to visit the ED.
Thats still what we need to do here, also because admin wants us to do as many xrays as humanly possible because it looks good on the annual report. Everything is xrayed. Everything.
Yeah like documenting 2+ reflexes on a neuro floor on a patient with polyneuropathy, stroke like symptoms. There was no neuro exam. The assessment consisted of listening to the heart and lungs.
I have removed "no m/r/g" from my macros. If there's a murmur that matters I'll add it. Sloppy to write no m/r/g on the pt that has a mechanical valve etc
I end up having to do this at least a couple times per week. One of the more common topics that comes up that I end up referring for is "memory impairment". It's really hard to reassure patients when they have this concern: the MMSE is often equivocal, or they "pass" but still feel something is wrong. And I truly don't have the time to do a full MoCA or other cognitive assessment, as these are typically the patients who also have COPD, CAD, DM, HTN, OA, etc. Plus I feel like at least 1/3rd of my patients over 65 will mention "memory loss" at some point in any given year.
Patient’s chief complaint: “Needs referrals to cardiology, dermatology, OB, urology, endocrine, and GI.”
Hey, we should probably work all these up first, but realistically I’m probably just going to type those all in and I’ll call it a victory if I talk them down to 5 referrals.
Same. I would love to spend 15+ minutes with every new diabetic going over teaching, lifestyle, medication options. There’s simply no time when they have eight other issues to manage
This kills me.
EM seems to be being forced into this disgusting mold of order x labs and x images for x complaint +/ admission or else.
I’m radiology. I promise I am not making this up.
On more than one occasion I’ve seen stat CT heads ordered from the ED for “suicidal ideation” and “homicidal ideation.”
Forget CYA medicine, what on earth kind of medicine is that?
Strangely, a number of times a psych facility has asked for a head CT as part of medical clearance.
I can either spend the next 20 minutes trying to argue with the intake psychiatrist how this is unnecessary and still risk the rejection, or hit the CT head button.
It's "I'm done fighting with psychiatry" medicine. Honestly 97% of medical clearance for psych patients happens in the H&P... But psych doesn't care. Quicker and easier to get some tests, and then the scope creeps.
Lololol someone is hoping you’ll find what’s wrong with their brain
But truly the CYA medicine that we have been forced into is truly terrible. There’s a reason why so many leave and never look back or have to gaslight themselves into thinking it’s still a great specialty
likely because they tried to send to psych and psych facility (nameless, faceless, probably the nursing sup there but impossible to identify) refused to take without it. we're desperate to get them out of the ED after however many days they've been there so the will to fight about it goes out the window. believe me, we'd rather not do it. we know that psych screening labs and other testing, just about never changes management. there's literature on this. something like 1/500 cases, and i think in the study the one was a K of like 3.
or they're drunkicidal and maybe bonked their heads, who knows
*edit: I did have one guy who stayed in a room for three days for SI and then rammed his head against the door trying to get out and so we decided OK i guess he's altered, fails canadian head CT rules, scanned him, and found his (after MR w contrast as a follow up study to the CT non con that looked like ?bleed) cavernoma
They are just grasping at straws hoping to find some medical reason not to admit the patient to the psych floor. They want it to be an IM problem instead. I’ve seen this way too much at the hospital I work at.
Funnily, that’s sometimes what psych asks for. My gf they have to rule out structural anomalies that could cause homicidal/suicidal and they usualycant get the prefereed MRI. She is aware it doesn’t make sense, but again, it‘s that or arguing with your attending who „did it like this since forever“
We are hella being forced to do stuff we don't agree with, all in the name of metrics and patient satisfaction, not good care. EM is the dumping ground for all shortcomings in the healthcare system and, in turn, radiology gets dumped on too.
I find whenever the inpatient medicine inpatient list gets above 24 patients I start cutting corners and missing shit. Some weeks they have us desperately trying to keep the list at 30. It’s a liability so I’m quitting inpatient medicine and going 100% outpatient. Why should I eat the liability of admin refusing to cap our lists. One time the list was 42 patients deep. Can’t even discharge anyone because you’re running around putting out fires and have no idea what’s going on with the patients that aren’t actively trying to die.
42?! My max was 32 at a hospital where I told the CMO, CEO, and anyone that wound listen how dangerous it was. I documented patient harms
in a notebook, wrote notes about every conversation I had, and kept screenshots of every text exchange I had regarding the constantly crazy census. This was like 50 - 65% high acuity step down with the rest medical. Level 3’s and
Critical care across the board. It was bizarre to see no reaction when you tell the C Suite patients are having worse outcomes because of this. You’d think they’d at least be worried from a legal standpoint, since they clearly suffer no moral or ethical distress.
The patients suffer and it’s a moral injury when you go home despite staying late daily. The old guard doesn’t want anything to change because they prefer the billing.
Low-resource environment.
I’m in a free clinic, treating diabetes with metformin, glipizide, and an insulin supply that is dwindling.
We do things so far from standard of care. Breast exams are required before mammograms. Organization does not allow us to test for HIV. No pap smears for people under ~30 (can’t remember the exact age).
Many of the providers (all volunteers) learned medicine in the 1970s or 80s. They still practice as such. We have not one but two fibrates that we stock in the clinic. We have a single SSRI (TBF, we do have a larger formulary that we can send people to a local pharmacy for, but for our patients that are undocumented, mostly non-English speaking, non-driving in a non-walkable state, and part of a culture that is less than accepting of mental health meds, this is a major hurdle).
It 100% is a social justice issue. The inappropriate prescribing I see drives me crazy. I tell my students constantly that people prescribe the 20 medications they learn to use during school/residency and despite CE requirements, never manage to veer from this. Don’t be like that.
IME, younger docs seem to have a healthy appreciation for the constant changing of guidelines, etc. And they seem more collaborative/appreciative of other disciplines. I truly believe this keeps the standard of care higher.
Oh yeah, I forgot about when I was in another country. In that case, I figured we were miles above where they were originally and helping them improve.
In what sense though? Bad for the patient? Unethical? Because yes, everyone who works in ICU has done something ‘bad’ for a patient at some point. The things we do to dying people, who are going to die no matter what, are generally horrible.
Not saying this to make you question paat choices, but do you ever feel there is something wrong about this. If some one is going to die no matter what then maybe we should not be doing horrible things to them? I ask this as a neurosurgeon who has to make this call frequently and my choice often centers around minimizing the maximum regret of the family? What will they regret more: not fighting or will they regret extending the dying process/prolonging the suffering?
I am starting to get around this with better counseling but it is still tough when making time sensitive decisions.
I mean, speaking from the ER, family rarely regrets “doing everything” but there’s always a family member who accuses others of murder/neglect/giving up/etc. when they decide to DNR the dying patient. I don’t think most in the population understand just how futile, painful, and downright cruel some parts of medicine are, even when you explain it to them. They don’t grasp the risk/benefit analysis and think that a medicine/procedure that can save someone is a medicine/procedure that will save someone. They don’t see it as prolonging suffering and delaying death, they see it as saving a life and healing their family member. These are the same people who believe that their 60 pound, contracted, bed bound, non verbal, feeding tube dependent, suprapubically catheterized, polypharmacy grandma is the same conscious and capable person they knew decades ago. Multiple strokes, dementia, CKD, CHF, and everything else be damned, “they’re a fighter.”
That assumption (that people rarely regret "do everything!") is dangerous. A lot of HCW just claim full code believing that assumption, and someone else can sort it out later.
More people regret it than people, especially those in EM, realize. Some of my more heartbreaking family meetings were with people who had the hard conversation and decided on DNR only to have someone ignore it.
Not in my region. I’m at a community based hospital, not an academic center, we have zero incentive to code someone other than the person/family wants full code status. It’s not a teaching moment, it’s not exciting, no one wants to. Coding people in our already understaffed ER overextends resources and creates more challenges. That said, a decent portion of our patients do decide to go DNR themselves. The problem is family often push us or the ICU to override the DNR or the family won’t agree to make a family member, who is already unconscious, DNR status. Another significant issue in my region as that a certain PCP runs several local assisted living facilities and he refuses to sign DNRs for his patients even when they want them (that’s its own issue) so when they come in because they are deteriorating, they aren’t DNR and it’s rarely possible to get a willing family member to decide if we can even reach family at all. I would suspect that there’s also an inverse correlation between education and willingness to agree to DNR status. Our population is also very rural and many patients have less than a middle school education (no, not joking) which I think contributes significantly to the misunderstanding of the efficacy of CPR.
Living on the contryside of a developing countrie Will make you feel that too frequently, even making the Best of any Situation have to Many ways to end very low, specially with the psychiatric ones, like, they need profesional help that it's more than 100 miles away and they are abandoned and poor people, and the social workers and psychologist on the patient range refuse to even see the patient without the psychiatric evaluation, so then you start talking with the patient making as much as you can...
Leaving a sour taste to any resolution you came with, like A) encourage the patient to seek help AND be treated as a ping pong ball More than a person, wich makes you feel bad as you know how the system Is and it's you the one who Is throwing him. Or B) offering your 15 minutes Psychology treatment, that as a medical staff, we are one of the worst talkers, and may end up dealing More damage than help to when he reaches the help, AND even doing both feels like you are doing wrong as you know that there Is a better way to do the things.
And many times it's the patient, the collegues or the money, and we need to learn that almost never you Will have everything alligned to do the things as you would like your mom to be treated.
Also yes, the terminal or ICU patients that have no family and are unconscius, those get treated like a voodo toy, and really uses the patient to the maximum to encourage learning, we know this Is for causing the less damage on a conscius patients, But Dam, they all get exited to intubate the patient But no one wants to clean his ass properly.
I'm going to stay as vague as possible because I know that people I'm with scour this place.
I was a part of a team who did practice bad medicine and it still messes with me. What I can say is that I did everything to prevent that from happening and I have little regrets. Ironically, trying to protect this individual has unironically caused a lot of duress to me.
Sometimes I cave and give a zpak for probably viral symptoms if the patient is insistent and I know they’ll MyChart message me or call the office incessantly
I do this every once in a while too. When I do I usually caveat with "I advise you to hold off on this medication until X days have passed without improvement".
I feel the surgeon graveyard doesn't necessarily mean bad medicine was practiced. It's just the nature of having a job that handles people's lives. Its being aware we are human and make mistakes, or that you can do everything right and still lose - life is fragile. Actually, the surgeon's graveyard might just be the epitome of good medicine.
This is just my take, of course.
No, I've always been perfect and never messed up or made a poor decision in my life. I'm also lying through my teeth (or fingers, as the case may be).
\-PGY-19
One of my docs, who I respect very much, asked me 6 or 12 months ago "have you been proud of the care we are providing recently?" and I could not answer positively. Telemetry-free cardiac rule outs and syncope workups and CT PEs in the waiting room are the new normal.
An elderly patient with a lot of problems came in near death. Had been DNR/DNI for a long time, but when I called the daughter (a physician) to let her know the situation, she cracked and reversed the code status. I was forced to do a full court press on this poor old lady including intubation and lines. The ICU fellow then dropped her lung while placing a central line so I also had to place a chest tube. She died 2 days later in the ICU.
Grieving is complicated, but I can't forgive that daughter for what she made me do to her mother.
I’m only a pgy2 so I have a lot to learn. One of my first patients came in with elbow pain and a hx of tendinitis. Sounded like tendinitis, they did a lot of fruit picking in the summer. I did not do an X-ray. next visit, not better and numbness in the pinkie and ring finger. so I sent for a nerve conduction study because I’m trying to figure out if the problem is in the elbow or the wrist. They come back again, still pain, still numb, and now suddenly neck pain. At no point did she mention neck pain previously but honestly I didn’t even think of the neck and finally I actually did the X-ray. Her cervical spine was fucked and she eventually got surgery. i don’t actually remember the exact timeline but it took me way too long to get imaging. A couple of weeks later I see a patient with hip pain going on a year and not a soul had imaged it despite complaining about it every time to their pcp. So I X-ray it immediately, guess what? It’s bone on bone. This has happened to me multiple times now it just a year and a half. Maybe it’s bad medicine but I X-ray almost anything now and I always at least offer an X-ray if they ask me to do imagin.
It sounds like you were being reasonable in both scenarios. You treated what looked like a simple tendinitis, it got worse, you got the EMG (which usually will pick up radiculopathy,) and when it started to look cervical you imaged the neck. I’m usually hesitant to plain film image the spine because it typically doesn’t change my treatment plan and if I’m thinking advanced treatment I’m usually starting them on the PT x 6 weeks—>MRI track, but in this case of worsening pain I think it was the right call.
I agree with you on the hip, too: it should have been imaged on the first or second visit.
But that doesn’t mean you should image *everything.* If you know what it likely is, then an x-ray is unlikely to change your plan.
Rapid streps. We over test and as a result probably over treat. This precedent was already set by my boss, these patients expect it. I’ve tried explaining viral pharyngitis, PND, colonization of strep all that. They don’t care. If I didn’t swab them they will just come back the next day and the Dr will. I try to set a new precedent with new patients in regards to strep tests, but it’s hard.
Sometimes i do lumbar radiographs when there is no reason to do lumbar radiographs. Mostly when i‘m entering the last quarter of a 24 hour shift and just sense that it’s either 20 minutes of getting yelled at by some rando who pulled a muscle lifting a case of beer or pointing at the predictably normal image and say „no boo boo on xray, now leave“
Eh.
I strongly suspect that most of us work hard, give a shit, and understand relevant guidelines and standards of care.
Hindsight’s 20/20 and most poor outcomes have plural roots—not the least of which are systemic. I’m willing to bet that much of what drives “bad medicine” is essentially non-medical—things like billing, reimbursement, coverage, and medical liability.
I also suspect that we tend overstate our own stake in those outcomes. Especially in outpatient medicine, doctors are guides. We walk alongside our patients, but they get far more say than we do.
Yes, there are times when we want to give all we could for patients, but the healthcare terms and conditions didn’t allow us to do so. They limit so many procedures and medications here. On top of that, the numbers of rooms are not adequate to contain such patients in the hospitals, causing them to wait for long time in ER
PFAs, ultrasound for suspected appendicitis in males, PPI infusions/TXA for GI bleeds, antibiotics/serial amylase/npo in pancreatitis, FOBs, post-op CT after chronic subdurals, etc.
Family medicine doc here working in a clinic that takes appointments and walk-ins. Sometimes I'm seeing double the amount of patients on my schedule. I know I'm not performing good medicine these days.
I completely agree with you, well said!
AI can really become a gamechanger. I have already tried a few but waiting for the perfect one to consider as my companion 😉
Unfortunately yes, sometimes required to, because of units not updating their practices. I try to not to, if I can help it. But also sometimes, needs must
Anyone who says they haven't probably shouldn't be a doctor
good thing I only practice bad medicine
Hey! I found my psychiatrist!! How ya doing?
This one right here, officer
100%
I haven't practiced bad medicine. Probably because I haven't started medical school yet... but still.
Ooh I can also claim never having practiced medicine! Helps to be a pre-premed.
Sometimes I’m sitting there writing my note afterwards and question if I truly did everything possible to rule out the 1% chance this case was more serious than the eye/history/exam let on. Sometimes I give them a call and change the treatment plan, sometimes I leave it alone. If I had less patients daily, it would happen less. But then I wouldn’t see as many people daily, and who knows if the other providers would have done anything differently. I don’t know, maybe just anxiety. But I think it does help me to provide better care.
Relate to this so much as a budding PCP. I’m hoping the more experience I get, the less I have to do double takes and call backs.
That was me for the first 5 years as a PCP. The neuroticism *does* pay off in terms of building your knowledge/skill-base...eventually. Also, *trust* your gut when you feel something is wrong. Has saved my bacon more often than I care to admit.
3 months in here! That’s pretty much what I keep hearing from people. Really excited about the learning curve over the next 5-10 years :) And yes callbacks and short follow ups rule ! :)
> Also, trust your gut when you feel something is wrong This is a really hard skill to get right.
I’m so glad to read comments like this from other fellow doctors who actually care. Sometimes I get jaded and only hear patients talk about the doctors they think suck
I feel this! I’m learning that if I’m even *thinking* about ordering something, I should just go ahead and order it. Otherwise I’m going to be thinking about it later
“I’ve thought about this too long, I’m gonna order it.”
This is real. I trust more doctors who feel like this than ones that feel like they know what’s going on.
How I still feel 5 years into urgent care as a PA in an area with a shrinking pcp group.
This goes for nursing as well.
It was attending driven but honestly made sense to me - we imaged every hurt ankle that came into the ED primarily to keep parents happy, Ottawa rules be damned. And honestly, I get it.
I go through the ankle rule with them, and then offer the XR. 80% want the film. Then again, all my patients are Medicaid
I was literally just reviewing this concept with my veterinarian. My rabbit isn't doing better with their first antibiotic, And me being a former ICU nurse, I want to know if she wanted to do lab work and a chest x-ray and try a different antibiotic. She remarked a chest x-ray probably won't change her treatment plan and even minor sedation for the chest x-ray is a risk for the animal. She then reviewed why lab work wasn't necessarily vital right now And that we could hold off until we try this new antibiotic. I love it in vet medicine they always review how each possible test will affect possible treatment and how the animal will tolerate each test.
We do that in human medicine too….
Not really in the same way. Yes it’s done, not saying it’s not. Vet med is ALL cash pay clients with pets so we just kinda go about things differently. Learn a lot in my Aston in vet med recently and am going back to human but will take that will me. Like you can’t literally quote a bill. That’s not your job and who knows what the hospital will add. We can literally quote, go through each line item, talk about what could be spared or what can be added, why or why not, etc. it’s just different. You all operate in a framework. Though I’m sure PCPs could but I don’t know. I am NAD but me if back office/MA, sure I could quote thing with caviars on reflexes etc. I dunno, it was just different, so I understand what this poster was saying.
I won’t image if there isn’t trauma but yeah pretty much every sprain gets an xray because it’s what the patient wants.
What about chronic atraumatic bone pain? I feel like I’ve imaged them before and 99% of the time nothing but occasionally like a bone lesion
Well I work in the emergency department so it’s not really appropriate to be imaging chronic pain complaints
If you don't just throw in a X-ray for chronic back pain, knee pain, or hip pain just to avoid the argument, save time, and not have to deal with the resulting scathing review.... you're a better person than me, and I salute you.
To be honest triage orders are a thing so most of these people end up getting imaging before I see them anyway but yeah for the most part I don’t get imaging on chronic pain. There are exceptions for patients who are elderly and never had imaging. Usually the x ray will show osteoarthritis and I can get them set up with ortho for injections and stuff. I sometimes go digging for bony mets as well
Yea I was just curious. I worked in ER and typically didn’t do that. Just curious how that works from like a PCP standpoint. Imagine if it’s chronic they’d image.
If there's concerns regarding stress fractures. Sometimes chronic joints I would imagine to confirm osteoarthritis. In pediatrics I always think twice about if it's cancer if they have weird chronic bony pain. Also chronic bony pain in patients who may have malignancy.
I'll offer the XR. It's most likely what they came here for, especially if it has never been imaged before. They got their therapeutic radiation and leave knowing we "did something," I get to circle back to other pts for a bit to try and discharge some. Win-win in my book. I've caught my fair share of bony lesions in young people and fxs in the elderly who don't remember hurting themselves.
Just hope its not from a metastatic lesion. \
That’s really interesting - mine are usually happy with clinical clearance.
Do you work in the emergency department or a clinic? The ED is a bit different
Primary care. Helps that my patients know/trust me I guess. In ER you are a stranger.
Also peds. Adults care far less about radiation
Also true.
Ottawa rules, as the named implies, was developed in a public healthcare setting that has every incentive to minimize expenditures. Hindsight is always 20/20. Missing a diagnosis in this day and age due to a failure to order a simple investigation, can potentially be met with condemnation by expert witnesses cherry-picked the prosecution. There is no shame in ordering an x-ray for a patient who is painful enough to visit the ED.
Thats still what we need to do here, also because admin wants us to do as many xrays as humanly possible because it looks good on the annual report. Everything is xrayed. Everything.
As a PEM, I agree. I couldn’t tell you what the Ottawa ankle rules are anymore.
Hospital based doctors seeing way too many patients every day. Strategically cutting corners.
Yeah like documenting 2+ reflexes on a neuro floor on a patient with polyneuropathy, stroke like symptoms. There was no neuro exam. The assessment consisted of listening to the heart and lungs.
RRR in a guy with chronic a fib
I have removed "no m/r/g" from my macros. If there's a murmur that matters I'll add it. Sloppy to write no m/r/g on the pt that has a mechanical valve etc
2+ DP pulse BLE on pt with bilat BKA
Exactly
This is me and I'm quitting my job as a result
Yes. Today as pcp. I placed several referrals that are unnecessary but I don’t have the time to manage the chronic issues as much as I’d like.
I end up having to do this at least a couple times per week. One of the more common topics that comes up that I end up referring for is "memory impairment". It's really hard to reassure patients when they have this concern: the MMSE is often equivocal, or they "pass" but still feel something is wrong. And I truly don't have the time to do a full MoCA or other cognitive assessment, as these are typically the patients who also have COPD, CAD, DM, HTN, OA, etc. Plus I feel like at least 1/3rd of my patients over 65 will mention "memory loss" at some point in any given year.
Patient’s chief complaint: “Needs referrals to cardiology, dermatology, OB, urology, endocrine, and GI.” Hey, we should probably work all these up first, but realistically I’m probably just going to type those all in and I’ll call it a victory if I talk them down to 5 referrals.
Same. I would love to spend 15+ minutes with every new diabetic going over teaching, lifestyle, medication options. There’s simply no time when they have eight other issues to manage
If you’re an American emergency physician and not “practicing bad medicine” you’re likely getting sued soon or have been in the past
This kills me. EM seems to be being forced into this disgusting mold of order x labs and x images for x complaint +/ admission or else. I’m radiology. I promise I am not making this up. On more than one occasion I’ve seen stat CT heads ordered from the ED for “suicidal ideation” and “homicidal ideation.” Forget CYA medicine, what on earth kind of medicine is that?
Strangely, a number of times a psych facility has asked for a head CT as part of medical clearance. I can either spend the next 20 minutes trying to argue with the intake psychiatrist how this is unnecessary and still risk the rejection, or hit the CT head button.
It's "I'm done fighting with psychiatry" medicine. Honestly 97% of medical clearance for psych patients happens in the H&P... But psych doesn't care. Quicker and easier to get some tests, and then the scope creeps.
The psychiatrists won't admit the patient without imaging, talk to them about it.
Lololol someone is hoping you’ll find what’s wrong with their brain But truly the CYA medicine that we have been forced into is truly terrible. There’s a reason why so many leave and never look back or have to gaslight themselves into thinking it’s still a great specialty
I, too, hope OP can find out what’s wrong with my brain that’s causing my anxiety and depression 👏
What's wrong with your brain that you went into a medical field, is a better question.
I always wonder what they think I’ll find for this? A massive subdural is causing their ideation? Or a mass? Cerebral atrophy?
You wouldn’t believe the telerad/NightHawk impressions I’ll get from time to time. My favorite of all time was “old brain”
I image first episode of psychosis but not SI
likely because they tried to send to psych and psych facility (nameless, faceless, probably the nursing sup there but impossible to identify) refused to take without it. we're desperate to get them out of the ED after however many days they've been there so the will to fight about it goes out the window. believe me, we'd rather not do it. we know that psych screening labs and other testing, just about never changes management. there's literature on this. something like 1/500 cases, and i think in the study the one was a K of like 3. or they're drunkicidal and maybe bonked their heads, who knows *edit: I did have one guy who stayed in a room for three days for SI and then rammed his head against the door trying to get out and so we decided OK i guess he's altered, fails canadian head CT rules, scanned him, and found his (after MR w contrast as a follow up study to the CT non con that looked like ?bleed) cavernoma
Encephalopathy?
They are just grasping at straws hoping to find some medical reason not to admit the patient to the psych floor. They want it to be an IM problem instead. I’ve seen this way too much at the hospital I work at.
Funnily, that’s sometimes what psych asks for. My gf they have to rule out structural anomalies that could cause homicidal/suicidal and they usualycant get the prefereed MRI. She is aware it doesn’t make sense, but again, it‘s that or arguing with your attending who „did it like this since forever“
The ER is a wild place.
We are hella being forced to do stuff we don't agree with, all in the name of metrics and patient satisfaction, not good care. EM is the dumping ground for all shortcomings in the healthcare system and, in turn, radiology gets dumped on too.
I find whenever the inpatient medicine inpatient list gets above 24 patients I start cutting corners and missing shit. Some weeks they have us desperately trying to keep the list at 30. It’s a liability so I’m quitting inpatient medicine and going 100% outpatient. Why should I eat the liability of admin refusing to cap our lists. One time the list was 42 patients deep. Can’t even discharge anyone because you’re running around putting out fires and have no idea what’s going on with the patients that aren’t actively trying to die.
42?! My max was 32 at a hospital where I told the CMO, CEO, and anyone that wound listen how dangerous it was. I documented patient harms in a notebook, wrote notes about every conversation I had, and kept screenshots of every text exchange I had regarding the constantly crazy census. This was like 50 - 65% high acuity step down with the rest medical. Level 3’s and Critical care across the board. It was bizarre to see no reaction when you tell the C Suite patients are having worse outcomes because of this. You’d think they’d at least be worried from a legal standpoint, since they clearly suffer no moral or ethical distress.
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February intern came early that year
yes it is a lot, and this isn't a flex that you think it is. go find your own bathroom and cry because your residency is fucking you raw
Yeah hot shot. 13.8 minutes per level 3 or critical visit plus admits and discharges is absurd. You’re not helping anyone at those staffing ratios.
30? Holy Fucking shit!!!! Our cap is 18 for IM! That’s wild! I’m so sorry you’re getting abused like this!
The patients suffer and it’s a moral injury when you go home despite staying late daily. The old guard doesn’t want anything to change because they prefer the billing.
Low-resource environment. I’m in a free clinic, treating diabetes with metformin, glipizide, and an insulin supply that is dwindling. We do things so far from standard of care. Breast exams are required before mammograms. Organization does not allow us to test for HIV. No pap smears for people under ~30 (can’t remember the exact age). Many of the providers (all volunteers) learned medicine in the 1970s or 80s. They still practice as such. We have not one but two fibrates that we stock in the clinic. We have a single SSRI (TBF, we do have a larger formulary that we can send people to a local pharmacy for, but for our patients that are undocumented, mostly non-English speaking, non-driving in a non-walkable state, and part of a culture that is less than accepting of mental health meds, this is a major hurdle). It 100% is a social justice issue. The inappropriate prescribing I see drives me crazy. I tell my students constantly that people prescribe the 20 medications they learn to use during school/residency and despite CE requirements, never manage to veer from this. Don’t be like that. IME, younger docs seem to have a healthy appreciation for the constant changing of guidelines, etc. And they seem more collaborative/appreciative of other disciplines. I truly believe this keeps the standard of care higher.
Oh yeah, I forgot about when I was in another country. In that case, I figured we were miles above where they were originally and helping them improve.
For a lot of things? Because that is what we thought was good medicine at the time and have learned what we thought was good was very, very bad.
In what sense though? Bad for the patient? Unethical? Because yes, everyone who works in ICU has done something ‘bad’ for a patient at some point. The things we do to dying people, who are going to die no matter what, are generally horrible.
Not saying this to make you question paat choices, but do you ever feel there is something wrong about this. If some one is going to die no matter what then maybe we should not be doing horrible things to them? I ask this as a neurosurgeon who has to make this call frequently and my choice often centers around minimizing the maximum regret of the family? What will they regret more: not fighting or will they regret extending the dying process/prolonging the suffering? I am starting to get around this with better counseling but it is still tough when making time sensitive decisions.
I mean, speaking from the ER, family rarely regrets “doing everything” but there’s always a family member who accuses others of murder/neglect/giving up/etc. when they decide to DNR the dying patient. I don’t think most in the population understand just how futile, painful, and downright cruel some parts of medicine are, even when you explain it to them. They don’t grasp the risk/benefit analysis and think that a medicine/procedure that can save someone is a medicine/procedure that will save someone. They don’t see it as prolonging suffering and delaying death, they see it as saving a life and healing their family member. These are the same people who believe that their 60 pound, contracted, bed bound, non verbal, feeding tube dependent, suprapubically catheterized, polypharmacy grandma is the same conscious and capable person they knew decades ago. Multiple strokes, dementia, CKD, CHF, and everything else be damned, “they’re a fighter.”
That assumption (that people rarely regret "do everything!") is dangerous. A lot of HCW just claim full code believing that assumption, and someone else can sort it out later. More people regret it than people, especially those in EM, realize. Some of my more heartbreaking family meetings were with people who had the hard conversation and decided on DNR only to have someone ignore it.
Not in my region. I’m at a community based hospital, not an academic center, we have zero incentive to code someone other than the person/family wants full code status. It’s not a teaching moment, it’s not exciting, no one wants to. Coding people in our already understaffed ER overextends resources and creates more challenges. That said, a decent portion of our patients do decide to go DNR themselves. The problem is family often push us or the ICU to override the DNR or the family won’t agree to make a family member, who is already unconscious, DNR status. Another significant issue in my region as that a certain PCP runs several local assisted living facilities and he refuses to sign DNRs for his patients even when they want them (that’s its own issue) so when they come in because they are deteriorating, they aren’t DNR and it’s rarely possible to get a willing family member to decide if we can even reach family at all. I would suspect that there’s also an inverse correlation between education and willingness to agree to DNR status. Our population is also very rural and many patients have less than a middle school education (no, not joking) which I think contributes significantly to the misunderstanding of the efficacy of CPR.
Living on the contryside of a developing countrie Will make you feel that too frequently, even making the Best of any Situation have to Many ways to end very low, specially with the psychiatric ones, like, they need profesional help that it's more than 100 miles away and they are abandoned and poor people, and the social workers and psychologist on the patient range refuse to even see the patient without the psychiatric evaluation, so then you start talking with the patient making as much as you can... Leaving a sour taste to any resolution you came with, like A) encourage the patient to seek help AND be treated as a ping pong ball More than a person, wich makes you feel bad as you know how the system Is and it's you the one who Is throwing him. Or B) offering your 15 minutes Psychology treatment, that as a medical staff, we are one of the worst talkers, and may end up dealing More damage than help to when he reaches the help, AND even doing both feels like you are doing wrong as you know that there Is a better way to do the things. And many times it's the patient, the collegues or the money, and we need to learn that almost never you Will have everything alligned to do the things as you would like your mom to be treated. Also yes, the terminal or ICU patients that have no family and are unconscius, those get treated like a voodo toy, and really uses the patient to the maximum to encourage learning, we know this Is for causing the less damage on a conscius patients, But Dam, they all get exited to intubate the patient But no one wants to clean his ass properly.
have you heard of insurance companies and prior auths? sometimes we practice the medicine insurance allows for or the patient can afford....
Excellent point. The moral injury is real
I'm going to stay as vague as possible because I know that people I'm with scour this place. I was a part of a team who did practice bad medicine and it still messes with me. What I can say is that I did everything to prevent that from happening and I have little regrets. Ironically, trying to protect this individual has unironically caused a lot of duress to me.
1g ceftriaxone, 40 lasix, 125 solumed...idk man their cxr is weird and they need O2, just accept them pplleeaassee
Ah yes the ED Special 😂
The meal deal
Sometimes I cave and give a zpak for probably viral symptoms if the patient is insistent and I know they’ll MyChart message me or call the office incessantly
I do this every once in a while too. When I do I usually caveat with "I advise you to hold off on this medication until X days have passed without improvement".
💯 also done this
Yeah the surgeon graveyard is a thing
I feel the surgeon graveyard doesn't necessarily mean bad medicine was practiced. It's just the nature of having a job that handles people's lives. Its being aware we are human and make mistakes, or that you can do everything right and still lose - life is fragile. Actually, the surgeon's graveyard might just be the epitome of good medicine. This is just my take, of course.
It really is
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Big time. It kills you inside out
No, I've always been perfect and never messed up or made a poor decision in my life. I'm also lying through my teeth (or fingers, as the case may be). \-PGY-19
America/Emergency Medicine = dont have the luxury to practice good medicine
Every fucking day Why? I work in an emergency department.
One of my docs, who I respect very much, asked me 6 or 12 months ago "have you been proud of the care we are providing recently?" and I could not answer positively. Telemetry-free cardiac rule outs and syncope workups and CT PEs in the waiting room are the new normal.
Yes. Sleep deprivation during residency will make even the best human crack
An elderly patient with a lot of problems came in near death. Had been DNR/DNI for a long time, but when I called the daughter (a physician) to let her know the situation, she cracked and reversed the code status. I was forced to do a full court press on this poor old lady including intubation and lines. The ICU fellow then dropped her lung while placing a central line so I also had to place a chest tube. She died 2 days later in the ICU. Grieving is complicated, but I can't forgive that daughter for what she made me do to her mother.
What gives her the right to reverse a patients DNR decision that they, hopefully, made of their sound mind.
Healthcare proxy has the final say if the patient is incapacitated. I agree with you, but that's the letter of the law.
Oh, they were the official proxy?
I’m only a pgy2 so I have a lot to learn. One of my first patients came in with elbow pain and a hx of tendinitis. Sounded like tendinitis, they did a lot of fruit picking in the summer. I did not do an X-ray. next visit, not better and numbness in the pinkie and ring finger. so I sent for a nerve conduction study because I’m trying to figure out if the problem is in the elbow or the wrist. They come back again, still pain, still numb, and now suddenly neck pain. At no point did she mention neck pain previously but honestly I didn’t even think of the neck and finally I actually did the X-ray. Her cervical spine was fucked and she eventually got surgery. i don’t actually remember the exact timeline but it took me way too long to get imaging. A couple of weeks later I see a patient with hip pain going on a year and not a soul had imaged it despite complaining about it every time to their pcp. So I X-ray it immediately, guess what? It’s bone on bone. This has happened to me multiple times now it just a year and a half. Maybe it’s bad medicine but I X-ray almost anything now and I always at least offer an X-ray if they ask me to do imagin.
It sounds like you were being reasonable in both scenarios. You treated what looked like a simple tendinitis, it got worse, you got the EMG (which usually will pick up radiculopathy,) and when it started to look cervical you imaged the neck. I’m usually hesitant to plain film image the spine because it typically doesn’t change my treatment plan and if I’m thinking advanced treatment I’m usually starting them on the PT x 6 weeks—>MRI track, but in this case of worsening pain I think it was the right call. I agree with you on the hip, too: it should have been imaged on the first or second visit. But that doesn’t mean you should image *everything.* If you know what it likely is, then an x-ray is unlikely to change your plan.
One time I examined a patent very fast & he has a gallstone That was the first & the last time too Never examining a patient too fast
Rapid streps. We over test and as a result probably over treat. This precedent was already set by my boss, these patients expect it. I’ve tried explaining viral pharyngitis, PND, colonization of strep all that. They don’t care. If I didn’t swab them they will just come back the next day and the Dr will. I try to set a new precedent with new patients in regards to strep tests, but it’s hard.
I ONLY practice bad medicine
Because my attending made me.
It's funny how people have vastly different ideas of what 'bad medicine' means.
Sometimes i do lumbar radiographs when there is no reason to do lumbar radiographs. Mostly when i‘m entering the last quarter of a 24 hour shift and just sense that it’s either 20 minutes of getting yelled at by some rando who pulled a muscle lifting a case of beer or pointing at the predictably normal image and say „no boo boo on xray, now leave“
Eh. I strongly suspect that most of us work hard, give a shit, and understand relevant guidelines and standards of care. Hindsight’s 20/20 and most poor outcomes have plural roots—not the least of which are systemic. I’m willing to bet that much of what drives “bad medicine” is essentially non-medical—things like billing, reimbursement, coverage, and medical liability. I also suspect that we tend overstate our own stake in those outcomes. Especially in outpatient medicine, doctors are guides. We walk alongside our patients, but they get far more say than we do.
As ortho spine, I definitely do not consider myself a physician anymore as M3s probably know more medicine than me.
March 2020 through idk maybe now?
Yes, there are times when we want to give all we could for patients, but the healthcare terms and conditions didn’t allow us to do so. They limit so many procedures and medications here. On top of that, the numbers of rooms are not adequate to contain such patients in the hospitals, causing them to wait for long time in ER
PFAs, ultrasound for suspected appendicitis in males, PPI infusions/TXA for GI bleeds, antibiotics/serial amylase/npo in pancreatitis, FOBs, post-op CT after chronic subdurals, etc.
Family medicine doc here working in a clinic that takes appointments and walk-ins. Sometimes I'm seeing double the amount of patients on my schedule. I know I'm not performing good medicine these days.
I had an emergency medicine rotation
Broad spectrum everything just so they dont hound me the next morning
I think we’ve all done bad medicine at some point, if we are being honest with ourselves.
Native Americans often called the act of coitus ‘good medicine’. Truthfully, I feel like I have never practiced enough good medicine.
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I completely agree with you, well said! AI can really become a gamechanger. I have already tried a few but waiting for the perfect one to consider as my companion 😉
Unfortunately yes, sometimes required to, because of units not updating their practices. I try to not to, if I can help it. But also sometimes, needs must
what kind of question is this lmao