Friday, April 14, 2017

Should a consultant pass through the ED to see what's up?

A couple of weeks ago, this tweet appeared.
I could relate to it for two reasons. One, I lived in New York City in 1975, and here is the other.

Early in my career, I thought it was a good idea when leaving the hospital at night to exit via the emergency department to see if there were any potential surgery cases brewing. I was hoping to avoid going all the way home, getting paged to the ED, and having to go right back to the hospital. I soon learned to stop that practice because it was similar to poking a skunk.

I replied: I would NEVER go near the ED unless formally consulted. Nothing worse than "Now that you're here, can you take a look at ..."

@msiuba reminded me of another gambit that well-meaning emergency docs play which is, "I just wanted to give you a heads up." This usually involved a patient with abdominal pain who had just arrived and either had not been seen yet or was awaiting the inevitable CT scan. Over 90% of the time these patients turned out to not have a problem requiring a surgical consultation.

@Amberitis9 offered this one: "Can you just lay hands on their belly?" Now that everyone with abdominal pain gets a CT scan, you don’t hear that questions as frequently. In fact, does anyone lays hands on the belly these days?

That segues into another recent tweet.

STEXIT = Stethoscope exit—meaning throw it away. In case you haven't heard, many say the stethoscope is useless for examining the lungs, heart, or abdomen. Now all you need is an ultrasound machine.

Will patients experience the same sort of connection with their doctors if instead of the personal touch of a warm hand, all they feel is cold gel and a probe?

14 comments:

Mary Evenson said...

As a patient - the answer to your question about Stexit and patient doctor connection is a resounding NO. There seems to be more and more technology used even in exams and the less interaction there is between my doctor and me the less I trust him and the less I am willing to tell him.

Josh Farkas said...

The STEXIT tweet got a lot of attention, ranging from very positive to very negative. I didn't respond to most of it on twitter, due to lack of the necessary number of characters.

As some folks rightly pointed out, this is a bit of a false dichotomy. Neither the stethescope nor the ultrasound is perfect. Stethescopes are better for some things (wheeze, screening for aortic stenosis). Ultrasound is overall more powerful (although occasionally confounded by poor windows).

With regards to the personal connection, I think that ultrasonography is actually helpful. Before point-of-care ultrasonography, I would often examine a patient briefly before ordering a definitive test (CT scan, formal ultrasonography, etc.). Point-of-care ultrasonography actually forces me to spend more time with the patient.

I should also credit the UAlberta Critical Care Ultrasound site (@UAlberta_CCUS) with creating the STEXIT graphic. I would have cited them on my initial tweet, but I wasn't initially sure who the origional creator of the graphic was.

Sunday Onimisi Salami said...

In my part of the world. You have no choice...no stexit..You must lay hands, eyes and ears...

Skeptical Scalpel said...

Thanks for the two opposing views about the impact of technology on patient engagement and the perspective from outside of the US.

William Reichert said...

Remember, if you want to look like a real doctor in a picture in the media, no matter whether you ever use a stethoscope or not, you must be photographed with a stethoscope dangling from your neck. Even pathologists must comply with this edict.

Skeptical Scalpel said...

Dangling? You're showing your age. I think you meant to say "draped around your neck."

Unknown said...

27 years in a Level 1 trauma center ER doc here: There's very few consultants whose opinion I want when I'm seeing a pt in the ED anymore and it's not because they aren't good people or good docs, but because they don't offer their judgement. Instead, they suggest ordering a litany of tests. Neurologists see the pt only after they see their MRI. I don't know a practicing surgeon anymore who will take out an appy without a CT. I know which tests to order. What I want from a consultant is opinion and judgement and those, sadly, seem to be somewhat endangered skills in the modern doctor. I learned probabilistic thinking and I enjoy consulting on my younger partners' patients with their "what would you do with this?" questions. I've certainly seen improvements in medicine during my career, but those improvements have not come close to keeping pace with the increase in testing.

Skeptical Scalpel said...

Unknown, thanks. Good points, especially about testing. I can't deny we surgeons do like our abd CT scans. It's hard to argue against them. In my experience, they are very accurate. In a non-teaching hospital, you can't expect surgeons to examine every pt with abd pain.

artiger said...

A surgeon passing through the ER just to see what might be going on is akin to what my parents told me in my high school years about staying out past midnight...rarely does anything good come out of it.

No offense to primary care, but our small ER is staffed by family practice docs who couldn't stand office practice any longer. If they see your face they will ask you to look at something, and usually it's not something that requires a surgeon. I got asked for an opinion about a nose laceration last week. I suggested gluing it. Not exactly a complex level of decision making.

Macha said...

As an obgyn resident I was taught by my senior resident never to exit the hospital via the ED. "We don't want to remind them that there's such a thing as a gynecologist."

Skeptical Scalpel said...

Macha, that is good advice.

Anonymous said...

As a surgeon, I was trained not to wear the stethoscope around the neck (aka flea collar style). It goes folded into the coat or pants pocket (where it inevitably catches on door handles).

SolitaryFlower said...

I read this blog post about 6 hours before staggering into my local ER with horrid abdominal pain. I remember thinking "i wish i'd read the comments section more closely!" A doctor ~did~ palpate my abdomen, although it was several hours after my CT scan.

Skeptical Scalpel said...

Anon, I had that same problem. No way to stop it happening.

Solitary, at least it was eventually palpated. I hope you are feeling better.

Post a Comment