A colleague and master of medical neologism, Dr. Dean Frate, coined a new term, “diagnonsense,” to characterize some of the work in which we physicians engage. I’m introducing a new word myself, “theraputrids,” for some of the wild prescribing that occurs in conjunction with diagnonsense.
Diagnonsense includes ordering a CT scan of the head in a patient presenting with cervical radiculopathy, a carotid ultrasound in a patient suffering from syncope, and then it progresses downwards from there. There is the practice of ordering a dimer on a patient with no suggestion of pulmonary embolism, a troponin on a 93-year-old with cellulitis, ankle/brachial ratios on someone who needs amputation, mammography for 89-year olds and a CT of the abdomen on almost everyone. Seems ridiculous as you read it, doesn’t it?
Oh medical mates, we have seen it all, have we not? Weekly or monthly head CT’s for narcotic addicted patients presenting to the ED with “headache.” In one patient I documented fourteen head CT’s within a year. That whiff of atelectasis diagnosed as pneumonia. Serial phlebotomies to monitor what does not need monitoring, or that induce anemia which leads to hematological consultation. Patients nearing the end of life subjected to screening colonoscopies. Imaging embarked upon for one problem that reveals some other lesion and then leads to an avalanche of radiological misadventures.
The best recent anecdote of this was an engaging lecture I attended delivered by a radiologist regarding the state of imaging in America. Not surprisingly, the field of radiology is in the midst of explosive growth. Warning that perhaps some of the imaging was unwarranted, she presented the case of a radiologist who decided to undergo screening CT colonoscopy. The colon was fine, but the CT showed an uncertain lesion of a kidney and the liver. Biopsy of the liver was negative. Biopsy of the kidney lesion was complicated by bleeding requiring operative intervention. The lesion was benign, but the physician patient lost five months from work with medical costs over fifty thousand dollars.The lecturer estimated the magnitude of radiation we are showering on the American public in the range of multiple Hiroshima bombs.
Ay, colleagues, you could pull out your hair over electronic order systems that make you consider Heparin or Lovenox in patients admitted for Coumidin coagulopathy and gastrointestinal bleeding. Then there are the vague radiological reports suggesting the need for further imaging. Do we heroically act upon Vitamin D levels that are meaningless in terminally demented patients? There are times mates, are there not times, when mesmerized at the computer screen, you just want to scream to be let out of this movie?
Take heart. Many clinicians are writing about and researching these issues. Choosing Wisely is an initiative by the American Board of Internal Medicine. Go to their website; there you can find links to sane guidelines for diagnosis and treatment that attempt to minimize waste, unnecessary testing and therapeutics. Try to have meaningful conversations with patients regarding the value of the things we do. “Think twice, stick once.”