Are we overdoing it? (2)

Its obvious and true that we are overinvestigating and overtreating our patients. But knowing the very fact does not change our current mode of practice, why is that?

As usual I had my overnight duty last Sunday. It had been a very miserable night and I could bearly take a breath until 3am. While still busy preparing patients for cardiac cath the other day, I received a call from nurse informing me of a old gentleman complaining of chest pain.

Attending the patient, after only a few lines of chat I know almost for sure it is not cardiac type of pain -he clearly illustrated to me the classic symptoms of gastric reflux after lying flat on bed. Then of course I gave him a tab of antacid and went back to document it on case notes.

But then the struggle came. A loud voice emerged within my brain (which was in sleep mode): could this be an atypical presentation of heart disease? I am pretty sure it isnt. Then the next bombarded: Could I bare the consequence if it's really a case of heart attack?

I hesitated.

Argued with myself for another minute, I surrendered. Walking with my heavy eyelids I carried with me the ECG machine and find the gentlemen again, added for him a few blood tests. Of course, as predicted, not a single clue of heart disease can be seen. Feeling stupid yet much relieved - I then carried on with my work.

Reading through the NEJM article as recommended by my teacher, it echoed a whole lot with the current situation we are facing here in Hong Kong. Medicine is now not only evidence-based as we proudly claimed, but also highly defensive and protective - not to patient but to ourselves. Many a time we order tests to fulfil our uncertainties, regardless of the pre-test probabilities or indications.

As in the old gentleman in the night, fear has overrided my clinical judgement. I would not say I was hundred percent sure to exclude heart attack, but as there exists such a tiny possibility (as it would always do) and that I could not afford to miss - it rationalised my decision.

To complicate, patient's wish also urged us to switch towards this very mode of practice. We are now in the age of consumerism, doctors no longer hold the authoritative power in patient care. Not uncommonly we encounter patients who demand extra and sometimes redundant investigations - having paid the bills, they insist they own the rights to request the best (percievingly) for their health. This phenomenon is particularly pathological among Hong Kongers, who consider personal benefits the utmost important asset to protect.

Lets not talk about the financial implication, and put aside the potential health hazards posed if we continue patient care of this kind.

What truly bothers me is the gradual loss of the art of clinical medicine. When our decisions are not guided by clinical deduction but fear, when we act not to protect our patient but overselves - what roles do we doctor serve?

Are we overdoing it? (1)

Let me share a recent story.

Well, he is a businessman in his fifties. Living with his family he enjoys quite a good past health. Only that he found himself a lingering headache for a week, together with on and off cough and occasional sneezes. Coming to the emergency department, he met a busy doctor, diagnosing him with chest infection, X-ray taken with some bloods drawn, he was then sent to our unit.

Few minutes after entering ward, nurses found him with fever. With the headache going, he was pushed down urgently at night again to AED for urgent CT brain.

Enjoyed the radiation shower, he was then transferred again back to the ward, started on intravenous antibiotics. Sputum and urine saved for bugs screening, blood taken again for further culture and investigations.

Results back, his liver function is slightly derranged. An urgent ultrasound abdomen was done the other morning, to look for possible liver abscess. Turn out - only fatty liver.

Finally his nasopharyngeal aspirate results are back - yielded Influenza A.

Then he stayed in-hospital for 5 more days, to complete his antibiotics, together with an antiviral, and finally discharged.

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He is just a regular everyday normal guy.
A middle age gentleman with fatty liver and common flu.

What have we offered him?
- Blood tests >30 items
- Needle sticks >10 times
- Chest radiograph x 3
- Nasopharyngeal aspiration x 1
- CT Brain x 1 (with radiation ~200 chest X-ray)
- Intravenous antibiotic x 1
- Antiviral x 1
- Hospitialization x 5 days
- Uncertainty, fear, worry

What did he actually need?
- A good rest
- Reassurance
- Good education for diet and exercising
- Sickleave x 2 days

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