Instead of a risk alert, what about an intervention alert for the interventions most likely to make a difference in the pt’s life? We humans are not great at judging risk, and just because a treatment is indicated doesn’t mean it’s going to make a huge difference. This is what MDs get paid for, I know, it’s complex, and we don’t all do it well, which is why it’s reasonable to get the standardized help.
Sometimes, the best antidote is when DRI happens to a physician as a patient. Several years ago, I had a bladder stone. It was retrieved, and my pain and hematuria resolved. But for completeness, a renal ultrasound was ordered. The kidneys were normal, but there was a suggestion of a hepatic mass. I had no hepatic symptoms, and my liver enzymes were normal. My pretest likelihood of having hepatic cancer was as close to zero as possible, but my physician felt compelled to order a CT of the abdomen with contrast, which was normal. I have stopped ordering all routine annual tests. I prefer to have a patient come in before ordering tests. Unless I have no idea what is going on and am worried, I try to order a small number of specific tests. Depending on the results of those tests, I can then order more tests or seek a consultation, or just see the patient back at another point in time. I have attracted patients who prefer that approach and probably have lost others. It would be nice to see a controlled experiment on the net effect of automatic alerts but I suspect the cat is already out of the barn
Thank you for an insightful look into how the rules of engagement have forever changed in clinical medicine. You would think today’s policymakers would have taken note that unfortunate unintended consequences inevitably arise when algorithmic conditions are applied to complex disciplines where non-discrete intuitive processes are necessary to perform well. It gets back to the notion that medicine is still more art than science, despite our efforts to deny this truism.
Considering the risk of false positives in testing, and the tendency for patients to die when the doctor tells them they will, I think that the paradigm needs to change.
A wonderful piece. In the US, the so called Best Practice Alerts (BPAs), originally designed to detect obvious errors, such as the unwitting prescription of incompatible drugs before the pharmacist could detect the combination, has evolved to produce a frustrating array of alerts and warnings (analogous to the cancer risk alert ) that busy clinicians end up clicking through. Most really serve only to provide legal protection for the institution. This is DRI at its worst. These alerts are emblematic of the US dependence on protocolized medicine, such that trainees are not taught to generate differential diagnoses, but, instead, to order huge batteries of studies (a percentage of which will be abnormal by chance) and then to follow disease-based “pathways”.
Of course, “common things are common” and many common conditions probably should be treated in much the same way in most patients.
However, this emphasis on protocol (and DRI from multiple unnecessary studies) robs the patient of the full diagnostic attention of the physician at the time of presentation, when it is needed the most, before the patient is labeled with a diagnosis.
I am not a healthcare professional. This article reminded me of an experience 30 years ago that changed how I participate in my own healthcare.
Twenty weeks pregnant and with a healthy toddler at home, unbeknownst to me my doctor ordered a “triple screen” blood test. I received an urgent phone call telling me to come in to the office to learn the results which were communicated like this: an increased risk of Downs and spina bifida. That’s it. When I pressed for more information I was told that the risk was that of a 35 year old woman, though I was 32. How on earth is this helpful information? Also I was told, at this point, the only way to know for sure was to have an amniocentesis which of course would risk the baby’s life for 24-48 hours. But now, with the concern placed in my head, it couldn’t be removed. It seemed necessary to know one way or the other, considering the impact on our toddler but also how we would better prepare our lives. And I didn’t want the remainder of the pregnancy to be anxiety-ridden for the baby—better to know than wonder.
This, after an uneventful first pregnancy and birth—not even an ultrasound.
I had the amnio.
For 30 years, every time I find myself on the bridge I was driving over when I saw the dash clock indicating the amnio risk period has passed and felt the baby kicking, I remember. I remember the unnecessary angst that unnecessary test caused.
I no longer consent to medical tests, for myself or those in my care, unless and until I understand their purpose and possible outcomes.
Often, in giving patients discharge instructions, I would allude to the uncertainty inherent in medical practice by telling them that we - the patient and I - were engaging in an experiment. I would say something like “this is my diagnosis, and for this diagnosis, this is what is usually done, and if I’m right about the diagnosis, then this is how you should respond to the treatment. If you’re not responding as predicted, then this is what you should do next.” Most patients seemed to understand this “experiment” description and to appreciate this kind of explanation.
When you consider the the way most social media works -- pulling bits of information from richer contexts, stripping them of that context, and throwing them all out there for others to mix and match with other "decontextualized" bits of information -- I'd say the same phenomenon is happening in all arenas of society, not just healthcare. And just as you say, it's leading to conflict, rather than synergy. In fact, the purpose of so many seems to be to sow discord, not empathy or cooperation.
Instead of a risk alert, what about an intervention alert for the interventions most likely to make a difference in the pt’s life? We humans are not great at judging risk, and just because a treatment is indicated doesn’t mean it’s going to make a huge difference. This is what MDs get paid for, I know, it’s complex, and we don’t all do it well, which is why it’s reasonable to get the standardized help.
Sometimes, the best antidote is when DRI happens to a physician as a patient. Several years ago, I had a bladder stone. It was retrieved, and my pain and hematuria resolved. But for completeness, a renal ultrasound was ordered. The kidneys were normal, but there was a suggestion of a hepatic mass. I had no hepatic symptoms, and my liver enzymes were normal. My pretest likelihood of having hepatic cancer was as close to zero as possible, but my physician felt compelled to order a CT of the abdomen with contrast, which was normal. I have stopped ordering all routine annual tests. I prefer to have a patient come in before ordering tests. Unless I have no idea what is going on and am worried, I try to order a small number of specific tests. Depending on the results of those tests, I can then order more tests or seek a consultation, or just see the patient back at another point in time. I have attracted patients who prefer that approach and probably have lost others. It would be nice to see a controlled experiment on the net effect of automatic alerts but I suspect the cat is already out of the barn
Thank you for an insightful look into how the rules of engagement have forever changed in clinical medicine. You would think today’s policymakers would have taken note that unfortunate unintended consequences inevitably arise when algorithmic conditions are applied to complex disciplines where non-discrete intuitive processes are necessary to perform well. It gets back to the notion that medicine is still more art than science, despite our efforts to deny this truism.
Considering the risk of false positives in testing, and the tendency for patients to die when the doctor tells them they will, I think that the paradigm needs to change.
Good article. Thank you
What was your explanation to the patient about the D Dimer?
THANK YOU. I attended this conference a few years ago; best conference I ever attended.
A wonderful piece. In the US, the so called Best Practice Alerts (BPAs), originally designed to detect obvious errors, such as the unwitting prescription of incompatible drugs before the pharmacist could detect the combination, has evolved to produce a frustrating array of alerts and warnings (analogous to the cancer risk alert ) that busy clinicians end up clicking through. Most really serve only to provide legal protection for the institution. This is DRI at its worst. These alerts are emblematic of the US dependence on protocolized medicine, such that trainees are not taught to generate differential diagnoses, but, instead, to order huge batteries of studies (a percentage of which will be abnormal by chance) and then to follow disease-based “pathways”.
Of course, “common things are common” and many common conditions probably should be treated in much the same way in most patients.
However, this emphasis on protocol (and DRI from multiple unnecessary studies) robs the patient of the full diagnostic attention of the physician at the time of presentation, when it is needed the most, before the patient is labeled with a diagnosis.
What a wonderful essay. Makes me want to move to Cornwall.
Excellent article; as well, good turn on to CEBM; I’ve downloaded several podcasts for future reference. Thnx.
I am not a healthcare professional. This article reminded me of an experience 30 years ago that changed how I participate in my own healthcare.
Twenty weeks pregnant and with a healthy toddler at home, unbeknownst to me my doctor ordered a “triple screen” blood test. I received an urgent phone call telling me to come in to the office to learn the results which were communicated like this: an increased risk of Downs and spina bifida. That’s it. When I pressed for more information I was told that the risk was that of a 35 year old woman, though I was 32. How on earth is this helpful information? Also I was told, at this point, the only way to know for sure was to have an amniocentesis which of course would risk the baby’s life for 24-48 hours. But now, with the concern placed in my head, it couldn’t be removed. It seemed necessary to know one way or the other, considering the impact on our toddler but also how we would better prepare our lives. And I didn’t want the remainder of the pregnancy to be anxiety-ridden for the baby—better to know than wonder.
This, after an uneventful first pregnancy and birth—not even an ultrasound.
I had the amnio.
For 30 years, every time I find myself on the bridge I was driving over when I saw the dash clock indicating the amnio risk period has passed and felt the baby kicking, I remember. I remember the unnecessary angst that unnecessary test caused.
I no longer consent to medical tests, for myself or those in my care, unless and until I understand their purpose and possible outcomes.
Melanie, this is an excellent post and I am sorry for the angst and unneeded worry our profession caused.
Often, in giving patients discharge instructions, I would allude to the uncertainty inherent in medical practice by telling them that we - the patient and I - were engaging in an experiment. I would say something like “this is my diagnosis, and for this diagnosis, this is what is usually done, and if I’m right about the diagnosis, then this is how you should respond to the treatment. If you’re not responding as predicted, then this is what you should do next.” Most patients seemed to understand this “experiment” description and to appreciate this kind of explanation.
Truly enjoyed this article, thank you.
Brilliant!
When you consider the the way most social media works -- pulling bits of information from richer contexts, stripping them of that context, and throwing them all out there for others to mix and match with other "decontextualized" bits of information -- I'd say the same phenomenon is happening in all arenas of society, not just healthcare. And just as you say, it's leading to conflict, rather than synergy. In fact, the purpose of so many seems to be to sow discord, not empathy or cooperation.