diagnosis by the seat of the pants

Monday, October 8, 2012

October is the best time to be a sports fan with evenings and weekends filled with baseball playoffs, football and hockey… perhaps no hockey this year. It is the time to appreciate the effort of the head coach who has imprinted his system on his staff and players to win one for the Gipper or the alma mater. Each coach has developed their own way of doing things, after years of working for other head coaches, just to get the chance to run the show. By the time the season has ended and the playoffs begin, successful coaches have developed their own unique and individual personality and the team follows suit. Imagine sitting these successful leaders down in a conference room and trying to encourage them to run the same system. Welcome to world of emergency medicine and the Scientific Assembly of the American College of Emergency Physicians.

Thousands of ER docs have descended upon Denver, sitting in lecture halls, as they try to learn the latest and greatest information on how to look after patients. People who go into emergency medicine tend to be like head coaches, set in their ways, headstrong and obstinate. Changing behavior took time since textbooks were the way to go to form the basis of medical knowledge, but by the time the book was written, published and sold, it was woefully out of date. With IT and the internet, the stuff being taught in Denver is hot off the press, sometime only weeks old and ER docs have had to learn how to be nimble and flexible. While football players have the same system to apply in every game, the emergency team of nurses, techs and ward secretaries may have to adjust three or four different styles in an eight hour shift. Imagine bringing in a different quarterback for every other play. The ER personalities are very much the same and changing how patients are cared for can be a woefully slow process.

So it came as a surprise when I sat in on two lectures in the Denver Convention Center, surrounded by hundreds of my peers. New information was being shared about people who are short of breath, specifically those in congestive heart failure and those with pulmonary emboli, and how to make the diagnosis and care for them. Heart failure describes a patient whose weakened heart muscle cannot adequately pump the blood within the body causing it to leak into the lungs. Emboli are blood clots that travel to the lung and can stop oxygen getting from the air to the bloodstream causing shortness of breath and pain and it can be lethal. Sometimes the diagnosis is easy but most of the time it is tough to make. In the past, each doctor has had their own way of caring for the patient, but the promise of technology, like blood tests and CT scans were thought to be the holy grail of preventing medical errors by developing cookbook medicine. Everybody might take the same steps in making the diagnosis and providing care. Like lemmings, doctors embraced the technology and found that the diagnosis was still as murky as ever with unexpected complications arising, especially for the increased use of chest CT scans to look inside the body. Aside from the excess radiation, some patients were put at risk for kidney failure because of the dye that had to be injected in to the body. The new holy grail was to give up on the concept of always being right but instead use clinical judgment to decide who was sick and who wasn’t and perhaps not use massive amounts of blood tests for every patient. The doctor needed to develop their own style to decide which test might be of benefit and which test was a waste of time.

It seems that the way coaches ran their system, based on their own experiences and pattern recognition was the way doctors should care for their patients. If the doctor felt that there was a low likelihood that the patient had a pulmonary embolus, then the decision to do more testing to prove an even lower likelihood might be futile and dangerous. One test leads to another and the next thing you know, the patient has suffered a complication of their care. Most of the decision making strategies could be made by talking to the patient and performing a physical exam. The same was true in making the diagnosis of heart failure. The lecture was IT blasphemy. The doctor’s gestalt might be better than high tech and clinical experience caring for patients might trump the high cost of testing to prove that something isn’t there. This is a tough concept. How do you prove a diagnosis that isn’t. Patients have come to like tangible evidence of a doctor’s opinion like x-rays that show normal bones without fracture and CT scans that shows normal brain. They are less thrilled with the diagnosis that begins with “I think” instead of “I know”.

This is where the teamwork comes into play. The nurses have a strong role in making the diagnosis and explaining what in the world is happening. They are the ones spending time at the bedside and patients often feel threatened to question their doctor with issues that worry them. There are daily stories in every ER where the nurses and docs butt heads. If only the patients and families knew that the care they receive is a consensus, or at least when it goes that way.

Ultimately, the coach can only prepare the players to perform on the field but it’s up to them to win or lose the game with their performance. In medicine, the doctor is not only coach-manager but also a player. It may be that medical performance may be more thinking than doing but the path to the right diagnosis and the style may be markedly different. It’s hard to fit a square peg into a round hole, but the Denver lectures have given some latitude to let doctors try just that and it seems that doctors might be given permission to call their own plays, at least for this week.

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