It has been an observation of mine that patients would rather have something "done" than have a discussion about it. When I do a cardiac catheterization and tell people who have a coronary artery blockage that it is not "critical " enough to perform angioplasty, the conversation is 10 times longer than the patients who gets an angioplasty. The patient who got "fixed" is happy, and the patient who got the discussion is often unsure how to proceed. I can see it in the body language and hear it in their voices. I have blogged about a test that we have, known as fractional flow reserve, that can predict which indeterminate coronary lesions need treatment and which do not. If you do something like a test, which then shows you something and then talk to the patients about it, they are much more accepting than without the test results. It is like the "test" is some sort of guarantee that it is the correct course of action. This concept of "you have to do something" pervades medicine. Much of it is given to a reimbursement model that rewards me for "doing" and not for "thinking and talking." If the fees for the test and talking were exchanged in today's health care environment, people would get much more thinking and talking and much less testing. This simple fact is the major problem with medicine today. If they paid for thinking, we would all be much better off. The trouble is that thinking is hard to quantify, and the pencil heads need to quantify it to justify it. See my blogs on the way physicians are reimbursed for office visits. I am a big believer in that you have to be able to quantify things to know how an issue is going. It's how you quantify it that is the problem which is not solved at this point, and I have not read any bright ideas lately. This is the conundrum of chest pain and the emergency room. The stakes are high: death and permanent disability if the physician is wrong. Is there a test that will help us out? In any evaluation of chest pain, the first and most important test is the interview with the patient. I say this in all honesty because chest discomfort related to myocardial ischemia does have some predictable characteristics. The history, in a perfect world, will almost always tell you the story. That is the perfect world. In our vastly imperfect world, the history is often done in a haphazard way or barely at all. Studies have shown that doctors in general don't listen to much and often make up their minds what is and is not correct in just a few incomplete minutes. Part of this is being busy and part is frustration. Often, patients cannot even communicate, the whole interview is done in the third person, and any nuances that may be present are certainly lost. Patients are separated into "high risk," those with electrocardiographic changes (a test) or positive cardiac enzymes (another test), and "intermediate" or "low risk" (just a history). This is not rocket science. What we need is a test...
↧