08 July 2008

Running Scared

I sat down next to my partner -- during the day shifts we are in double- and triple-physician coverage, and we work side-by-side.  I couldn't help but notice that he was filling out a request form for a Head CT on a certain patient we all knew, who had been to the ER at least thirty times this year for chronic migraines.

"Hey," I said, "Are you scanning Andrea? What's up?"
"Oh, she's just here with another headache."
"So why are you scanning her?"
"Well, she says this is the worst headache of her life, so I need to scan her to rule out a head bleed."
"But she always says that it's the 'worst headache,' to get more drugs."
"Yeah, but what if this time she really did have a bleed?"

You notice things when you are working side-by-side with the same docs regularly. Practice styles. Who's direct and to the point. Who dithers endlessly before admitting patients. Who needs a consult for everything. Who gets frazzled when things fly out of control. Because we are usually working in parallel, in our own little worlds, there's not too much direct interaction, but you notice what people are up to.

I have noticed over the years that there seems to be a certain subset of ER docs who practice scared. They are terrified of missing something, so they work everything up to the hilt, above and beyond what is normal for an ER doc, or rationally required given the patient presentation.

Quick caveat: ER docs are by the nature of the beast, paranoid and cautious. The ER doc who has not been burned by the bizarre and unexpected is one who has not been in practice very long. So a certain modicum of over-testing and wariness is expected, necessary and praise-worthy, so long as it's guided by best practices and rational algorithms.  That's not the ER docs who I am describing here.

What I am describing are the ones who are afraid, and that fear informs their approach to patient care. The ones who go home at night and worry about the patients they sent home. The ones who obsess over extremely unlikely possibilities in situations where they are not really indicated.  The ones who over-test and over-treat all comers.   The ones who keep lists of all their patients and follow up on all of them, to make sure none died.

They are enslaved by that terrible question with no answer: What if?

I've seen this behavior in a number of ER physicians over the years. Some couldn't live with it and changed to a different specialty. Others, to my surprise, persevere despite exhibiting what seems to me to be a crippling level of professional anxiety. There is a learned skill of becoming comfortable with uncertainty that is an essential survival skill in this profession.   Some doctors never seem to develop that ability.

I trust my judgment, which is not to say that I think I am infallible (though I have been accused), but that I know what I know, I know the limits of what I know, and I know the limits of what is knowable. And I am comfortable with that.

I know that one day I will send home someone with an MI, and they will die. Hasn't happened yet, that I know of, but it's inevitable. I see about 700 patients with chest pain annually, give or take, and I've been doing this for ten years, so I've probably seen 5000 chest pain patients in my career. I can't admit them all, and to think that I can continue to do this without either making an error or getting blindsided by something unpredictable is not realistic. When it happens that I get the call from the medical director: "Hey, remember that patient you saw," I will be disappointed or worse.

But I'm not scared of it.

Part of this may come from the fact that I have made some mistakes, have already faced the consequences of my imperfections and have come to terms with it.   But that is not all of it, because I wasn't scared even when I was new, and many of our new hires are not scared either, at least not once they get over the jitters of their first "real job."

I don't know what separates the doctors who practice scared from the rest.   Maybe there's a difficulty in accepting the responsibility that comes from the life-and-death decisions we make.  Maybe there's a fear of or past trauma from the criticism that invariably follows a bad outcome.   Perhaps it's a simple fear of failure -- that the patient who does poorly is necessarily a reflection on you and your judgement, and your worth as a physician.   Curiously, most of the docs I've known like this have never been sued, but there is a constant genuflection to the altar of "I don't want to get sued."  I suspect that they use the bogeyman of malpractice as a proxy for their real fear -- the imagined consequences of making a mistake.

Some patient advocates might object that caution and diligence are good things in a physician, and if fear is the motivation, so be it.   But bear in mind that there are costs to excessive medical care, beyond the financial.   Would you want to take time off work and your personal life to be admitted to the hospital unnecessarily?   Would you want a needle stuck in your back if it was not to benefit you but to assuage the anxieties of the doctor?   CT scans use radiation which causes cancer.  And so on.   

I feel bad for these physicians.   I think they are missing out on much of the joy and satisfaction this job has to offer.  They don't seem happy.   As an employer, I worry about their career longevity, but as a partner and friend, I mostly just feel sad for them.   It's no way to live.


  1. feel bad for all the people who have to admit these patients. :)

    j/k. what a great topic. i was just pondering this the other day after another 4 am call from a nervous doc. i'm the only one in my specialty in my town so i am on call 24/7. i almost want to take my vacation only days certain docs are on. a few too many 4 am calls basically destroy the week for me. the nurses on the floor, after years of coaxing, educating, begging, have pretty much understood what can wait till morning and what can't. unfortunately some docs, not so much.

    as to your point of feeling comfortable with being able to discriminate chest pain patients, i often wonder how accurate that is. is it based on description of the pain? demographic data and family history/social history? ecg findings? are we tricking ourselves into being more comfortable than we ought to be? as you note, it is impossible to know for sure our miss rate. policy wonks might even accuse you of relying too much on your anecdotal experience and clinical judgement rather than goldman criteria or other guidelines, which supposedly are based on 'good' data. that seems to be all the rage these days. don't need to listen to patient or examine patient, just plug them into the formula and presto-you know what to do with them.

    anyhow, great great post. agree that it is no way to practice. although, when a colleague receives notice of a lawsuit, the sphincter tone goes way up for everyone for a few months.

  2. I think your comment on using the fear of malpractice as an excuse for being overly cautious is very true. I've caught myself doing that once or twice, and I've certainly seen it in my colleagues. When it involves adhering to well-established standards of care, I think it's forgivable. But when it involves unnecessary over-testing, over-admitting, and over-treating, then it becomes harmful for the patient and the health care system as a whole.

  3. Two issues:
    One is risk tolerance versus risk adversity. Those who overorder testing are risk adverse. Whether it is adverse to "missing the zebra" or adverse to facing the trial lawyers doesn't matter.
    Second thing is experience/education. Those who are comfortable with their history taking and physical examination skills are less likely to order the million dollar workups.
    If the number of tests ordered were put on a graph in the doctor's lounge, I bet that the outliers would improve.

  4. I'm reminded of the George Carlin joke: "Have you ever noticed that anybody driving slower than you is an idiot, and anyone going faster than you is a maniac?"

  5. to think that I can continue to do this without either making an error or getting blindsided by something unpredictable is not realistic. --Dr. Shadowfax

    I would add, such an event won't make you a bad doctor. If only patients understood this. The popular press has managed expectations of patients in another direction, i.e., that every poor outcome which could have been prevented by a different choice is the result of poor practice.

    Dr. WhiteCoat, interesting proposal.

    Dr. Scalpel, I always say that perspective is everything.

  6. Nurses HATE working with CYA Doctors.

  7. RR,

    Likewise, doctor hate working with nurses that discount everything.

  8. This is one of the best medical blog posts I've ever read. Thanks you for writing it.

  9. In the great "learned helplessness" environment of the ER, the theory goes that you develop behaviors to help you cope with a situation which you cannot control. I think what you are observing in your ER (and similarly in mine) is the end product... behaviors in coworkers that help them adapt to a situation they cannot influence or control. As an employer, you probably have a little more perceived control, thus your more confidence in your abilities. All the grunt (ER Doc) on the front line sees is the crush of patients in random spurts, the parade of ambulances at random intervals, the demanding entitled with nothing wrong except a bad attitude and inability to control the volume of their voice, and the stable people that turn for the worse when you least need. The grunt listens to the ranting of the consultants with the "why did you CT that appendicitis" when the last call to his partner "why didn't you CT that suspected appendicitis". And, increasingly with specialists fleeing hospitals and leaving holes in the call schedule, you end up sitting on head bleeds for hours while you phone every hospital in the state and adjoining states to try to find a bed with a neurosurgeon. The grunt has no control over the working conditions, little control over their salary and only slight control over the schedule, relying on your beneficence.
    So the grunt, in what little spare time he has, begins to ask "what if". What if I can't find a surgeon? What if I can't find a bed? What if the drug seeker destroys my Press Gainey scores and I have to get another job, or worse yet, customer satisfaction re-education. What if the patient dies here and the lawyers get to do another anal probing.

    No, shadowfax, I disagree somewhat with your premise. What you are seeing with your coworkers is not practicing scared. Your coworker with the chronic migraine is actually doing the proper algorithm for "worst headache of your life" ... CT, and LP if negative. Your coworker is just exhibiting the major side effect of learned helplessness... he is running the algorithms. He is attempting to exert control in the one area he can... There is nothing wrong and you can go home.

    I suspect that when you see the ER Docs have the same level of control over the ER as Surgeons have in the OR (like 1 to 1 nursing, an expert at the head of the bed monitoring the patient, someone to run messages etc), a lot of the behaviors disappear. Until then, we are doing crash tracheostomies with a one quarter of a nurse, a suture kit, a free 11 blade, a skin hook and a number 8 ET tube because central supply hasn't caught up yet. Oh yeah, and in the hallway because all the rooms are full. Then 3 hours on the phone to find a bed.

  10. Shadowfax specifically mentioned doctors practicing over and above:

    "So a certain modicum of over-testing and wariness is expected, necessary and praise-worthy, so long as it's guided by best practices and rational algorithms. That's not the ER docs who I am describing here."

    I think a few people missed that part based on their comments. I can attest that there were a few ER docs that would wake me up multiple times throughout the night every time I was on-call to "rule out DVT" on all sorts of people who's Wells Scores and clinical presentation did not suggest that an ultrasound was required (much less an emergency u/s at 3am). I can't speak to their practice in general, but there were several who, in vascular medicine, were cookbook docs with no clinical judgement whatsoever. I'm sure they could run a code like a mofo, but forget diagnosing vascular disease.

    I can remember a doc that I argued with about the necessity of the exam and he told me to "just do it," and then afterwards wanted to know my interpretation and said "You know more about that stuff than I do." Right; which is why you should have listened to me BEFORE -- and it's negative! I left medicine because of BS like that, and I'm SO happy to be gone.

  11. Great post Shadowfax. I've been thinking about this stuff a lot lately. I seem to fluctuate with being more/less conservative, though I don't think I'm ever as conservative as the partner you've described.

    Dan, what do you do now?

  12. We send chronic "typical" migraines to the Fast Track where they get a choice of Compazine/Benadryl, Toradol, Solumedrol and/or a prescription for a non-narcotic migraine pill.

  13. I see this bleeding into pediatrics some, too. With all of the litigation out there for things like leaving the wheel of an RV while it is moving to get some coffee, suing the manufacturer because the owner's manual doesn't say you can't leave the wheel, and winning - some people have gotten the idea that they can sue for anything and win. At times I am a little gun-shy of someone looking for a "deep pocket" and will order more testing than necessary, I don't think I could live like your colleague. At my hospital, I've seen great docs who take on tough cases get sued while the dingbats keep doing dumb things without fear of reprisal.

  14. Remember this?

    "Richard got up and walked on his own. A slow, shaky walk but he made it on his own and didn't fall. He was awfully shaky though. The Pit Bosses and the Admiral conferred for a few seconds. The head CT and labs were all cancelled. Pit Boss Jr. scribbled orders for thiamine and Td 0.5cc IM. "Looks like he passed the road test to me," Pit Boss Sr. remarked as he imitated the drop kicking of a football to indicate the ol' booting out the door time.

    "Once that bag runs in, discharge him," Pit Boss Jr. instructed, pointing the saline hanging on the pole. "Better get him out of here before he goes into DT's."

    "I don't smell any alcohol on him," I retorted.

    "Dude, he's hammered," Pit Boss Sr. disagreed and pigeon-holed me back into my status as an intern from the ho hum midwest.

    The Pit Bosses led the Admiral over to the next patient. Just that quick, a critical medical decision was made. Full circle 4 years later, I would come to regret that I had not fought harder for my patient's well being and spoken louder on his behalf...

    Just when you've build up enough experience to become confident and a little cocky, you find yourself quickly humbled. I walked out to the parking lot and ended my residency sobbing in my car."

    I miss Charity Doc.

  15. Scalpel,

    Yes, you must do the work-up from time to time. But some of our migranuers, I'm sorry to say, like the chronic kidney stoners, and chronic abdominal painers get so many CT's they nearly glow.

    30 ED visits should not result in 30 or even 10 head CTs. I think we would agree on that point.

  16. Everyone will agree not to do the CT until the visit where the CT needs to be done. Figuring that out is why we get the "big" bucks. You will never be rewarded for the money and radiation saved, but will be penalized for the one CT you didn't do. You may call this running scared, but as I suggested above (rather poorly perhaps) that the behaviors are a product of what your coworker has learned. Not necessarily fear.

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  18. Anon,

    Strangely enough I'm an analyst for a Fortune 50 global manufacturing company. I love it: no clock punching and my work is self-directed (the best thing after being ordered around for years). I come up with all kinds of crazy ideas and get to try them out, it's awesome.

  19. I'm just playing devil's advocate, but multiple recurring ER visits for the same problem can also be a sign that something is being missed.

    The paraspinal abscess in the chronic back painer who is out of his meds. The subdural hematoma in the chronic headache patient. It's better to be the one to diagnose them correctly than to be the one who sent them home last visit with a handful of vicodin.

    Have you ever gotten any kudos from an administrator for ordering fewer CT scans than your colleagues or for saving the hospital some money? Or a thank-you note from a patient because you didn't order a CT scan? I sure haven't.

    Have you seen any studies or textbooks suggest that it's OK to skimp on the workup for "worst headache ever" simply because the patient has several visits for headache?

  20. Scalpel,

    But you also know there are definite and measurable downsides to medical tests and interventions. I remember a case from residency where a headache that was really "borderline" got a CT/LP, the tap was traumatic, and got admitted as a presumed SAH. The patient had a three-vessel angio, which showed no vascular lesion, but the patient did suffer a stroke as a consequence of the angio.

    Not common -- but then neither is the unsuspected new brain tumor in the migraineur.

    Every medical intervention has its risks -- whether it's radiation from the CT, to hospital-acquired infections, to false positives, to actual iatrogenic injuries. Which isn't to say you should blow stuff off, but that you need to apply judgment and a rational approach to selective intervention. To be indiscriminate in the approach may seem safer to the physician, but is not a responsible use of limited resources, nor is it in the best interest of the patient.

    But to return to the more central point here, I was not describing the conservative vs minimalist docs, which is a legitimate debate, but a different and distinct subspecies who are beyond the 2-standard-deviations in terms of practice style.

  21. Your colleague may be reacting to an environment where her every judgment is subject to public scrutiny on the Internet.

  22. Anonymous said...

    "Your colleague may be reacting to an environment where her every judgment is subject to public scrutiny on the Internet."

    Well, that is the cure to defensive medicine. No more medical blogs. Genius. :-)

    Excellent post that brings the discussion to places it usually does not go.

  23. Maybe what we need is to penalize doctors for ordering unnecessary tests. One defense of defensive medicine is that it is the path of least resistance. Why not decrease, or eliminate, the incentive to just test for everything?

  24. Everyone whom has ever had a headache in their life has had a "worst headache of their life" so getting a CT scan because this one happens to be the worst headache is the most lame ass excuse I've ever heard.

    This idea that ordering every test in the book is somehow going to protect you from lawsuits is insane. What protects you from lawsuits is correctly diagnosing and treating the patient. If a doctor is unable to correctly diagnose a patient without ordering every test in the book they have no skills and shouldn't be practicing medicine.

    If someone is unable to differentiate between a simple migraine headache in a patient with well documented migraines and a head bleed in a patient then they have no business practicing emergency medicine.

    In the ER where I work we had a patient that used to come in probably 2 or 3 times a month for migraines for 5 years. They were always the "worst headache of her life." She rarely got CT's unless one of the bonehead doc's got her. Once one of our nonboneheads was looking after her and after her usual dose of narcs she didn't improve and he thought she didn't seem her usual self. He ordered a CT and yes, she had a bleed. But he based his decision to order the CT on his clinical observation and instincts, not on some reflex reaction to "worst headache of my life."

    I notice in my ED when we have over orderers on the waits are longer than when we have the docs who rely on their own instinct and skills.

    In the Portland area, we now have frequent 2 and 3 hour waits in the lobby for an ER bed. If the docs order every test on every patient that comes in the room those waits increase. That is increasing the risk for those patients waiting in the lobby. The docs need to take responsibility for the flow of the entire ED.

    Those patients waiting for 3 hours in the lobby while the simple migraine patient gets their 5th CT scan are also a lawsuit or a missed diagnosis waiting to happen.


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