What ever happened to courage?

Jim came through the cholecystectomy beautifully. In fact, he did so well that in no time he was back on the basketball court. Three weeks later he was in my office with a sore, swollen leg. He thought it was from twisting his ankle the day before. And indeed, it had all the appearances of a sports injury. I examined the extremity carefully, and decided to get a venous doppler to evaluate for DVT given the recent surgery.

My suspicions were confirmed when the technician called to tell me that he had found a clot in the deep veins of the thigh. Shortly after hanging up, my phone started to ring again. Jim was calling on his mobile. He was having chest pain when taking deep breaths, and his heart was racing. He was struggling to catch his breath. Certain that he was having a pulmonary embolism, I instructed him to walk down the stairs from the doppler suite to the emergency room.

I phoned ahead and talked to the ER doc on shift for the evening. I let him know of the positive study and my suspicion of a pulmonary embolism. We needed to start anticoagulation and admit overnight. He informed me that the ER was full, and likely it would be late evening before a bed was assigned.

I fell asleep early, awaiting the call from the floor nurse to give admitting orders. It never came.

I woke up the next morning disoriented and rushed to the hospital. Apparently Jim was accidentally admitted to the hospitalist on call. After reading the chart, I started to feel the blood rise to my forehead. The hospitalist ordered a CT scan of the chest as well as hypercoaguability studies. I was seething.

Why ever would he needlessly expose my patient to the radiation of a CT scan when the diagnosis of a pulmonary embolism was all but certain given the positive lower extremity doppler? And why would anyone order hypercoaguability studies when we had two perfectly good reasons for a clot to form: recent surgery and a sports related injury?

The CT scan showed a pulmonary embolism and the hypercoaguability studies were negative. I called the hospitalist to ask why he ordered such expensive and possibly dangerous studies on my patient when they weren’t necessary. After much bickering back and forth, it became clear that although the diagnosis was certain, he didn’t feel comfortable without having proof. The hypercoaguability studies were done “just to be extra careful.”

I was pissed.

Now more then ever, in this time of economic upheaval and floundering medical quality, we physicians have to have the courage to practice responsible, informed medicine. We can no longer offer costly or dangerous medical care just to “reassure” ourselves. We have to make the tough decisions.

We must have the courage to not treat minor bronchitis with antibiotics.

We must have the courage to not use narcotics for run of the mill back pain.

We must have the courage to use palliative care and hospice effectively when appropriate.

We spent years developing the knowledge and skill to efficiently and effectively treat our patients in a sound and thoughtful manner.

When will we develop the backbone?

Jordan Grumet is an internal medicine physician and founder, CrisisMD.  He blogs at In My Humble Opinion.