February 10, 2011

The Lazy Doc Orders the CT?

I jump into the mix by commenting on the great Dr. Centor's blog post about why emergency docs order too many CTs... because we're too lazy to talk to our patients.

Basic timeline:

1) A bunch of current (and former) SLR docs publish a great study that shows that their department orders more CTs now than they did before.

2) Dr. Centor calls us lazy.

3) Many, including GW at TCL  and GruntDoc (comment on the original), rebut.

4) Dr. Centor rerebuts, correct some, but not all, of his editorial mistakes.

5) One of my favorite Canadians forwards me GW's TCL post; I read instead of doing real, actual work.

6) I post the following comment (currently awaiting moderation) on Centor's original post:
The idea that ordering a CT saves time versus a detailed H&P underscores the mistaken assumptions made by non-emergency physicians about how we care for our patients. Any emergency physician worth her salt knows understands that obviating a CT scan by adding an extra 20-30 minutes interviewing and examining a patient saves much more time & work than simply ordering a scan.
Patients who wait for CT scans take up much more time and many more resources than those who don't. If we can discharge a patient clinically (maybe because of a low Centor score) than they free up all of those resources (e.g. nursing). This is essentially the same reasons why we love to admit those pesky low-risk chest pain patients BEFORE the first troponin comes back — boarding is bad for our patients.
 7) I repost that here, doubling the number of posts at my nascient blog (potentially inflating my stats artificially with a self-referencing link).

8) PAndrus corrects my typo.


Other points:

Dr. Centor came up with a clinical decision rule to (over) treat largely innocuous infections with a positive predictive value <60% at the TOP of his scale (all 4 points) and now advocates treating strep so as to avoid The Lemierre Syndrome, concluding:
We therefore suggest that adolescents and young adults who present with worsening pharyngitis and clinical suggestions of bacteremia need hospitalization and empiric antibiotic therapy with either a penicillin/metronidazole combination or clindamycin. While we cannot prove that this aggressive management will prevent the development of Lemierre syndrome, this approach seems prudent given the potential severity of F. necrophorum infections. (3)
Furthermore, in my anecdotal and biased sample of patients that I review clinic notes or follow up on as inpatients, we lowly emergentologists are not at all alone in our imagophilia.

-nst



Updates:

1) Shadowfax has the best commentary I've seen on this
2) my response to Centor's response at TCL