Wednesday, October 15, 2008

One Way to Obtain Less Wasteful Test Ordering Behavior: Recognize that Physicians Also Need to Manage Uncertainty

The Disease Management Care Blog delighted in reading Dr. Lisa Rosenbaum’s personal essay that appeared in the October 16 New England Journal of Medicine. It was the high point of the weekly “Perspective” section of the Journal that was otherwise abysmally hijacked by a pair competing partisan pseudo-evaluations of the McCain and Obama health care plans. The DMCB has decided that it’s going to stop paying attention to the two candidates’ health care proposals until after the election, especially when they're reported in the Journal. It's not until after January 2009 when the real swordsmanship begins.

Dr. Rosenbaum is a 2nd year internal medicine resident in training in Boston. She wryly describes in wonderful narrative the struggles of a young physician in dealing with patient symptoms for which there is no explanation. Caring for such individuals is a struggle, she writes because 1) the culture of modern medicine has little patience for the unknown, 2) patient-consumers want answers and 3) it’s practically impossible to submit a bill without a diagnosis code. An EHResque ‘Rise of Machines’ is only adding fuel to this fire, since electronic formatting of patient encounters makes it impossible complete them without a diagnosis. As a result, physicians are being cornered into diagnoses of pseudo-certainty like “Lupus” or “prostatitis” that take on a zombie electronic life of their own. These faux diseases work their way into patient problem lists, past medical history records and care plans not only long as these patients live, but well beyond.

In the DMCB’s former life as a primary care physician, symptoms of lingering numbness, unsteadiness, fatigue, aching, poor memory, vision changes and the like were quite common. Docs deal with it, usually with some combination of intuitive understanding of what could be serious versus what isn’t, providing comfort with assurances of what isn’t wrong and using the most important test of all: time backed by a confident caring demeanor, ready availability if things change and firm plans for a follow-up appointment.

Note that the DMCB did not indicate that it routinely ordered many blood or imaging tests or referred patients to many specialists to help sort out the known from the unknown. That’s because it quickly discovered that tests commonly ‘lie’ thanks to ‘sensitivities’ and ‘specificities’ that are commonly south of 100%.

That’s right. Stress tests, CAT scans and blood tests can be remarkably imperfect, with falsely positive (positive tests in persons without any disease) and falsely negative (normal tests in persons with disease) test rates that can approach 30%. It’s the job of smart docs to weigh the probability that ‘positive’ test result is a lie and if the likelihood of a lie is greater than the possibility of real disease.

The DMCB also got used to many of his specialist colleagues’ inability to grasp that fundamental truth. The DMCB is not surprised that electronic records (and their evil twin, our latest generation billing systems) are also unable to accommodate this.

To Dr. Rosenbaum, the DMCB says hang in there. The system needs good docs like you to rescue us from ourselves.

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