Patient Decision-Making
The previous post stirred up a bit of controversy over informed consent, and whether the "unnecessary" tests I order are for my benefit or the patient's benefit. Ultimately, everything I do is for the patient's benefit. I would never order a test or perform a procedure that had no chance of helping a patient. But many of the tests and interventions I perform do benefit me, and I'm not going to feel bad about that. I go to work every night to benefit me and my family, and I'm blessed that I can earn a living while helping people at the same time. I can think of worse jobs.
Let's discuss a simple laceration repair, for example. Currently, we cannot bill for Dermabond closure of simple lacerations, even though many of the wounds that are able to be closed with this "superglue" could also be closed with sutures and wouldn't take much longer to do so. There is a certain amount of expertise required to skillfully close a wound with skin adhesive, but we cannot charge for the procedure, only for the ER visit. A one inch laceration that is closed with 4 or 5 sutures adds a couple of hundred bucks or more to my charges. Sometimes Dermabond is more appropriate or desirable than suture placement, for various reasons, and it would be inappropriate for me to not give patients that option, even though I stand to make less money. I have never once recommended a procedure only for my own benefit, when another procedure would suffice.
Another example is the chest pain workup. The undeniable fact is that chest pain is one of the complaints that can signify a life-threatening process, so the workup of patients with chest pain in the emergency department is invariably expensive and complicated. No matter what tests are ordered, the physician fee is going to approach $500, and the other charges are going to be expensive as well. And that's before the admission for stress testing, echocardiography, and telemetry observation.
If I see a patient who is unlikely to have a life-threatening cause of chest pain, I might be comfortable with just doing an ECG and a chest X-ray. Usually, lab tests are performed as well. Some patients are hesitant to undergo such an expensive workup, and are comfortable with limiting the number of tests that we do. Here is how I explain the process:
Let's discuss a simple laceration repair, for example. Currently, we cannot bill for Dermabond closure of simple lacerations, even though many of the wounds that are able to be closed with this "superglue" could also be closed with sutures and wouldn't take much longer to do so. There is a certain amount of expertise required to skillfully close a wound with skin adhesive, but we cannot charge for the procedure, only for the ER visit. A one inch laceration that is closed with 4 or 5 sutures adds a couple of hundred bucks or more to my charges. Sometimes Dermabond is more appropriate or desirable than suture placement, for various reasons, and it would be inappropriate for me to not give patients that option, even though I stand to make less money. I have never once recommended a procedure only for my own benefit, when another procedure would suffice.
Another example is the chest pain workup. The undeniable fact is that chest pain is one of the complaints that can signify a life-threatening process, so the workup of patients with chest pain in the emergency department is invariably expensive and complicated. No matter what tests are ordered, the physician fee is going to approach $500, and the other charges are going to be expensive as well. And that's before the admission for stress testing, echocardiography, and telemetry observation.
If I see a patient who is unlikely to have a life-threatening cause of chest pain, I might be comfortable with just doing an ECG and a chest X-ray. Usually, lab tests are performed as well. Some patients are hesitant to undergo such an expensive workup, and are comfortable with limiting the number of tests that we do. Here is how I explain the process:
"You have chest pain, which may be as benign as a sprained ankle or as deadly serious as a heart attack. My clinical impression is that it is not serious, but I would recommend some tests to help sort things out. If we do no tests at all, you have a certain amount of risk. If we do an ECG, we can reduce the risk somewhat, and a chest X-ray will reduce the risk a bit more. Laboratory tests can give us more information, but ultimately none of those tests are sufficient to exclude a heart attack. Some people who come into the ER with heart attacks have all of those tests initially come back normal, and the injury isn't picked up until the next day. So we typically admit patients with chest pain to the hospital for observation and cardiac monitoring, and put them on the treadmill for a stress test in the morning.
Why do we do all of these tests? Because we really can't tell who is having a heart attack and who isn't when they come into the ER. I've discharged patients who have died before they even made it home, and I've admitted patients who I was sure were going to have heart disease who ultimately didn't. So my recommendation is to be cautious.
It's your decision.....what do you want to do? How safe do you want to be?"
Labels: chest pain, ER, medical
posted by scalpel at 5:43 PM
25 Comments:
I agree. One time I had a 40-year old woman come in complaining of chest pain. Everybody laughed at me for putting her in a cardiac bed and starting the cardiac work-up. She ended up coding on the table and was brought back by IV amiodarone after shocking didn't work. She probably wouldn't have made it out of the waiting room if we hadn't gotten her back there so quickly to witness the V-fib.
But then there's the times I didn't call it right---where I'd think someone was in a major cardiac episode and it was gas or back pain or something.
Making decisions about chest pain complaints in the ER is dicey and I've even seen doctors arguing with each other during a Code Blue.
It just ain't an easy call to make and so I have a HELL of a lot of sympathy for ER docs over it.
Why don't you bill for dermabond? CPT code G0168, "Laceration repair, tissue adhesive only," 0.7 RVUs. Not as well reimbursed as suturing, to be sure, but better than just the E/M code.
Cheers,
SF
BTW, my chest pain verbiage is similar, but I like to emphasize the "odds" approach. I guesstimate the risk of a low-risk patient's CP being cardiac as about 5%. "I like those odds, don't you? But that's one in twenty, isn't it? I'm gonna see 20 patients today. Do you want to be the one?"
I always want to add, "Do you feel lucky, punk?" but have generally manager to resist the impulse.
What makes Nurse Kelly homicidal and suicidal?
What?
Doctors that do indiscriminate chest CTs and cardiac labs on every 20 year old patient with a cough and pain on inspiration with normal sats. There are a couple like this in our dept. We'll send giggling, sniffling 21 year old chicks over to the chest CT because it hurts to cough.
Thanks for setting me straight, SF. I've been misled by sources I considered authoritative that there was no such code.
I've stood in the ER and watched a "MI" work up. It's worth every penny and then some.
They used Dermabond on hubby a few weeks ago. Its very cool but very itchy but it doesn't so much for scarring.
But it you DO say that, Shadowfax, you've at least got to remember to be holding the defib paddles in your hand like a Magnum.....
I agree with Shadowfax in that I would've liked to see odds described. Without any kind of numbers, it is difficult for a patient to make an informed decision. Would your patient consider the test necessary if you were to say that her odds are 1/1000? Some patients might consider a test to rule out 1/10,000 chance of something as necessary, while some would be upset if you ordered a test to rule out 1/100 chance of something without informing them of how small or big this risk is. Different people have different views of what is necessary for them, especially if they are paying for it.
The other thing that is completely missing from your informed consent discussion are the risks of tests.
Some of the tests you order have a certain risk of false positive leading to more invasive tests that carry a serious risk of complifations, even death. Let's say a hypothetical test you order has a 10% chance of a false positive, and the more invasive test that would follow has 1/100 chance of death. This seem small if the probability that your patient will benefit is 1/100, but if you order the test to rule out 1/10,000 chance of a condition, then the risks of test significantly outweight the chance of benefit for the patient (although it would still likely to benefit you in terms of reducing your risk of malpractice). I'd imagine many patients would consider a test unnecessary if the risk of harm from the test is higher (or even comparable) to the chance of benefit.
1) The risk of the tests is negligible. If I'm ordering or recommending the test, the benefit (to the patient) outweighs the risk.
2) "Informed consent" is not required for CT scans, even with IV contrast.
3) We don't have time to go through a 10 minute discussion about whether s patient is going to agree to the CT scan. Either get with the program or sign the AMA form. I've got a couple of dozen other folks that want to be seen sometime tonight too, and every minute an anxious would-be statistician spends with their hand-wringing angst is a minute more every single one of the others has to wait.
4) Anyone who says they can give even ballpark accuracy of probability statistics like the ones you seek is deluding both of you.
methinks you have not taken care of anyone with post-CT contrast nephropathy scalpel.
"methinks you have not taken care of anyone with post-CT contrast nephropathy scalpel."
We're always wary of it, and we take steps to prevent it. But ultimately the clinical significance in properly screened patients is negligible. In the typically healthy 30 year old woman with chest pain, the risk isn't even worth mentioning.
"It's your decision.....what do you want to do?"
Gee, Scalpel, I want you to be free to make the best medical decision based on your experience - not what the insurance companies and hospital weenies tell you to use. Um, what country are we living in again? Just want to make sure...
I prefer to not have any of my patients die under my care (or even shortly thereafter). So I am inclined to recommend conservative management, including lots of expensive tests and frequent hospital admissions whenever death, disability, or clinical deterioration with the potential for complications is reasonably possible.
This concept is similar to insurance (risk pooling), in which numerous people pay more into the system than they utilize in order to mitigate the risk of the occasional high-dollar loss. The extraordinarily high medical bills incurred by patients and their insurance companies for these overly conservative measures can be considered "insurance" against the occasional bad outcome that might be prevented by these measures.
Performing 100 chest CT scans to pick up one pulmonary embolism is cost-effective. Admitting 100 "soft" chest painers to pick up one heart attack is also cost-effective.
Hi Scalpel-I would ALWAYS want to do what the doctor thinks is best regarding a cardiac work-up. While I don't have money to burn, I won't spend it when I am dead either.
In all my years working with the ED, I never realized they did chest X-rays for chest pain unless a respiratory ailment was suspected. I am aware of the labs and ecg's but what does the chest X-ray show in a cardiac work up?
We had a co-worker at the hospital who had a hx of HTN and smoked but had just undergone a complete physical and was totally cleared. Not long after that he was out at a public event, stood up and simultaneously clutched his chest and said"oh my God!" and fell face down on the pavement, dying instantly from a massive MI.
Why does something like that happen? Have all the right tests, get told all is well and then die suddenly?
One last question. An ED doc I worked with once said that the first warning of a heart attack for 50% of the people is sudden death. He said this years ago. Are the stats on that still the same or have they gone up or down?
Seaspray: the chest x-ray can reveal many causes of chest pain, from lung or mediastinal tumors to collapsed lungs to pneumonias to pleural effusions to rib fractures to bone mets to hiatal hernias, etc etc. It's also relatively cheap, quick, easy, and painless.
Sudden death can occur even soon after a negative workup, and is often the cause of lawsuits. If someone presents to an ER for chest pain and is NOT fully worked up, we might as well write a blank check to the family and their attorney. A complete workup at least demonstrates our concern for the patient and their symptoms, and occasionally reveals treatable life-threatening processes. It looks bad to not do any tests and send such a patient home with a Motrin prescription.
A patient might undergo a cardiac cath for heart disease which is normal but present to the ER later the same week with a huge pulmonary embolus that was not initially considered (I've seen it happen).
And your last statement is still true. If you make it to the hospital with your heart attack, your chance of survival is much greater. That's also why we admit so many patients with initially negative ER cardiac workups: a patient with a "warning sign of a heart attack" often has normal ECG and lab tests, but is still dangerous. It's a clinical diagnosis. When an ischemic malignant arrhythmia occurs, the patient may not even have time to reach for the phone to call 911. If they are already in the hospital on a monitor, their chance of survival is greatly increased.
"BTW, my chest pain verbiage is similar, but I like to emphasize the "odds" approach. I guesstimate the risk of a low-risk patient's CP being cardiac as about 5%. "I like those odds, don't you? But that's one in twenty, isn't it? I'm gonna see 20 patients today. Do you want to be the one?""
You're dealing with independent variables. Each person's shot is 5%. That doesn't mean that this person's odds are higher because you've already seen 15 people that night with chest pain, which is the message that they're likely to receive.
Similar to flipping heads or tails on a coin. Just because you've done 8 tails in a row, doesn't mean that your chance of flipping heads is greater than before simply because you haven't flipped it in a while... It's still exactly 50%.
In your case, you peg it at 5% for the chest pain, so it's always going to be 5%. Bringing in the number of patients you're likely to see is meaningless from a probability point of view... :)
just curious, but has anyone with contrast induced nephropathy ever sued after not being told the risk or otherwise giving a meaningful informed consent?
Not in Guatemala.
scapel, what do you do when a 69 YP male shows up in yrou ER with chest pains..but, he also has a long history of reflux disease with hiatal hernia?
I ask this because this was my father. the BIGGEST mistake we ever made was informing the ER staff of his history of reflux and hernia. they immediately assumed this was the cause of his chest pains and only did EKG and blood work, which was normal. They increased his stomach acid medication and sent him on his way. He then promptly had a massive heart attack and died.
This was back 17 years ago but now I have acid reflux disease with barrett's. When I have chest pains it scares me to death to admit that to the ER staff.
Thanks Scalpel :)
scalpel, what do you do when a 69 YO male shows up in your ER with chest pains...but, he also has a long history of reflux disease with hiatal hernia?
Great question. At the very least an ECG, chest x-ray, and cardiac enzymes should be performed, and possibly liver function tests and amylase/lipase tests if the upper abdomen is tender. Further management would depend on the detailed history and physical examination and the results of the tests, but a recommendation for admission and careful documentation of that recommendation (if refused by the patient) would be my approach.
The cost of this 23 hour observation visit from ER presentation to hospital discharge would cost over $10,000 if everything came back normal, and obviously quite a bit more if cath/stent/bypass/endoscopy and the associated additional hospital days were required.
Or, we could give a shot of Maalox and discharge him home without any tests at all. 9 out of 10 times he would be fine. But nobody wants to be the 1, do they?
"Performing 100 chest CT scans to pick up one pulmonary embolism is cost-effective."
How about testing for D-dimer first? If it is negative here we would never order a CT scan.
I would only rely on the d-dimer in the lowest risk cases. We have had a couple of PEs at our facility with "normal" d-dimers. I've also personally picked up two spontaneous pneumothoraces with CT scans that weren't appreciated on chest X-ray. One of them I blogged about here.
Well if you want to catch one in a hundred like you say, about 95 of those must be at low risk. That is exactly the group where the D-dimer is very useful in reducing that risk even more. The occasionally PE that has a false-negative D-dimer usually is a very small one.
Hi Scalpel,
Since this is an older blog, I'm not sure if you'll see the comment. Anyway, I'm a 31 yr. old female and have had chest pain and episodes of tachycardia since January. Last week I had a bad attack: I was short of breath, my heart rate was 160 and my BP was low and I blacked out. When I came to, the EMS guy looking at my EKG was saying "she's in a-fib, she's all over the place." In the ambulance the medic told me it was probably something called SVT.
The problem is that by the time I got to the hospital, my HR was down to 120 and my BP was up. My doctor did some blood work, a repeat EKG, and sent me home, despite my continued elevated pulse/chest pain/dizziness. When I asked what had caused all of this, he shrugged and said, "I don't know." As he walked out of the room he said, "Oops, I forgot about the girl in room X with the ankle pain" and giggled. Needless to say I didn't feel that great about going home or the care I received. :)
It seemed to me like there was a communication breakdown between the medics and the doctor. I was sick when the ambulance arrived at my home, but less sick by the time I got to the ER. If this happens again, should I ask for other tests, like a chest x-ray? You seem to be very thorough w/your patients and do all you can to keep them safe. I hope that if this happens again I am lucky enough to get a doc like you.
Thanks,
Elizabeth
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