One of the EM:RAP listener favorites returns this month..Bouncebacks with Mike Weinstock. Patient satisfaction is the topic of this conversation recorded at the LAC+USC DEM grand rounds.
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I agree 100% with Mel's summation about how things actually happen in the real World.
Dr. Hoffman is to be commended for not doing the CT scan in the girl that obviously did not need it. But his take on the EMD who ordered the CTPA on the syncope patient is just ridiculous. As far as I can tell, there was not enough information in the chart to determine if CTPA was warranted, but there certainly was not enough to say it wasn't. Further, unless you are on a mission to rid the World of particularly terrible physicians, the notion that Dr. Hoffman actually does testify against Emergency Physicians is, IMO, just as pathetic as can be imagined. In the case at hand, he is in no position whatsoever to say that ordering the CTPA that was ordered was terrible medicine. In fact, I know for a fact that just on the information given, many fine, experienced emergency physicians would have done the same. In fact, I know for a fact that in my 16 years of practice, I have caught at least two central PE's in very similar scenarios.
Dr. Hoffman is, indeed, to be commended. The needless stress of a demanding, impatient, arrogant family member who seeks to intimitdate and strongarm the medical evaluation and disposition is exhausting. The stress of caring for the ill and injured is, by comparison, pretty relaxing, empowering and challenging.
Jerry Hoffman gives me the strength to go on, feeling that I'm a reasonable, well-informed, and valuable practitioner--regardless of the vagaries of patient satisfaction.
Jerry is 100% right on both cases. For case 1 I would have monitored the patient on telemetry, but not done a CTPA if he was asymptomatic. I work a lot in Africa where I cannot get a CTPA or a million other tests. I can admit to hospital patients I'm not sure about. It's so reassuring just to see a sick child or adult the next morning, and those extra data points and reassessments are golden. Obviously, we cannot admit everyone but my point is we can hand-over patients and re-assess them. As Jerry and Mel I believe have said - sick patients are sick (with rare exceptions). VIPs - also - I believe can tell the difference between a doting, fearful MD and someone who is honest and realistic.
Agree with Dr. Hoffman. However, in his characteristic quirky way, Mel speaks the absolute truth here. Outside of the ivory tower, there are small group of factors that make or brake one's career: 1) Pt sat scores 2) productivity goals 3) liability avoidance. Each of these factors contributes to over-testing in its own way. The individual physician while trying his/her best to care for the patient CANNOT avoid caring for his/her own family, children, spouse. This means protecting his/her career and it means taking those 3 factors into consideration. The conflict will indeed wear one down eventually.
Jerry speaks as a typical academic clinician. Their world is very black and white. He uses the term "never" and "always" frequently. Even my little niece who has barely finished elementary school is aware that using these terms is almost invariably folly. Yet in med school and residency we are frequently taught in this fashion. Knowing first hand that he does testify against ER physicians and does not adhere to ACEP regulations for expert testimony (ie one should not advocate for either side, simply present medical fact) I have come to be less enamored of the man. He has contributed immensely to our practice and obviously has a tremendous amount of knowledge and wisdom that he passes on. For this I thank him. For contributing to the insanity that is our medical malpractice system I do not. If we lived in a world where missing a one in a million case would be nothing to fear, his take would be spot on. Unfortunately we do not, and Docs like him that testify against their own kind are a big reason that we don't.
Interesting conversation. I'm liking this Hoffman guy. He expressed all my thoughts on the proper evaluation and disposition of the case patient, with clarity. Just for the record Dr Weinstock, a bat in the room is a sick bat. For several reasons, that patient would have earned rabies PEP. Bats are a special case.
Yeah Dr Hoffman!!! Id comment on the syncope pt though: as one report was he stood up and passed out and other was passed out in chair, I would have "double asked". Id have felt better about a DC if it was a for sure "stood up too fast" had some positive otrho stats to go with it. Anyway, I love listening, I feel like Im in the stream and you guys remind me why we do what we do! Thanks
any medical legal conversation should start with a definition of standard of care. almost every time people start throwing around the term they are confusing best care with standard of care. Standard of care is what would a similarly trained doctor do. People need to stop using the terms interchangeably. Jerry's thoughts are typical ivory tower nonsense. totally agree with Sean Gs comments. There is nothing black and white about ordering the ct. To look backwards on a case and act as if the right answer is so clear and that your judgment is so clear is just delusional or you're a liar. That kind of rigid and self serving hindsite is the root cause of the medical legal problem, as not every expert witness has bad intentions...some just have bad thinking or bad egos.
Just as I won't tolerate poor medicine for patients, I will not vilify anyone doctor for testifying against another doctor to prevent poor care. We are here for the patients, not for creating a Mafioso style of omerta doctoring. And yes, I've been sued. I've also seen doctors that should be discouraged from practicing. we're not seeing the chart.
I have to take issue with Dr Hoffman regarding his strong stance against the CTPA. I may not have ordered it- I can't be sure as I'm not seeing the whole picture. I probably would have anticoagulated for the possibilty of a cardiac arrhythmic cause and admitted to patient. But as we are all well aware, ER textbooks worldwide list PE as a cause of syncope. You can be sure these texts would be paraded out there in a court of law if the patient had had a PE and a bad outcome. It's hard to believe that the legal liability to the ER physician would have been worse or equivalent if there had been an adverse outcome from the anticoagulation for the false positive CTPA reading vs. missing a PE in the first place with an adverse outcome.
Now that the weightier matters have been thoroughly discussed: I enjoyed the brief, but revealing discussion of energy-drink contents. My favorite is the "Lo-Carb" Rockstar. It's especially nice on the rocks with a splash of vodka ... aka "SVT on the Beach."
After 11 years of practice, first in the US, then Australia, the Middle East and Europe, I am back in the US and I am freaking out ! Why...? In my international practice I sent home MANY patients who in my heart of hearts didn't have anything serious. None of them dropped death, and I know because in some of those places we were the referral center, so if something catastrophic happened I would have known. Now, I want to do the same here and people look at me as if I had 3 heads! WE are doing this to our selves. We are hostage of our own fears and insecurities, all fired up by the parasitic ghost of the medmal lawyers. Let's stop this madness, let's do what is right for our patients and fight for the so much needed reforms this country is craving for. The lawyer have had a looooong boogie night and become a blood sucking giant tick anchored right on the collective behind of the tax payers. Enough is enough !
what type of wound warrants rabies pep. I had a case of a stray dog that bite a woman thru her clothing and caused some bruising but no real deep tissue penetration .
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Episode 131Full episode audio for MD edition239:08 min - 101 MB - M4AEM:RAP August 2012 Written Summmary617 KB - PDFC3 Project Written Summary August 20122 MB - PDF
Kevin M. - August 2, 2012 7:18 AM
Great conversation. I have a couple of comments.
I agree 100% with Mel's summation about how things actually happen in the real World.
Dr. Hoffman is to be commended for not doing the CT scan in the girl that obviously did not need it. But his take on the EMD who ordered the CTPA on the syncope patient is just ridiculous. As far as I can tell, there was not enough information in the chart to determine if CTPA was warranted, but there certainly was not enough to say it wasn't. Further, unless you are on a mission to rid the World of particularly terrible physicians, the notion that Dr. Hoffman actually does testify against Emergency Physicians is, IMO, just as pathetic as can be imagined. In the case at hand, he is in no position whatsoever to say that ordering the CTPA that was ordered was terrible medicine. In fact, I know for a fact that just on the information given, many fine, experienced emergency physicians would have done the same. In fact, I know for a fact that in my 16 years of practice, I have caught at least two central PE's in very similar scenarios.
David L., M.D. - August 2, 2012 1:45 PM
Dr. Hoffman is, indeed, to be commended. The needless stress of a demanding, impatient, arrogant family member who seeks to intimitdate and strongarm the medical evaluation and disposition is exhausting. The stress of caring for the ill and injured is, by comparison, pretty relaxing, empowering and challenging.
Jerry Hoffman gives me the strength to go on, feeling that I'm a reasonable, well-informed, and valuable practitioner--regardless of the vagaries of patient satisfaction.
Raghu V. - August 13, 2012 3:34 PM
Jerry is 100% right on both cases. For case 1 I would have monitored the patient on telemetry, but not done a CTPA if he was asymptomatic. I work a lot in Africa where I cannot get a CTPA or a million other tests. I can admit to hospital patients I'm not sure about. It's so reassuring just to see a sick child or adult the next morning, and those extra data points and reassessments are golden. Obviously, we cannot admit everyone but my point is we can hand-over patients and re-assess them. As Jerry and Mel I believe have said - sick patients are sick (with rare exceptions). VIPs - also - I believe can tell the difference between a doting, fearful MD and someone who is honest and realistic.
mark g. - August 17, 2012 10:45 AM
Agree with Dr. Hoffman. However, in his characteristic quirky way, Mel speaks the absolute truth here. Outside of the ivory tower, there are small group of factors that make or brake one's career: 1) Pt sat scores 2) productivity goals 3) liability avoidance.
Each of these factors contributes to over-testing in its own way. The individual physician while trying his/her best to care for the patient CANNOT avoid caring for his/her own family, children, spouse. This means protecting his/her career and it means taking those 3 factors into consideration. The conflict will indeed wear one down eventually.
Sean G., M.D. - August 22, 2012 1:11 AM
Jerry speaks as a typical academic clinician. Their world is very black and white. He uses the term "never" and "always" frequently. Even my little niece who has barely finished elementary school is aware that using these terms is almost invariably folly. Yet in med school and residency we are frequently taught in this fashion. Knowing first hand that he does testify against ER physicians and does not adhere to ACEP regulations for expert testimony (ie one should not advocate for either side, simply present medical fact) I have come to be less enamored of the man. He has contributed immensely to our practice and obviously has a tremendous amount of knowledge and wisdom that he passes on. For this I thank him. For contributing to the insanity that is our medical malpractice system I do not. If we lived in a world where missing a one in a million case would be nothing to fear, his take would be spot on. Unfortunately we do not, and Docs like him that testify against their own kind are a big reason that we don't.
Kevin M. - August 24, 2012 8:15 PM
Great comments Sean G.
Patrick S., M.D. - August 27, 2012 6:10 AM
Interesting conversation. I'm liking this Hoffman guy. He expressed all my thoughts on the proper evaluation and disposition of the case patient, with clarity. Just for the record Dr Weinstock, a bat in the room is a sick bat. For several reasons, that patient would have earned rabies PEP. Bats are a special case.
Chris B. - August 29, 2012 2:21 AM
I highly agree with Sean G., well said.
Jane D., PA-C - September 5, 2012 5:39 AM
Yeah Dr Hoffman!!!
Id comment on the syncope pt though: as one report was he stood up and passed out and other was passed out in chair, I would have "double asked". Id have felt better about a DC if it was a for sure "stood up too fast" had some positive otrho stats to go with it.
Anyway, I love listening, I feel like Im in the stream and you guys remind me why we do what we do! Thanks
Kenneth K. - October 1, 2012 5:22 AM
any medical legal conversation should start with a definition of standard of care. almost every time people start throwing around the term they are confusing best care with standard of care. Standard of care is what would a similarly trained doctor do. People need to stop using the terms interchangeably. Jerry's thoughts are typical ivory tower nonsense. totally agree with Sean Gs comments. There is nothing black and white about ordering the ct. To look backwards on a case and act as if the right answer is so clear and that your judgment is so clear is just delusional or you're a liar. That kind of rigid and self serving hindsite is the root cause of the medical legal problem, as not every expert witness has bad intentions...some just have bad thinking or bad egos.
Helen R. - October 13, 2012 12:45 PM
Just as I won't tolerate poor medicine for patients, I will not vilify anyone doctor for testifying against another doctor to prevent poor care. We are here for the patients, not for creating a Mafioso style of omerta doctoring. And yes, I've been sued. I've also seen doctors that should be discouraged from practicing.
we're not seeing the chart.
Jonathan G. - December 25, 2012 8:11 PM
I have to take issue with Dr Hoffman regarding his strong stance against the CTPA. I may not have ordered it- I can't be sure as I'm not seeing the whole picture. I probably would have anticoagulated for the possibilty of a cardiac arrhythmic cause and admitted to patient.
But as we are all well aware, ER textbooks worldwide list PE as a cause of syncope.
You can be sure these texts would be paraded out there in a court of law if the patient had had a PE and a bad outcome.
It's hard to believe that the legal liability to the ER physician would have been worse or equivalent if there had been an adverse outcome from the anticoagulation for the false positive CTPA reading vs. missing a PE in the first place with an adverse outcome.
John J., P.A. - December 28, 2012 3:30 AM
Now that the weightier matters have been thoroughly discussed: I enjoyed the brief, but revealing discussion of energy-drink contents. My favorite is the "Lo-Carb" Rockstar. It's especially nice on the rocks with a splash of vodka ... aka "SVT on the Beach."
Adan A. - January 24, 2013 10:50 PM
After 11 years of practice, first in the US, then Australia, the Middle East and Europe, I am back in the US and I am freaking out ! Why...? In my international practice I sent home MANY patients who in my heart of hearts didn't have anything serious. None of them dropped death, and I know because in some of those places we were the referral center, so if something catastrophic happened I would have known. Now, I want to do the same here and people look at me as if I had 3 heads! WE are doing this to our selves. We are hostage of our own fears and insecurities, all fired up by the parasitic ghost of the medmal lawyers. Let's stop this madness, let's do what is right for our patients and fight for the so much needed reforms this country is craving for. The lawyer have had a looooong boogie night and become a blood sucking giant tick anchored right on the collective behind of the tax payers. Enough is enough !
DOUG S. - March 14, 2013 4:53 PM
So ultimately the guy didn't have a PE... What did he have?
Did he close the 50 gazillion dollar deal?
Is he still walking / talking - has he reached any morbidity / mortality endpoint?
christopher e. - December 20, 2016 4:08 PM
what type of wound warrants rabies pep. I had a case of a stray dog that bite a woman thru her clothing and caused some bruising but no real deep tissue penetration .