Improving medical students

How to Make Clinical Decisions and Avoid Defensive Medicine

Posted by medliorator on August 29, 2008

I was asked to examine a patient who was scheduled for an emergency amputation of her leg because of gangrene. I went over her chart and discovered that one of the junior residents had seen her the night before and had requested two consults… I cancelled the consults because they were unnecessary.

The next day, I ran into the resident who requested the consults… I asked him why he asked for the consults. His reply made me see red. It is the reply of the imbecile, of the doctor who is afraid to think and make decisions, and it drives me to distraction: “To spread around the responsibility”. To be fair, it is not all his fault, he learned this “defensive medicine” posture from [the chief of anesthesiology].

I told him that even if he really believes in that philosophy, he should never actually say it out loud, it’s just plain embarrassing. I proceeded to impart two pearls of wisdom that I believe are universal:

  1. If you ask the consultant a stupid question, you will, invariably, get a stupid answer. Don’t just ask for a “cardiology consult”. One must ask the consult a specific (and hopefully intelligent) question. For example, “Does this patient need further workup and/or intervention for her chest pain?”
  2. You better have a damn good justification for delaying surgery if the delay endangers the patient. In this case, delaying the amputation exposed the patient to another day of infection that could have developed into full blown sepsis with septic shock… Had such a complication occurred, the first question the judge will ask is: “What did you gain from the consults that justified delaying surgery and endangering the patient”.

I believe in this guiding principle: Any investigation, whether a consultation or a blood test should be done only if the results will affect patient management. Not only is an unnecessary test a waste of money, it may even endanger the patient.

Unnecessary Tests [The Sandman]

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