Skip to content
  • About
  • Contact
  • Contribute
  • Book
  • Careers
  • Podcast
  • Recommended
  • Speaking
  • All
  • Physician
  • Practice
  • Policy
  • Finance
  • Conditions
  • .edu
  • Patient
  • Meds
  • Tech
  • Social
  • Video
    • All
    • Physician
    • Practice
    • Policy
    • Finance
    • Conditions
    • .edu
    • Patient
    • Meds
    • Tech
    • Social
    • Video
    • About
    • Contact
    • Contribute
    • Book
    • Careers
    • Podcast
    • Recommended
    • Speaking

The price of certainty in the ICU

Tom Peteet, MD
Physician
August 19, 2015
Share
Tweet
Share

Mr. J was as close to a typical sixty-year-old patient as possible, wary of doctors and selective in when he took his blood pressure medications. On a sunny Thursday, he woke up nauseated and called an ambulance. During evaluation in the emergency room, his blood pressures reached atmospheric levels (nearly 300 systolic). He began seizing, which soon stopped and was transferred to the ICU. As the admitting resident, I dutifully went through the potential causes of his elevated blood pressure: medication noncompliance, surreptitious cocaine use, and even the zebra diagnosis of a pheochromocytoma. As for the seizure, I held firm on the diagnosis of PRES: an acronym for posterior reversible encephalopathy syndrome — an under-diagnosed condition of abnormal blood flow to the brain in the setting of high blood pressure.

Mr. J was on course for a typical hospital admission. We would run a battery of tests, determine a singular diagnosis for his problem, and send him home on treatment. The hospital would be reimbursed for his coded diagnoses of hypertension, PRES, seizure, and he would have close follow-up with specialists.

If Mr. J was a typical case, our discussion of costs and appropriateness of testing was not. Despite a resurgence of “cost-consciousness” within medicine, the word cost rarely comes up in the ICU. Much of the discourse around cost and of the Choosing Wisely campaign is an effort to avoid unnecessary tests in clearly defined circumstances. However, Mr. J’s case shows us that the vast majority of clinical decisions live in a gray zone of appropriateness. On rounds, the question came down to this: does he need a brain MRI and angiography (MRA) to “prove” he has PRES? The clinical history seemed to support the diagnosis, and the study could potentially offer limited prognostic information. Also, in the highly improbable scenario the patient did have a small stroke, we would see it on the MRI. What is the value we place on this minimal increase in certainty? According to the Healthcare Bluebook, the cost of both studies is $1,206.

Taking a step back, I wondered about our zeal to “prove” a diagnosis. Physicians so frequently frame clinical questions around diagnostic proof that we forget this is not the only way. Why not frame clinical questions around appropriateness, cost, or even risk-benefit to the patient? Context matters. In settings like the emergency room or ICU, ruling out the worst is highly valued. If he continued to be stable after a few days, the diagnosis would be PRES by exclusion, and we would all save time and money.  Similarly, in one month, if Mr. J remained fine, his primary care doctor would not rush to get an MRI. But he was in the ICU, we needed an answer, and a test offered us the psychological boost we needed.

Mr. J walked out of the hospital five days later on a different regimen of blood pressure medications. He thanked the staff profusely, who in turn, felt they provided excellent care. Each actor behaved rationally: the patient and clinician to get a diagnosis, and the hospital to generate revenue. The system, however, behaved irrationally, to the cost of the public and also the patient. Despite a confirmed diagnosis of PRES, Mr. J will follow up with two specialists to verify the results of other rare causes for high blood pressure, again generating revenue, visits, and a minimal gain in certainty.

As a physician in this structure, I struggle to maintain hope, as thoughtfulness contradicts rationality. For Mr. J, I pushed against getting the MRI because I valued diagnostic utility and system costs over diagnostic accuracy. The system pushed back. The neurologist highly recommended the test, the ICU attending changed over, and the fellow “needed to rule out a mass.” Considering the cost and appropriateness of each test is hard work, and too great a task for one person. While I am skeptical of top-down change, I take solace in the ability of clinicians to think complexly: to weigh accuracy alongside cost, risk, and benefit. In the gray areas of medicine, we as clinicians would do well to ask and wrestle with the question, “What is the price of the certainty we seek?

Tom Peteet is an internal medicine resident.

costs_of_care_logo_small This post originally appeared on the Costs of Care Blog. Costs of Care is a 501c3 nonprofit that is transforming American health care delivery by empowering patients and their caregivers to deflate medical bills. Follow us on Twitter @costsofcare.

Prev

The day I operated on my daughter

August 19, 2015 Kevin 4
…
Next

You won't necessarily be admitted to the hospital. Here's why.

August 19, 2015 Kevin 7
…

Tagged as: Cardiology, Critical Care

Post navigation

< Previous Post
The day I operated on my daughter
Next Post >
You won't necessarily be admitted to the hospital. Here's why.

ADVERTISEMENT

More by Tom Peteet, MD

  • A tribute to Paul Kalanithi

    Tom Peteet, MD
  • a desk with keyboard and ipad with the kevinmd logo

    Searching for the holy grail of clinical reasoning

    Tom Peteet, MD
  • Are preoperative consultations worthless?

    Tom Peteet, MD

Related Posts

  • Millions of Americans without ICU doctors due to the “Biden ban”

    Seth Rabinowitz
  • Are generic drug price hikes media hype?

    Peter Ubel, MD
  • Understanding critical care in the ICU: then and now [PODCAST]

    The Podcast by KevinMD
  • A physician’s addiction to social media

    Amanda Xi, MD
  • Death in the cardiac ICU

    Adela Wu
  • At the top of patients’ wish lists: price transparency

    Miranda Gill, MSN, RN

More in Physician

  • How to handle chronically late patients in your medical practice

    Neil Baum, MD
  • How early meetings and after-hours events penalize physician-mothers

    Samira Jeimy, MD, PhD and Menaka Pai, MD
  • Why medicine must evolve to support modern physicians

    Ryan Nadelson, MD
  • Why listening to parents’ intuition can save lives in pediatric care

    Tokunbo Akande, MD, MPH
  • Finding balance and meaning in medical practice: a holistic approach to professional fulfillment

    Dr. Saad S. Alshohaib
  • How regulatory overreach is destroying innovation in U.S. health care

    Kayvan Haddadan, MD
  • Most Popular

  • Past Week

    • Forced voicemail and diagnosis codes are endangering patient access to medications

      Arthur Lazarus, MD, MBA | Meds
    • How President Biden’s cognitive health shapes political and legal trust

      Muhamad Aly Rifai, MD | Conditions
    • The One Big Beautiful Bill and the fragile heart of rural health care

      Holland Haynie, MD | Policy
    • Why timing, not surgery, determines patient survival

      Michael Karch, MD | Conditions
    • Why health care leaders fail at execution—and how to fix it

      Dave Cummings, RN | Policy
    • How digital tools are reshaping the doctor-patient relationship

      Vineet Vishwanath | Tech
  • Past 6 Months

    • Forced voicemail and diagnosis codes are endangering patient access to medications

      Arthur Lazarus, MD, MBA | Meds
    • How President Biden’s cognitive health shapes political and legal trust

      Muhamad Aly Rifai, MD | Conditions
    • Why are medical students turning away from primary care? [PODCAST]

      The Podcast by KevinMD | Podcast
    • The One Big Beautiful Bill and the fragile heart of rural health care

      Holland Haynie, MD | Policy
    • Why “do no harm” might be harming modern medicine

      Sabooh S. Mubbashar, MD | Physician
    • The hidden health risks in the One Big Beautiful Bill Act

      Trevor Lyford, MPH | Policy
  • Recent Posts

    • Why point-of-care ultrasound belongs in every emergency department triage [PODCAST]

      The Podcast by KevinMD | Podcast
    • Why PSA levels alone shouldn’t define your prostate cancer risk

      Martina Ambardjieva, MD, PhD | Conditions
    • How to handle chronically late patients in your medical practice

      Neil Baum, MD | Physician
    • Reframing chronic pain and dignity: What a pain clinic teaches us about MAiD and chronic suffering

      Olumuyiwa Bamgbade, MD | Conditions
    • How early meetings and after-hours events penalize physician-mothers

      Samira Jeimy, MD, PhD and Menaka Pai, MD | Physician
    • Why medicine must evolve to support modern physicians

      Ryan Nadelson, MD | Physician

Subscribe to KevinMD and never miss a story!

Get free updates delivered free to your inbox.


Find jobs at
Careers by KevinMD.com

Search thousands of physician, PA, NP, and CRNA jobs now.

Learn more

View 3 Comments >

Founded in 2004 by Kevin Pho, MD, KevinMD.com is the web’s leading platform where physicians, advanced practitioners, nurses, medical students, and patients share their insight and tell their stories.

Social

  • Like on Facebook
  • Follow on Twitter
  • Connect on Linkedin
  • Subscribe on Youtube
  • Instagram

ADVERTISEMENT

  • Most Popular

  • Past Week

    • Forced voicemail and diagnosis codes are endangering patient access to medications

      Arthur Lazarus, MD, MBA | Meds
    • How President Biden’s cognitive health shapes political and legal trust

      Muhamad Aly Rifai, MD | Conditions
    • The One Big Beautiful Bill and the fragile heart of rural health care

      Holland Haynie, MD | Policy
    • Why timing, not surgery, determines patient survival

      Michael Karch, MD | Conditions
    • Why health care leaders fail at execution—and how to fix it

      Dave Cummings, RN | Policy
    • How digital tools are reshaping the doctor-patient relationship

      Vineet Vishwanath | Tech
  • Past 6 Months

    • Forced voicemail and diagnosis codes are endangering patient access to medications

      Arthur Lazarus, MD, MBA | Meds
    • How President Biden’s cognitive health shapes political and legal trust

      Muhamad Aly Rifai, MD | Conditions
    • Why are medical students turning away from primary care? [PODCAST]

      The Podcast by KevinMD | Podcast
    • The One Big Beautiful Bill and the fragile heart of rural health care

      Holland Haynie, MD | Policy
    • Why “do no harm” might be harming modern medicine

      Sabooh S. Mubbashar, MD | Physician
    • The hidden health risks in the One Big Beautiful Bill Act

      Trevor Lyford, MPH | Policy
  • Recent Posts

    • Why point-of-care ultrasound belongs in every emergency department triage [PODCAST]

      The Podcast by KevinMD | Podcast
    • Why PSA levels alone shouldn’t define your prostate cancer risk

      Martina Ambardjieva, MD, PhD | Conditions
    • How to handle chronically late patients in your medical practice

      Neil Baum, MD | Physician
    • Reframing chronic pain and dignity: What a pain clinic teaches us about MAiD and chronic suffering

      Olumuyiwa Bamgbade, MD | Conditions
    • How early meetings and after-hours events penalize physician-mothers

      Samira Jeimy, MD, PhD and Menaka Pai, MD | Physician
    • Why medicine must evolve to support modern physicians

      Ryan Nadelson, MD | Physician

MedPage Today Professional

An Everyday Health Property Medpage Today
  • Terms of Use | Disclaimer
  • Privacy Policy
  • DMCA Policy
All Content © KevinMD, LLC
Site by Outthink Group

The price of certainty in the ICU
3 comments

Comments are moderated before they are published. Please read the comment policy.

Loading Comments...