Respectful Insolence

The Buckeye Surgeon educates us with a case.

In brief, it’s the case of an elderly woman with a clinical picture, including right upper quadrant pain and an elevated white blood cell count consistent with rip-roaring cholecystitis who was admitted to the medical service for her right upper quadrant pain. She underwent an ultrasound, which was consistent with rip-roaring cholecystitis, after which she was admitted to the medical service, which duly consulted the gastroenterology service. Then a CT scan was ordered, which showed a rip-roaring case of cholecystitis. Then the patient was bowel-prepped and underwent upper and lower endoscopy and the patient treated for gastritis. Then she underwent a cardiology consult, which failed to find a cardiac cause. Finally she underwent a HIDA scan, which is very specific for cholecystitis.

And then the surgeon was called.

This was a case about which a couple of old attendings in my residency program would have a sarcastic saying about, one that they used in castigating residents who failed to make a mind-numbingly obvious diagnosis. When that happened, they’d say, “The janitor is calling you and asking you when you’re going to take this woman’s gallbladder out.” Either that, or they’d say it’s a diagnosis that the janitor can make from across the room.

Observes the Buckeye Surgeon:

The next morning she underwent a laparoscopic cholecystectomy, with severe inflammation of the gallbladder noted. She was in the hospital three days before a surgeon saw her. Multiple radiographic tests were obtained. Invasive procedures were performed. What is going on here? I’d love to see her hospital bill and tally up all the unnecessary work that was done. Multiply this case by the surprisingly numerous times similar patients are managed you’ll find a gigantic sinkhole into which much of our health care dollars are lost.

I have one additional observation about cases like this.

I’m sure there are other specialties for which this sort of thing happens, but in my anecdotal experience not as much as surgery, much to the patient’s detriment. One major aspect of the problem is that surgeons have ceded much of the evaluation of abdominal pain to internists and gastroenterologists, along with endoscopy, endoscopic retrograde cholangiopancreatography, and other diagnostic modalities. It’s a narrow-mindedness and, yes, downright laziness that we’ve developed, in which we don’t want to see abdominal pain unless it’s a surgical disease; i.e., unless the pain is such that it indicates that the patient “needs an operation.”

Some of this was to the patient’s benefit. After all, removing gallstones from the common bile duct by endoscopy is just as effective and less invasive than doing it the old-fashioned way, by an operation called a common bile duct exploration. However, along with the advantages, we as surgeons have allowed ourselves to become marginalized in the evaluation of what was previously considered our forté, our raison d’être, abdominal pain. As the Buckeye Surgeon puts it:

The troubling thing is, primary care and internal medicine increasingly look primarily to GI for ANY abdominal complaint. I can’t tell you how many times I’ve seen a patient with an incarcerated hernia or appendicitis AFTER the GI consultant.

And we have no one to blame for this but ourselves as a profession.

Another tendency is the trend towards increasingly “noninvasive” treatments. Unfortunately, this attitude and trend has taken hold even for diseases for which the best treatment is surgical, such as acute cholecystitis.

Comments

  1. #1 PalMD
    December 1, 2007

    From one internists perspective, surgeons (many of them my friends) are not particularly interested in patients who do not clearly need an operation.

    The ER calls me to admit cholecystitis, pancreatitis, partial small bowel obstructions, etc, simply because the surgeons won’t do it.

    Don’t get me started on orthopedics.

  2. #2 emergencydoc
    December 1, 2007

    Where I work/have worked, surgeons won’t take acute cholecystitis because they maintain that the treatment is medical – they say it is wrong to operate on an acutely inflamed gallbladder because there is a high risk of complications. So the medics take them, along with pancreatitis (call us if you see a pseudocyst on scan) and most other problems that don’t actually involve making holes in people. Most American surgeons are horrified at the way UK surgeons have conceded postop ITU care to intensivists.

    I still think she got rubbish care, though.

  3. #3 Orac
    December 1, 2007

    The ER calls me to admit cholecystitis, pancreatitis, partial small bowel obstructions, etc, simply because the surgeons won’t do it.

    Actually, as I pointed out, a lot of this is our own damned fault as a profession.

    In whipping off this quick post, I forgot to mention that I also partially blame the reimbursement system, which actually provides perverse incentives for this kind of behavior. For instance, if you admit a patient too soon before he needs an operation, the care before the operation ends up being folded into the global service charge along with the post-op care, whereas the internist can bill for every visit while the patient is in the hospital. Consequently, financially, it is often to the surgeon’s advantage to have the patient on the medical service for the preoperative workup, bill as a consultant while that’s being done, and then not take the patient on his service until after an operation. It also incentivizes getting lots of medical consults on surgical patients. After all, a surgeon’s not going to get paid any more for dealing with comorbidities such as a patient’s diabetes; it’s far easier and saves the surgeon time just to consult the experts on the endocrinology service than to bother dealing with even relatively uncomplicated diabetic blood sugar control themselves. Ditto, for example, consulting hematology to manage a patient’s anticoagulation, even though on vascular surgery rotations we’ve all been trained to anticoagulate patients with heparin and then get them on coumadin.

    And so on…

    Back in the “days of giants,” it used to be that general surgeons were proud to call themselves “internists who could operate.” (I always thought it was a bit of an exaggeration to say that, but the basic sentiment was true and admirable.) Nowadays, it’s only the old-timers who still say that or aspire to that ideal.

    And don’t get me started on orthopedic surgeons, either. I can’t recall how many times when I was on the trauma service as a resident that the orthopods would refuse to take isolate extremity fracture patients on their service; they were really good at finding some other injury that made the patient’s injuries “multisystem.” We used to joke that if the patient had a hangnail ripped off in the car crash, orthopods would say that they couldn’t deal with it and want the patient to stay on the trauma service.

    …End orthopod bashing…

  4. #4 Sid Schwab
    December 1, 2007

    In a similar vein (or is it a duct?), when I told ER docs I’d like to be called BEFORE they ordered CT scans, etc, for suspected appendicitis, they told me every other surgeon in town only wanted to be called AFTER. So yeah, I agree surgeons have ceded a lot of the diagnostic work. On the other hand, given the lower and lower reimbursements, and the greater and greater amount of work one must do to maintain income, it’s not too surprising that surgeons don’t want to take the time for diagnostic work.

  5. #5 Orac
    December 1, 2007

    Where I work/have worked, surgeons won’t take acute cholecystitis because they maintain that the treatment is medical – they say it is wrong to operate on an acutely inflamed gallbladder because there is a high risk of complications. So the medics take them, along with pancreatitis (call us if you see a pseudocyst on scan) and most other problems that don’t actually involve making holes in people.

    Often the initial treatment is medical (antibiotics, fluids, etc.), followed by removal of the gallbladder a few weeks later, after things have settled down and the inflammation subsided. However, the problem is that it’s still a surgical disease. Internists are not trained to recognize when medical management is failing and the patient should just be taken to the operating room. This goes back to the whole “surgeons as ‘just’ technicians” thing that irritates me so much. If we want to be looked upon as more than “just technicians,” we need to resist the temptation to act like “just” technicians whose role in patient care is limited to the operating room and immediately after.

    I used to be appalled by the concept of the ICU team. At the University of Michigan, where I went to medical school, the surgical team managed the patient in the ICU as well. I’ve become less dogmatic about that these days because the ICU team has expertise that we may not have. As long as communication between the primary team and the ICU team is good, it’s not a problem. However, it never fails to irk me when the ICU team does something like order a major test (such as a CT scan, for example) on one of my patients without calling me to discuss it and see if I concur. This happens all the time where I work now. One time I bitched out the ICU attending for not consulting me about ordering a test on my patient, and he basically shrugged his shoulders and looked at me as though he just couldn’t understand why this would bother me. At the very least, I need to be informed. If a patient’s family calls me to ask why a CT is being ordered and I don’t even know that one is being ordered, I look pretty stupid and inattentive.

  6. #6 Annie
    December 1, 2007

    Excuse me – none of you esteemed physicians mentioned a little detail: the patient’s well-being and comfort (withe the exception of Orac’s intimation that waiting three days might not have been the most comfortable time for the patient). Guess that doesn’t play in the equation. Care has been eliminated. It’s all about territory and reimbursement for you. Nice game you’re playing. The patient as pawn. Call the janitor. ;0

  7. #7 Orac
    December 1, 2007

    Excuse me – none of you esteemed physicians mentioned a little detail: the patient’s well-being and comfort (withe the exception of Orac’s intimation that waiting three days might not have been the most comfortable time for the patient)

    Give me a break.

    It should be clear that the very reason we lament this turn of events is precisely because it is not in the best interests of the patient. After that, it’s all discussions of how this sad state of affairs came about. The problem of incentives in the reimbursement system and turf wars play into it, and discussing them doesn’t mean we don’t care about the patient. In fact, we discuss them because we see them as impediments to good patient care.

  8. #8 Clare
    December 1, 2007

    When my son had appendicitis a couple of years ago, the first person he saw at an urgent care clinic was pretty sure it was appendicitis but couldn’t send him on until blood tests were done. When they appeared to confirm her suspicions, he was sent on to the hospital. The first people to see him were muttering about doing further scans and tests, but then the surgeon showed up pretty quickly and had him hauled in for surgery without any further heroic efforts at diagnosis. My son was a mess, with a perforated appendix, and he was in hospital for a week on antibiotics. We joked that the surgery took quite a long time because they had to go down to the supermarket to rent a shop-n-vac. It sounds like we were lucky the surgeon showed up and made the call as rapidly as he did.

  9. #9 Kassiane
    December 1, 2007

    Holy crap!

    If she wasn’t elderly and admitted for three days I’d swear they wrote me up! Only they didn’t take my gallbladder out because with all the stalling (did they NEED to take the blood work three times? With how much they took each time it might have been hazardous, I’m pretty small…) by the time they got me into ultrasound the stones were, like, moving. It was kinda gross. I didn’t even know you could see that on ultrasound. Echh…

    And ugh, orthopods. One decided to experiment on me. This is bad because I’m a gymnast, have Ehlers-Danlos (hypermobility stretchy skin thing), and he had NEVER OPERATED ON THE BONE I BROKE. Extra points for deciding I needed 2 arches in my previously flat foot, and double bonus for the fracture not needing surgical reduction at all…and not telling me any of this till the pins were placed was just extra special.

    Stuff like the above case, and orthopedists, are probably why people turn to woo. It appears to cost less.

  10. #10 Uncle Dave
    December 1, 2007

    Question;

    As medical professionals, do you feel that the intuitive diagnostic ability of the physician has not changed, gotten worse or improved over the years? Years being lets say 25-30. i.e. do the universities do a better, same, or worse job of training in diagnostics.

    I have wondered how more or less dependant physicians are today (versus the day when many of the diagnostic tools were not yet available) on diagnostic testing, prior to a judgement? Where in the past a physician may have likely made a diagnosis with potentially less information and more experience.

    This is an awfully broad question and not meant to be a dangerous one and is likely subject to a fair amount of age dependant opinion.

  11. #11 Grodge
    December 1, 2007

    As a consulting gynecologic surgeon in a hospital without ob/gyn residents but with IM and general surgery residents, I can attest that teaching services seem very inefficient compared to non-teaching services. ER docs complain that a patient with abdominal pain is handled more expeditiously when the pregnancy test is positive, mainly because the lonely attending gynecologist is called directly, the diagnosis is made and the proper treatment is given without all the mucking around with surgery and medicine teaching services.

    I appreciate Orac’s lament, but these may be isolated situations present in the rarefied areas of ivory tower medical centers. I doubt small town and community hospital docs in the trenches are wasting such hard-earned resources to make simple diagnoses, the obtuse re-imbursement system notwithstanding.

    A note to Annie: don’t read too much negativity into Orac’s curmudgeonly attitude, this is exactly how surgeons show compassion for their patients. And it is genuine.

  12. #12 Uncle Dave
    December 1, 2007

    That question was not intended to dredge up any issue about litigation (in perfect world where you would not be second quessed by someone with a law degree and lots of time), just an opinion quest for “diagnostic shoot from the hip” adeptness.

  13. #13 Dr Aust
    December 1, 2007

    Is there any sense that some of this happens because people are “covering their ass” over taking someone in for abdominal surgery that later turns out to have been unnecessary – i.e. “defensive test and investigation ordering”.

    Pal MD: “From one internist’s perspective, surgeons (many of them my friends) are not particularly interested in patients who do not clearly need an operation.”

    That is certainly the received perspective I get from my wife (general/internal medicine doc and some time anaesthetist/ intensivist) and her (medicine/ anaesthetics / ITU) friends.

    The other regular line they offer is that many surgeons (especially trainee ones) are fairly uninterested in managing post-op care since the “serious surgery action” stops once the patient is off the table alive and conscious. I have heard many of the UK medics and anaesthetists I know opine that it would be better all round if the surgeons did cede most inpatient post-op care to other people.

  14. #14 DLC
    December 1, 2007

    In the above article, was someone just being deliberately ignorant? Off on a zebra hunt ? I don’t understand enough about medicine to know, but if I take you at your word, these doctors should have been able to look at the symptoms and recognize the illness without indulging in deep thinking or ordering batteries of tests. This being the case I have to conclude that someone in the decision making loop there was not thinking in the best interest of the patient and considering their bank balance instead.

  15. #15 David Marjanović
    December 1, 2007

    Just wanted to mention that there is no accent in forte. It’s Italian. The e is pronounced simply because it’s there. (It’s pronounced like in “bed”, and the stress is on the first syllable.)

  16. #16 Ian Gould
    December 1, 2007

    Just out of curiosity, is there any reason to assume misdiagnosis is any more common in the US than in other developed countries?

  17. #17 PalMD
    December 2, 2007

    I did mean to mention the perverse reimbursement schema for hospital care which make it problematic for surgeons. It’s the only area in which internists are reimbursed somewhat more rationally than “interventionalists”.

    As to the question about current diagnostic skills, I would argue that they are neither better nor worse, just different. In the past, only ears, hands, nose, etc were available. New tools lead to new diagnostic skills. And of course, it becomes necessary to know what these new toys do and don’t tell us.

    I always ask my residents “why are you ordering that and what will you do with the result?”

  18. #18 scote
    December 2, 2007

    Hmmm…Christians have been willing to kill the person to “save” their souls, now possibly non-Christian doctors are willing to save a person and possibly “damage” their souls. If I had to err on one side or the other I’d go with the latter…

  19. #19 Brian
    December 2, 2007

    these doctors should have been able to look at the symptoms and recognize the illness without indulging in deep thinking or ordering batteries of tests.

    It gets much worse, I fear.

    Following a gunshot wound, a young patient was brought to the emergency room with classic signs of shock secondary to low blood volume. It was quite some time before it was determined he needed to be transfused, however, because, despite a presentation that doesn’t get much more textbook for shock, his hemoglobin levels were normal.

    My favorite trauma surgery quote ever:
    “If I slit your throat and let you bleed out right here, what’s the hemoglobin of the last drop of blood that comes out going to be? Same as the first.”

  20. #20 raddoc
    December 2, 2007

    As a Radiologist (we have our own substantial faults as a specialty, so I’m not meaning to start a flame war), I see this scenario…every…single…..day….multiple times.

    CT PE studies on patients with IVC filters (we need to know if they may have another clot)??

    HIDA scans to look at the GB even though the CT and Sono are grossly positive (as in this case)

    CT scan for abdominal pain…..the 6th one in 2 months, all negative. Ouch, the radiation.

    As disturbing as all of these scenarios are, they are, in fact, the exceptions, not the rule.

    I couldn’t agree more with the statement above: “What will you do with the information from the test if it is normal or abnormal??”.

    Great Blog, BTW.

  21. #21 Dr Aust
    December 2, 2007

    My favorite trauma surgery quote ever:
    “If I slit your throat and let you bleed out right here, what’s the hemoglobin of the last drop of blood that comes out going to be? Same as the first.”

    Yep. A classic trap (though a learning one) for med students studying blood loss. Feature in one of our “Problem Based” 1st yr med student scenarios… so we’re trying to get the message across at an early stage.

    In a less acute setting, my wife (the MD) likes to say that “Is the person producing urine? How much?” is another of these good old medical clues that often escapes test-focussed docs trying to assess ad/or manage fluid balance / fluid load / tissue perfusion with much fancier techniques.

  22. #22 Jennie
    December 3, 2007

    Sometimes the tests are needed though. My husband had upper right quadrant pain that even dilaudid couldn’t completely control. We thought it was his gallbladder because it got worse with eating, particularly of fatty foods; however, the only test which in any way showed a gallbladder problem was the HIDA, and the only result from it was that when the gall bladder contracted my husband experienced intense pain. It took eight months of constant chronic pain before he could persuade a surgeon to take out the gallbladder. The surgeon said the gallbladder looked normal; but pathology showed chronic inflammation of the walls. The pain got better too :) . If he hadn’t had that one result from the HIDA, the surgeon probably would have been unpersuadeable; and he’d still be in excruciating pain. He still grumbles that they didn’t take it out right after the HIDA, when he begged them to.

  23. #23 Cam
    December 5, 2007

    Jennie posted:
    Sometimes the tests are needed though… If he hadn’t had that one result from the HIDA, the surgeon probably would have been unpersuadeable; and he’d still be in excruciating pain.

    I’m willing to bet that your husband had multiple blood tests, at least one ultrasound, some abdominal films, probably a CT and possibly endoscopy from either end. Most of the time, any one of these tests, coupled with an appropriate H&P, would reveal cholecystitis amenable to surgery.

    I say “most” because on occasion – and unfortunately your husband falls under that category – earlier tests don’t show anything and more complex/invasive/expensive tests are necessary. The HIDA scan is great for what it’s designed for, but it’s certainly not the first choice for most situations.

    In the first post, everything after (and arguably including) the ultrasound was completely unnecessary, delayed treatment for the patient, and took resources away from other patients who could have used them. Sometimes I’m glad I’m training in Canada, where I’d get beaten upside the head for even suggesting the CT. Scarcity tends to make doctors a little more aware of what’s truly necessary to do their jobs.

    I’m glad your husband’s feeling better.

  24. #24 Flex
    December 5, 2007

    PalMD wrote, ‘I always ask my residents “why are you ordering that and what will you do with the result?”‘

    Heh. I can’t comment on any medical issue, but that’s almost word for word what I tell people in my engineering office who want to run a test simply because they think of it.

    Thanks, I enjoyed the chuckle of about the same sentiment showing up in another profession.

  25. #25 Paulie
    December 5, 2007

    As a second-year medical resident in a major academic program, working in the ER in 1985, I vividly remember seeing a 33 year old man with right upper quadrant pain, yellow eyes, shaking chills, and fever to 105 degrees. I called my counterpart on the surgical service, who requested that I order a nuclear gallbladder scan (PIPIDA in those days) which revealed complete non-visualization. The third-year surgical resident was called, saw the patient, and called his chief resident. The chief resident came to the ER, saw the patient, and told me to admit him to the medical service for viral hepatitis. Seeing no choice, I did so. Fortunately, there was a happy ending. The senior medical resident who admitted the patient called a surgeon friend of his at the private hospital across town, where the patient was transferred and operated upon the next morning.

  26. #26 Calli Arcale
    December 5, 2007

    Mentioning cases where the tests fail to reveal the cause….

    Chronic cystitis runs in my family, due to a malformation of the bladder. It’s evidently genetic, since three of us have it. My brother is one of them. His first UTI came with pretty clear symptoms — painful urination, lower abdominal pain, unproductive urgency. Yet the urinalysis and urine culture were both negative, so they concluded it must be something else, and sent him home. (It didn’t help that I came down with a mild case of gastroenteritis at the same time, confusing the issue.) Eventually he started passing blood, and my folks took him to the ER. The UC was positive now. They kept him for a few days on intravenous antibiotics, and then let him go home. Luckily, he hasn’t had another infection since. It must be nice being a guy. ;-) Being female and sharing the same abnormality, I am much more vulnerable. I’ve also had negative UAs when I later proved to have an infection, though I’ve never had a negative UC when I had an infection. Alas, most doctors won’t give me antibiotics until they confirm the infection (a few will take my word for it), so I tend to wait until its intolerable, reasoning that the UA is more likely to be positive at that point. No sense wasting a trip to the doctor.

    My last doctor was really nice. Since I’ve never had a false positive self-diagnosis of a UA, she gave me a prescription for antibiotics with three refills — if I feel like I’m getting an infection, I can just take that and not worry about going in for a formal diagnosis. I can’t tell you how relieved that makes me.

  27. #27 CW
    December 12, 2007

    While you’re thinking about the sources of inefficiency in American health care, read The Checklist (by Atul Gawande, The New Yorker, 12/10/2007) and listen to this interview.

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