Objective Findings = Alternative Findings for Expediency?

[jmj11]

This is somewhat of an opinion question, something I've been thinking about. As we are under more and more pressure to see patients faster and faster, do you think providers make up physical findings to take them to a quick diagnosis and treatment plan to get them out of the office?

 

Case in point. I saw a twenty eight year old lady back yesterday. She has been complaining of bilateral ear pain and headches. On the original visit, a month ago, she had been seen in the ER the previous night. The PA who saw her told her she had "red, swollen eardrums with a lot of fluid behind them." Those were her words, but the diagnosis in the record was OM.  When I examined her the next morning, she had easily visible TMs. They were perfect, no erythema  at all, no fluid behind them. When I gave her my opinion, that her ears were normal on the exam, she (understandable) was a little confused.

 

Because the pain has persisted she went to the ER again the night before my return visit (yesterday) and saw an ER physician. She told the patient that "You still have fluid and remaining infection behind your ear drums so I've giving you another round of antibiotics." The ER physician also got a head CT (because the patient was complaining of a generalized headache, the reason she is seeing me). She was told that "the CT was normal but still the ER physician though she saw a sinus infection causing her headaches."

 

So, I see her yesterday and the TMs are again perfect. No fluid, no retraction, no erythemia. I reviewed the head CT and the sinuses look perfect as well. Some people have some chronic thickening but she had perfect sinuses.  

 

When I explain this to her and her mother, and that her ear pain and headaches are probably more complicated than a simple infection, I don't think they believe me anymore. She does have an appointment with ENT, who I trust will agree with me.

 

So, this leads me to ask, do you think it is common practice by some tired, over-worked providers to "see" the simple to the problem they want to see for a quick and dirty diagnosis.

[sk732]

I remember an EM teacher in school telling us that there is a trap many fall into of  "the ear drums of screaming kids are always redder at 3 am".  I've caught myself on more than one occasion of pre-judging/diagnosing something based on triage notes and talking to the nurse and going and getting a history and exam that contradict everything I read and was told.  I've also seen bounce backs where I've had to bite my tongue and not blurt out "WTF were these people thinking?" when I see a history/exam/diagnosis mismatch.   I think that these days, especially with the "quality" metric being door to provider to door vs getting things right the first time, people will take the path of least resistance and go with the approaches of "common things happen commonly" coupled with the "I hear and see what I want to hear and see" (this isn't just a patient problem) and run with it. 

 

Having said all that, my long time SP in family med used to remind me that "the last doctor that sees someone is the one that has the right diagnosis"...since everyone before has had their opinion and it was wrong or they saw the person too early in the illness (something that NEVER happens in North America with our " everything must be fixed now"  attitude coupled with First World wussiness [insert eye rolling emoji]) to appreciate the full extent of what was going on.  Personally, I try to take the extra couple minutes to get it right the first time instead of causing a bounce back, which is a more reliable measure of actual "quality" care than door to doc to door times IMNSHO.

 

SK

[DizzyJ]

Yes! I see this often and generally to make a case of unneeded antibiotic treatment.  They want patient satisfaction and to avoid the hassle of needing to explain why antibiotics are not necessary.  With the patient you present here, did she even need an emergent CT scan in the ER or was the provider making her feel like they went above and beyond to see what was going on?  

[jmj11]

Yes! I see this often and generally to make a case of unneeded antibiotic treatment.  They want patient satisfaction and to avoid the hassle of needing to explain why antibiotics are not necessary.  With the patient you present here, did she even need an emergent CT scan in the ER or was the provider making her feel like they went above and beyond to see what was going on?  

She did not need an emergent CT. The ER doctor was thinking sinus, but got a full head CT with an indication of new headache (nothing notable such as thunderclap etc.) to also look at her sinuses.

[MedicinePower]

OM is rarely bacterial.

Fluid behind the TM is fluid behind the TM. It's more important to decongest than throw abx at it.

[GetMeOuttaThisMess]

I love eustachian tube dysfunction in adults. It's a great diagnosis for otalgia and can be source for many complaints. They always track down the mandibular arch with their index finger. How about mucosal membrane inflammation in sinus(es) as source for cephalgia? Even if fluid seen in sinuses it has no significance in differentiating bacterial/viral, especially considering <4% are bacterial.

[d2305]

I've seen a few with no objective ENT findings, and told them that I didn't know why their ears hurt. They were all women I think. 

[sk732]

I love eustachian tube dysfunction in adults. It's a great diagnosis for otalgia and can be source for many complaints. They always track down the mandibular arch with their index finger. How about mucosal membrane inflammation in sinus(es) as source for cephalgia? Even if fluid seen in sinuses it has no significance in differentiating bacterial/viral, especially considering <4% are bacterial.

 

I used to see a lot of ETD and resultant barotrauma when doing diving medicine in the military...had some cool pics on the clinic computer too, since I had a digital otoscope :-D.

 

SK

[GetMeOuttaThisMess]

ETD may present with frank distention of TM, or what I call the "under inflated car tire" look (inferior wall of TM is only section bulging.  Common condition which can be associated with positional dizziness (not vertigo).

[ventana]

I swear the ER mantra sometimes is "it is better to do something instead of do nothing"

 

Seriously, had an attending tell me after a pateint waiited 8 hours to be seen for a cold - "they deserve augmentin" with a normal exam.  I was younger in my career and just shook my head - now I think I would challenge them on this conclusion.

 

I personally went to the ER after "throwing my back out" (chronic problem that comes up every once in a while (thanks USAF).  I know that I need a vicodin and flexeril and a few good nights sleep.....  Freeking ADVANCED PRACTICE PROVIDER whom I helped train - does a SH%$Y exam, then orders IV valium and dilaudid - nurse comes in appologetic (and I rapidly turn her away and DEMAND PO MEDS of lesser strength)  provider comes in saying "that wont work but fine...."  30min later walking out (al be it gingerly and with caution (wanting to flip him off on the way by))  My point - he had previously told me this is the way he "clears the house" and I have patients complain that he did nothing but drug them (litteraly conscious sedation) and D/C

I have seen ER doc's and providers give Z-pak for obvious colds, perc #30 for sprained ankle and the list goes on and on

 

I have worked in the ER and the pressure to keep up is HUGE and you do your best

 

I think this is sometimes where we create our own problem.  If last time your cold got augmentin, well this time you have to go sit in the ER for another 8 hours and get another script cause your PCP told you it was just a cold...

 

 

 

The URI and simple common complaints I truly think are OVER managed in the ER - tests and drugs to move people through as fast with least resistance as possible.  

 

 

instead of explaining that there was no air fluid level on CT - and then having to defend the position, and having a possibly annoyed patient - easier to say here is your ABX

 

 

 

 

 

Yup one of the reasons I left EM - if i ever return it will be at my pace and I will practice as I see fit - including no drugs for addicts, and no ABX for colds......

[sk732]

ETD may present with frank distention of TM, or what I call the "under inflated car tire" look (inferior wall of TM is only section bulging.  Common condition which can be associated with positional dizziness (not vertigo).

 

Sometimes you get a vacuum effect causing the TM to get sucked into the middle ear as well...causes that hickey effect on it.

 

 

I swear the ER mantra sometimes is "it is better to do something instead of do nothing"

 

Seriously, had an attending tell me after a pateint waiited 8 hours to be seen for a cold - "they deserve augmentin" with a normal exam.  I was younger in my career and just shook my head - now I think I would challenge them on this conclusion.

 

 

I had a patient look at me and get upset that he had to wait for 6 hours to get told they had a cold...this after they took someone's amoxil.  I looked at him and gave him a Neil Med Rinse sample for his troubles...and then told him his friend broke the law by his unlicensed friend giving him a prescription drug. 

 

Sometimes I like to fan the flames a bit...and I always do that with controlled substances, but another story for another day.

 

SK

[ventana]

 

 

I had a patient look at me and get upset that he had to wait for 6 hours to get told they had a cold...this after they took someone's amoxil.  I looked at him and gave him a Neil Med Rinse sample for his troubles...and then told him his friend broke the law by his unlicensed friend giving him a prescription drug. 

 

Sometimes I like to fan the flames a bit...and I always do that with controlled substances, but another story for another day.

 

SK

 

 

We need more of you !!  strong work!!

[BruceBanner]

Yes I think it happens, and more often than anyone would admit.

 

Sometimes I'l be reading someone's chart and think "how the hell did you not see what I was seeing?"

 

I think there is a temptation when we are overworked to latch on to the easiest diagnosis in the differential. A little confirmation bias.

 

We are not given the time to really delve into someone's symptoms the way they want or even the way we should. To be totally honest, I think maybe 30-40% of the time most providers do NOT have a definitive answer as to what's causing someone's symptoms. A differential, sure, but you have to get people in and out of the room. No one likes to hear "i dont know". So for something not acute or life-threatening, a common diagnosis is just given. I see docs doing this ALL the time. I do it too. Nebulous ear pain with a normal exam? ETD. Cough with no cold sx and normal CXR? post-nasal drip. Patchy dry skin rash? Eczema.

 

Contributing to this is the job-threatening negative feedback you can get from patients because you weren't nice enough or didn't cure them immediately.

[DogLovingPA]

Agree with everything Ventana said.  Similar mindset in UC.  Patient waits 3 hours, pays $75 co pay..... they want SOMETHING.  I try very very very hard to find the battle of over prescribing abx, but some days you lose.  And as you mentioned, if other providers are giving abx on day #1, the patients come to expect it.  It is very frustrating. 

 

As for JMJ11's original question - I absolutely think overworked, stressed out providers who are being pushed to "move the meat" may sometimes fudge exam findings (whether intentional or subconsciously).  I particularly find this in kids and ears.....  so much easier to just say that screaming febrile kid has an ear infection because the TM is a little pink.  I once saw an infant that had been seen in the ER a few hrs earlier for a fever and diagnosed with OM.  On my exam, the TM is minimally pink.  (the only reason I saw the kid after they had been seen is I saw big brother who tested positive for flu and the mom wanted the younger sibling seen again for possible flu).   I think you have to constantly remind yourself not to move too fast just because people are waiting and give each pt the full attention they deserve. 

[Boatswain2PA]

Two other related issue that haven't been discussed.

First - EDs (especially corporate run EDs) are pushed by suits who want METRICS and MONEY rather than good patient care.  A primary metric they beat providers over the head with is patient satisfaction scores.  Since patients want both an absolute diagnosis AND a prescription for something...that's what they will get.  Furthermore, the more testing and treatment given in the ED, the more money, that could explain the head CT.  (plus, she was a bounceback headache to the ED...I would've scanned her at that point as well).

 

Second - things change, and sometimes rapidly.  Example:  Very remote ED, toddler brought in by mom with painful scrotal mass first noticed on diaper change few hours ago, now much bigger and painful.  Exam shows obvious large scrotal hernia.  Try to reduce but I get nothing but a very cranky kid.  Order labs and IV morphine so I can try it again, then go call surgeon.  Plan was to ship kid by POV to tertiary care.  Peds surgeon wants me to FLY him!  Err...okay...guess I'll fly him.  Go back to attempt reduction and.....it has reduced all by itself.  By that time flight crew is already in house....so I fly a kid with a reduced (but large) scrotal hernia to tertiary care.  

 

And lastly...EM operates in an environment of unknowns.  We (usually) don't know the patients, our ability to look at previous medical records is often limited, and they have self-selected themselves to come to the ED instead of waiting to go to clinic.