When Are ER Docs Hunting the Snark?

The old saying about the doctor who tells a patient to “take two of these and call me in the morning” is losing its meaning in today’s modern healthcare system. Today, doctors are weary of sending their patients home without something more, usually an expensive test that either confirms or (less commonly) contradicts their diagnosis. 

Consider, for example, the gap between patient and their physicians in the following three instances, all involving strokes or potential strokes.

• A few years ago my mother was worried she was having a stroke. My father, having just visited her in the emergency room, told me afterwards that everything was ok: “The doctors did every test imaginable before letting her go. They were great.” Knowing that an ED physician would admit my mother if they felt she was having a CVA or TIA, I thought back to cases of non-specific complaints where I ordered a CT to give patient piece of mind.
• A few days ago I was driving home and heard a radio commercial about stroke.  It featured a comedian giving a routine on how ridiculous his father seemed trying to “tough out” a paralyzed left arm and slurred speech. The conclusion was “Stroke is no Joke” and the commercial encouraged people to call 911 if they have weakness, slurred speech or dizziness. I thought, “Oh Lord, here come more weak and dizzies thinking they’re having a stroke.”
• Recently I spoke to a group of local business leaders about what we look for to diagnose a stroke, how there are ischemic and bleeding strokes, and how we can, in some cases, give thrombolytics if a patient arrives within a certain timeframe. It was well received and one person asked why we don’t do more to educate people about the symptoms of stroke and the need for rapid presentation to the ER. I thought about the patient to whom I last gave tPA after a long discussion of risks and benefits and how I felt when I learned that he had suffered a hemorrhagic conversion.

These three vignettes highlight the chasm between patients and their physicians. Healthcare providers have the knowledge of risks, benefits, complications and expected outcomes for many diseases. Patients generally don’t even know that there is no such thing as a “mini-stroke.” The ability to bridge this gap is one of the many the challenges facing emergency medicine.

Patients come to the ER worried that they are having an emergency. Often physicians leave an exam room knowing whether someone is going home or getting admitted. We are supposed to use lab tests to improve our decision-making, but sometimes it’s to reassure. This has been shown for example in surveys of patients with abdominal pain who feel more confident in their diagnosis after a CT Scan than with only a physician’s evaluation, according to a story in the Annals of Emergency Medicine.

We can take the time and the chance that counseling a patient will convince a patient that a CT is unlikely to alter their outcome and will definitely expose them to ionizing radiation, or we can order the test, see the next patient, and discharge the first when the scan is negative. All too often, especially when the ER is busy, I choose the latter.

Why do we do it? The answer is complicated. We do it because of those cases that stick with us: the 25 year old who actually was having a heart attack. The healthy 38 year-old woman whose weakness, that you swore was from a complex migraine, actually had an MRI-confirmed stroke. There was that case of funky flank pain that floored you when the abdominal CT caught a PE by luck.

A recent editorial (also in Annals) on the skyrocketing use of CT in the ED compares this behavior to Lewis Carroll’s poem, The Hunting of the Snark. In the poem, “an improbable crew guided by a blank map pursues a mythic but dangerous creature, to their own doom. One is struck by the feeling that, in our quest for ever more perfect certainty, we are reenacting that famous tragedy.”

We want patients to be satisfied because it makes our bosses happy. We think and surveys confirm that patients are more confident after diagnostic interventions. There are always those cases where we recall, and lawyers love to argue, that if we had just ordered one more test, something tragic would not have happened. But catching needles in haystacks has turned ED evaluation of complaints like chest pain into a convoluted and inordinately expensive endeavor that has yet to prove any benefit to patient outcomes. Yet to allay fears and satisfy lawyers, patients are admitted, observed, stress, and catheterized hunting a Snark once again.

Stepping back, it seems that our system works very well for the 15 percent of ED presentations that require emergent management and poorly for the 85 percent who do not, because I am unable or unwilling to say, “You’re fine, go home.” This failure arises from a perceived lack of confidence in my judgment, from my patients, or in the tort system. I think back to x-rays that I’ve ordered on pediatric fevers, and wish they made a public service announcement telling parents what febrile illnesses need emergent evaluation.

But we can’t blame patients, government ads, or lawyers when we don’t take the time to educate in a way that our patients can understand. Satisfaction arises from a fulfilled desire and a patient desires health. If we spend more time at the bedside and less at the computer clicking on tests, I believe patient satisfaction will rise and medical costs will fall. It scares me that patients believe a CT Scan more than their doctor. I’m disheartened when a mother won’t trust me when I say that antibiotics won’t help their child but will jump off a cliff if Dr. Oz says so. But maybe we’re to blame. Patients have spent too many 5 minute visits ending with a prescription and have been sent to too many tests in response to their complaints that when a doctor sits with them and says that nothing needs to be done… well, you can’t blame them for greeting that with circumspect. Doctors had it right all along. Take two Percocet and call me in the morning. (C’mon, aspirin’s a joke, right?)