Is It Any Wonder Many Physicians Think We Are Idiots?

[lkth487]

On 9/25/2018 at 3:17 PM, JMPA said:

try explaining to a jury why you failed to do an x-ray (minimal radiation exposure) and missed lithesis, cancer, fracture ect.

Well, what if every cold in a kid is caused by immunodeficiency secondary to congenital HIV or cancer?  You can't practice medicine this way or everyone would get a full body MRI.  There are guidelines and recommendations based on good science for many things (for many others - there are not, but thats the reason we go through all of this training....otherwise you could be done training in a month).

 

It is very rare that people get sued and lose for following something that is bread and butter standard of care (as long as you have good documentation).

[Hope2PA]

NP and PA's not exclusive to stupid comments or referrals.  Patient brought to ER by ambulance following auto accident with head injury visible on forehead, bilateral upper extremity paresthesia and weakness. ER doc, not Em med trained, but working as the ER physician, said something along lines of "not sure what the problem is with the numbness and tingling of arms, get a head CT because of obvious trauma.  Later added cervical and referred to neuro, but only after it was suggested, gently, by another provider.

Anyone can be stupid, lazy, what ever you want to call it.

[EMSGuy1982]

Pretty sure it was last month on UrgentCare RAP where they covered a case of a 60+ guy with lower back pain. Given muscle relaxers. Got worse. Went to ED and subsequently got admitted.(forget why. Perhaps INR. Pt was on anticoagulant). Hospitalist sees him and pt gets worse. End of the story, spontaneous retroperitoneal hemmorage.  3 providers missed. Anything can happen folks. 

Age 60+ With anticoagulation + back pain. Keep that differential wide open 

[EMSGuy1982]

Also, I believe the recommendation is 6 weeks before imaging for non traumatic back pain. I’ll do a prednisone taper on folks with chronic lower back pain that are already on a boat load of narcotics + gabapentin ect ect. 

[Reality Check 2]

I wouldn’t have imaged the patient in the original post at first visit with obvious mechanism. 

I would have suggested PT for modalities, core exercise and body mechanics for injury prevention.

NSAIDs if not HTN, muscle relaxant, ice, etc.

Neurosurgery/Ortho Spine if foot drop or acute neuro changes but our specialists want films with flexion/extension and MRI before they will even schedule. Drives me nuts. 

Private insurance won’t ok MRI until 6 weeks AND PT. The VA will do whatever I order. 

Bad form, lazy, patient could have been a lawyer..... lots to speculate

[ravenspac]

22 hours ago, cbrsmurf said:

Why chiro?

 

Why prednisone?  

Cuz Advil isn't going to cut it for most people coming in and I have a strict no narc policy.  and our local spine surgeons actually like the chiro...if it's good enough for them it's good enough for me. Everyone they don't open on is taking money out their pocket 

[Guest JMPA]

On 9/25/2018 at 3:23 PM, sas5814 said:

The "try explaining it to a jury" argument is a bit of cognitive dissonance that gets trotted out all too frequently. That argument holds for any and every patient you see for any and every problem. Any visit can have some zebra hiding out that has bad implications and "why didn't it get caught at the first visit." Why not do every test imaginable for every possible diagnosis at every visit so you don't have to explain anything to a jury? Because we have standards and recommendations based on good science. I am very cautious but never fearful.

dont chop my comment up, keep it whole, "for not doing an x-ray", the point was not to be scared to image for a complaint that has indication, x-rays are by far the best initial imaging for low back pain period, you do your patient injustice for failure to consider their complaints seriously

[Guest JMPA]

On 9/26/2018 at 4:21 PM, lkth487 said:

Well, what if every cold in a kid is caused by immunodeficiency secondary to congenital HIV or cancer?  You can't practice medicine this way or everyone would get a full body MRI.  There are guidelines and recommendations based on good science for many things (for many others - there are not, but thats the reason we go through all of this training....otherwise you could be done training in a month).

 

It is very rare that people get sued and lose for following something that is bread and butter standard of care (as long as you have good documentation).

why not just ignore every complaint until it comes back to sue you, oh because you would not have a license any more

Bread and butter of low back pain is to have x-rays, it is the initial study of choice and standard of care learned first day of medical training

[beattie228]

17 minutes ago, JMPA said:

why not just ignore every complaint until it comes back to sue you, oh because you would not have a license any more

Bread and butter of low back pain is to have x-rays, it is the initial study of choice and standard of care learned first day of medical training

The majority of patients with low back pain of less than four weeks duration do not require imaging. Most patients who present to primary care settings will have nonspecific pain without associated symptoms and will improve rapidly.

1. Chou R, Qaseem A, Snow V, et al. Diagnosis and treatment of low back pain: a joint clinical practice guideline from the American College of Physicians and the American Pain Society. Ann Intern Med 2007; 147:478.

X-rays for all low back pain is not bread and butter. The above is directly from Up-To-Date, which comes from a terrific paper that I'd recommend you check out.

[thinkertdm]

31 minutes ago, beattie228 said:

The majority of patients with low back pain of less than four weeks duration do not require imaging. Most patients who present to primary care settings will have nonspecific pain without associated symptoms and will improve rapidly.

1. Chou R, Qaseem A, Snow V, et al. Diagnosis and treatment of low back pain: a joint clinical practice guideline from the American College of Physicians and the American Pain Society. Ann Intern Med 2007; 147:478.

X-rays for all low back pain is not bread and butter. The above is directly from Up-To-Date, which comes from a terrific paper that I'd recommend you check out.

Absolutely.  The patients think they NEED x-rays, even MRIs, and ordering them may get them out of your office faster, but really do nothing aside from give the patients a false sense of a terrible terrible disease like "arthritis" or "stenosis" or something like that, things we look at and basically ignore, but to an obese, out of shape 50 yo, he gets to constantly. bring. it. up. at. every. appointment, like a badge of honor.

Of course, they are easy to get, so if in doubt, get a picture.  Just be sure it's the right test for what you are looking for.  X-rays don't show discs.  Sometimes I run 'em through twice.

[LT_Oneal_PAC]

18 minutes ago, JMPA said:

 

1 hour ago, beattie228 said:

The majority of patients with low back pain of less than four weeks duration do not require imaging. Most patients who present to primary care settings will have nonspecific pain without associated symptoms and will improve rapidly.

1. Chou R, Qaseem A, Snow V, et al. Diagnosis and treatment of low back pain: a joint clinical practice guideline from the American College of Physicians and the American Pain Society. Ann Intern Med 2007; 147:478.

X-rays for all low back pain is not bread and butter. The above is directly from Up-To-Date, which comes from a terrific paper that I'd recommend you check out.

 

[Guest JMPA]

12 hours ago, thinkertdm said:

Absolutely.  The patients think they NEED x-rays, even MRIs, and ordering them may get them out of your office faster, but really do nothing aside from give the patients a false sense of a terrible terrible disease like "arthritis" or "stenosis" or something like that, things we look at and basically ignore, but to an obese, out of shape 50 yo, he gets to constantly. bring. it. up. at. every. appointment, like a badge of honor.

Of course, they are easy to get, so if in doubt, get a picture.  Just be sure it's the right test for what you are looking for.  X-rays don't show discs.  Sometimes I run 'em through twice.

Did i ever say for "all back pain"? What has this forum turned into? a bunch of whining nurses? please, read the comment before making such ignorant remarks. this forum is really going down hill

[Guest JMPA]

12 hours ago, LT_Oneal_PAC said:

 

you should be ashamed of yourself for your racist video, and you are a moderator?

[drybones]

13 hours ago, JMPA said:

why not just ignore every complaint until it comes back to sue you, oh because you would not have a license any more

Bread and butter of low back pain is to have x-rays, it is the initial study of choice and standard of care learned first day of medical training

I'm not sure where this idea comes from. If we're referencing the anecdote that started this thread, imaging very likely isn't indicated. 

https://www.jospt.org/doi/full/10.2519/jospt.2011.3618

https://www.aafp.org/patient-care/clinical-recommendations/all/cw-back-pain.html

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2697333/

CYA plain films for non-specific low back pain is a poor practice habit. 

[LT_Oneal_PAC]

On 9/26/2018 at 3:21 PM, lkth487 said:

Well, what if every cold in a kid is caused by immunodeficiency secondary to congenital HIV or cancer?  You can't practice medicine this way or everyone would get a full body MRI.  There are guidelines and recommendations based on good science for many things (for many others - there are not, but thats the reason we go through all of this training....otherwise you could be done training in a month).

 

It is very rare that people get sued and lose for following something that is bread and butter standard of care (as long as you have good documentation).

 

15 hours ago, JMPA said:

why not just ignore every complaint until it comes back to sue you, oh because you would not have a license any more

Bread and butter of low back pain is to have x-rays, it is the initial study of choice and standard of care learned first day of medical training

 

2 hours ago, JMPA said:

Did i ever say for "all back pain"? What has this forum turned into? a bunch of whining nurses? please, read the comment before making such ignorant remarks. this forum is really going down hill

Assuming you are being honest that we misread your post, then you misread the original quoted post that it meant to never get XR. In which case, maybe you should practice some restraint and reaize you can misread and don’t be so upset when others do the same. However, I think you meant exactly what we think, and that is you often order unnecessary XR in low risk back pain.

Furthermore, if you have a problem with anything I post, you are welcome to report it as I am not above reproach.

[mgriffiths]

2 hours ago, JMPA said:

you should be ashamed of yourself for your racist video, and you are a moderator?

racist video?  I know this is taking this thread WAY off track...but, what was racist about the gif?  I am struggling to figure it out.

[thinkertdm]

On ‎9‎/‎25‎/‎2018 at 2:17 PM, JMPA said:

try explaining to a jury why you failed to do an x-ray (minimal radiation exposure) and missed lithesis, cancer, fracture ect.

Quote

why not just ignore every complaint until it comes back to sue you, oh because you would not have a license any more

Bread and butter of low back pain is to have x-rays, it is the initial study of choice and standard of care learned first day of medical training

My apologies to my esteemed presumed colleague in the interpretation of these "ambiguous" statements.  In the future,  treat me with respect as befitting your profession, but I do not consider being called a "nurse" insulting, but a compliment, as you are demonstrating.

[CAdamsPAC]

10 hours ago, JMPA said:

you should be ashamed of yourself for your racist video, and you are a moderator?

WTH are you talking about?? I'm so effing sick of moronic people tossing this pejorative out as the linchpin of a vacuous argument! At what point in your life were you appointed the guardian of people of color and arbitrator or other's thoughts?? Get a life.

 

[beattie228]

5 hours ago, JMPA said:

Did i ever say for "all back pain"? What has this forum turned into? a bunch of whining nurses? please, read the comment before making such ignorant remarks. this forum is really going down hill

Maybe I missed something, but I don't see any nurses chiming in. I see a collection of board certified PAs pointing out what was perceived to be misinformation regarding imaging recommendations. You didn't specify your statement of 'Bread and butter of low back pain is to have x-rays, it is the initial study of choice and standard of care learned first day of medical training' didn't apply to "all back pain"'. An internet forum can only go off of what is posted.

 

Rather than attacking your esteemed colleagues who simply posted to continue an educational conversation, you could have clarified your position for the sake of continuing the conversation.

 

 

[EndBulbsOfMouse]

On 9/27/2018 at 8:35 PM, JMPA said:

why not just ignore every complaint until it comes back to sue you, oh because you would not have a license any more

Bread and butter of low back pain is to have x-rays, it is the initial study of choice and standard of care learned first day of medical training

Reassuring someone and giving appropriate anticipatory guidance can also be appropriate medical care.

Maybe you might want to repeat that first day of medical training. 

[CAdamsPAC]

On 9/27/2018 at 8:35 PM, JMPA said:

why not just ignore every complaint until it comes back to sue you, oh because you would not have a license any more

Bread and butter of low back pain is to have x-rays, it is the initial study of choice and standard of care learned first day of medical training

Exactly what pathology are you looking for with an x-ray? How much information can be gleaned from x-rays for soft tissue injury or inflammation?BTW my "first day of medical training was in 1972 and did not include x-rays for back pain!

[sas5814]

"try explaining to a jury why you failed to do an x-ray (minimal radiation exposure) and missed lithesis, cancer, fracture ect."

 

It is interesting you lament our ability to stay on point with what you think the conversation should be about when you wandered afield first. This was not related to the subject at hand. You created a new conversation when you said this.

Lastly, and I have been away for a few days so I missed the bulk of this conversation, this was about a complete failure to even begin to do what should have been done for this patient and the neurosurgeon's (rightful) displeasure with this referral and how these kinds of things tend to reflect on all of us fairly or not. I think any of us who have been around for very long at all have heard plenty of  "those mid-levels" or "those PAs" as if we are all stamped out with a cookie cutter and have the same education, training, experience, and skill level.

[karebear12892]

[Guest JMPA]

My original comment stands, fear of obtaining imaging do to incompetence or lack of basic clinical reasoning is a major cause of delayed and missed diagnosis. Ignoring symptoms and cavalier attitudes lead to harm. The new wave of anti imaging and anti testing in an era of marked technological advancement is a detriment to our society. Twisted my words by adding/insinuating whether by one or many does not change facts.  

[Guest JMPA]

13 hours ago, CAdamsPAC said:

Exactly what pathology are you looking for with an x-ray? How much information can be gleaned from x-rays for soft tissue injury or inflammation?BTW my "first day of medical training was in 1972 and did not include x-rays for back pain!

This only reflects your limited understanding of x-ray application and interpretation. X-rays remain to be invaluable tools.