The Medical Thread

[MeoTwister5]

There is a stark difference considering some of us practice in poor countries where not everyone can afford a CT scan on the fly.

Theres is such a thing as excessive and pointless testing when even the basic exams have enough specificity and sensitivity to make the correct diagnosis majority of the time without subjecting the patient to diagnostics that are not only expensive but also have side effects (pain radiation etc.).

Its called medical economics.

[Cosmic Eagle]

Uh huh...most of the time. And what if the patient keeps returning to you with no let up in his problem? Do you continue to brush him off without further thought? Say wait and see until he just collapses?

[Pink Cow]

The problem is CT and MRI are additional charges to the patient especially if he/she doesn't need it. IF the patient requests for them to be done and is willing to spend, then of course, we as doctors give in because it is the right of the patient. But it's another story if the doctor recommends the imaging when the patient doesn't need it. A good history and physical exam can already detect a stroke. A CT scan / MRI help you localize where exactly in the brain the cause of the stroke is.

Doctors should refuse to run too many scans unless it's necessary. For example, if a patient has headache, does it mean he/she should have an MRI or CT scan right away? No. Depending on other symptoms, that headache could have been a migraine which is most definitely nothing compared to a stroke. It still boils down the the history they take and the physical exam they do. If the patient is just too worried and requests for a CT scan, it's natural for doctors to discourage the idea, but of course, the patient would have the final say.

[NoemiChan]

You know guys we got a patient who has severe abdominal pain and jaundice with positive choleliathiasis on ultrasound and our doctor still insist to have a CT-scan first before surgery and orders tons of "branded" pain meds and supplements, She says she just want to be sure... I just scratch my head and look at disappointment.... She decides to discharge the patient ( in that condition?!) but the SO insist of a transfer to a public hospital.....

[MeoTwister5]

Originally Posted by Cosmic Eagle

Uh huh...most of the time. And what if the patient keeps returning to you with no let up in his problem? Do you continue to brush him off without further thought? Say wait and see until he just collapses?

You're not getting the point. There are times when additional diagnostics are warranted and at times unecessary. The point of imaging and laboratories is to confirm what a doctor suspects, not to makethe diagnosis for him. If the latter were the case then doctors would judt routinely run a battery of tests for every little problem. Likewise medical ethics dictates that a doctor proceed with diagnostics in accordance to accepted and proven protocols mixed in with their own clinical judgement. A doctor can get his license revoked for being a gung ho maverick for his practice.

Real life isn't House MD where everyone is stuck into an MRI and poof diagnosis made. Not everyone has some mystery illness that requires all sorts of exams just to discover. If this were the case then there would be long lines in front of the CT scan.

But if you really want that scan go ahead and do it, even when your doctors think it is ultimately a waste of money. Just remember that not everyone needs it, and even more so not everyone can afford it.

[Pink Cow]

Originally Posted by Cosmic Eagle

They have to be sure no?

In fact you raise a very strong irritation of mine with doctors. When you have persistent condition lasting months, they refuse to run any scans on you until just lately.

What did you have?

Originally Posted by GenjiChan

You know guys we got a patient who has severe abdominal pain and jaundice with positive choleliathiasis on ultrasound and our doctor still insist to have a CT-scan first before surgery and orders tons of "branded" pain meds and supplements, She says she just want to be sure... I just scratch my head and look at disappointment.... She decides to discharge the patient ( in that condition?!) but the SO insist of a transfer to a public hospital.....

There's also the CT scanning of the abdomen for appendicitis. I think it's routine in America and it's starting to be routine in some hospitals here in the Philippines... Even though appendicitis can actually be diagnosed without imaging.

It all boils down to "defensive medicine" apparently. My dad (a senior surgeon) talked to me about this. Doctors overuse tests because of fear for being sued.

[NoemiChan]

That's in America... I think some doctor's do it to make more reason to "why they should be given higher pay"....

Anyway.. Is asking for P300,000 as "personal PF" by a surgeon reasonable? I mean for that surgery only, excluding the equipment and his service all throughout the patients stay in the hospital? and oh he's a neurologist

[SummeryDreams]

Okay I'm a registered nurse..So I guess I can help you with your problem.. The thing is, it's difficult to diagnose your problem as we need to do tests done.. Note that it's not always the same cyst that will occur.. The worst is if it's cancerous.. You should know that cancers may have same symptoms during earlier stage with some other benign tumors such as cyst, so all I can say is that.. Please do consult an ophthalmologist regarding that problem.. I hope you do understand your situation right now, and that needs immediate attention especially that you already have had the same symptoms before.. reoccuring cyst are not good..

[NoemiChan]

Originally Posted by SummeryDreams

Okay I'm a registered nurse..So I guess I can help you with your problem.. The thing is, it's difficult to diagnose your problem as we need to do tests done.. Note that it's not always the same cyst that will occur.. The worst is if it's cancerous.. You should know that cancers may have same symptoms during earlier stage with some other benign tumors such as cyst, so all I can say is that.. Please do consult an ophthalmologist regarding that problem.. I hope you do understand your situation right now, and that needs immediate attention especially that you already have had the same symptoms before.. reoccuring cyst are not good..

I think it depends on the location of the cyst.... I got a patient who went for surgery 8x because of a cyst regrowing under his eyelid.... It was never serious though it irritates his vision... I myself got a recurring cyst in my earlobe but it was never malignant.... The explanation was the blood vessel continues to pour to the region...

Cyst on the breast and ovary are pretty not to be ignored whether its benign or malignant (what more if its malignant LOls)

[Ledgem]

Originally Posted by Pink Cow

It all boils down to "defensive medicine" apparently. My dad (a senior surgeon) talked to me about this. Doctors overuse tests because of fear for being sued.

I love how you talk about defensive medicine and are outraged at the idea of ordering unnecessary tests as if they're fairly rare things. I don't say that in a belittling manner - I presume they're fairly uncommon in the Philippines, and the way that you speak about them is refreshing. Defensive medicine is incredibly common in America.

How do you know if a CT or MRI is unnecessary until you run it? Strokes aside, what if the patient has a brain tumor, infection, trauma, aneurysm, multiple sclerosis (less common in the Philippines, I know), and so on? If you don't order them and the patient goes on their way, only to have it discovered later, you could be on the receiving end of a lawsuit for negligence. Sure, your history and physical will correctly indicate that it is unnecessary the majority of the time, but there will be some cases that slip through that would otherwise be caught by the imaging. Should we image 100 people if only two really would have benefitted from it, driving up the costs for everyone? Most people would probably say yes, if it means that their chances of experiencing a missed diagnosis is decreased. The hospital would probably say yes, because an unused imaging machine is wasted space and investment for them. As a result there is little incentive not to order the test, aside from your own conscience. Even then, I wonder what will happen when you miss something that imaging could have caught.

It's true that we're ordering a lot of unnecessary tests in America, and there are more reasons than just defensive medicine. I won't deny that laziness may very well be a part of it. Order enough tests and the differential becomes clearer to you without having to do too much thinking. I agree that we should be more careful about the tests that we choose to run, but those lawsuits are tricky.

[MeoTwister5]

Originally Posted by Ledgem

I love how you talk about defensive medicine and are outraged at the idea of ordering unnecessary tests as if they're fairly rare things. I don't say that in a belittling manner - I presume they're fairly uncommon in the Philippines, and the way that you speak about them is refreshing. Defensive medicine is incredibly common in America.

How do you know if a CT or MRI is unnecessary until you run it? Strokes aside, what if the patient has a brain tumor, infection, trauma, aneurysm, multiple sclerosis (less common in the Philippines, I know), and so on? If you don't order them and the patient goes on their way, only to have it discovered later, you could be on the receiving end of a lawsuit for negligence. Sure, your history and physical will correctly indicate that it is unnecessary the majority of the time, but there will be some cases that slip through that would otherwise be caught by the imaging. Should we image 100 people if only two really would have benefitted from it, driving up the costs for everyone? Most people would probably say yes, if it means that their chances of experiencing a missed diagnosis is decreased. The hospital would probably say yes, because an unused imaging machine is wasted space and investment for them. As a result there is little incentive not to order the test, aside from your own conscience. Even then, I wonder what will happen when you miss something that imaging could have caught.

It's true that we're ordering a lot of unnecessary tests in America, and there are more reasons than just defensive medicine. I won't deny that laziness may very well be a part of it. Order enough tests and the differential becomes clearer to you without having to do too much thinking. I agree that we should be more careful about the tests that we choose to run, but those lawsuits are tricky.

Personally to me it all boils down to not so much defensive medicine as it is the stark contrast between health economics of a developed nation and a developing one. In the US I assume it's much, much more easy for a doctor to stick a patient into all the scanning tubes available and likewise stick all kinds of syringes into their antecubitals because there's always some sort of payment going to be available to cover these costs. You have some sort health insurance to cover even the poorest of the poor because your government mandates it, and AFAIK even those who technically lack it still have some sort of limited coverage.

This doesn't apply in third world countries like the Philippines, where 50% of the population can't even pay the rough equivalent of $5 monthly to be covered by the most basic health insurance (PhilHealth), much less pay for a CBC (~$4) or a chest xray ($5-$6 ish).

It's not so much to me defensive medicine as it is the fact that you can make a very good diagnosis assuming you were trained properly, while knowing that most of your patients will struggle to find payment for the tests they need, even more so unnecessary ones. I would gladly cut or waive my PF if it came down to it.

[monsta666]

Originally Posted by MeoTwister5

There is a stark difference considering some of us practice in poor countries where not everyone can afford a CT scan on the fly.

Theres is such a thing as excessive and pointless testing when even the basic exams have enough specificity and sensitivity to make the correct diagnosis majority of the time without subjecting the patient to diagnostics that are not only expensive but also have side effects (pain radiation etc.).

Its called medical economics.

As another side-note some tests or procedures can carry risks. I remember my dad (who is a heart doctor) told me a story were one of his colleagues carried out a Cardiac angiography test on a patient that didn't really need it. Basically that procedure involves the insertion of a tube into the heart to test heart function. When this colleague performed this procedure the patient died on the table.

It was a very unfortunate case and it can be argued that this is a relatively rare occurrence but the point remains that tests can be dangerous. The point my dad wanted to highlight in this story is doctors must take great care when they consider administrating any test on patients. Often there are financial and health costs to consider when performing these tests.

[Pink Cow]

Originally Posted by Ledgem

I love how you talk about defensive medicine and are outraged at the idea of ordering unnecessary tests as if they're fairly rare things. I don't say that in a belittling manner - I presume they're fairly uncommon in the Philippines, and the way that you speak about them is refreshing. Defensive medicine is incredibly common in America.

How do you know if a CT or MRI is unnecessary until you run it? Strokes aside, what if the patient has a brain tumor, infection, trauma, aneurysm, multiple sclerosis (less common in the Philippines, I know), and so on? If you don't order them and the patient goes on their way, only to have it discovered later, you could be on the receiving end of a lawsuit for negligence. Sure, your history and physical will correctly indicate that it is unnecessary the majority of the time, but there will be some cases that slip through that would otherwise be caught by the imaging. Should we image 100 people if only two really would have benefitted from it, driving up the costs for everyone? Most people would probably say yes, if it means that their chances of experiencing a missed diagnosis is decreased. The hospital would probably say yes, because an unused imaging machine is wasted space and investment for them. As a result there is little incentive not to order the test, aside from your own conscience. Even then, I wonder what will happen when you miss something that imaging could have caught.

It's true that we're ordering a lot of unnecessary tests in America, and there are more reasons than just defensive medicine. I won't deny that laziness may very well be a part of it. Order enough tests and the differential becomes clearer to you without having to do too much thinking. I agree that we should be more careful about the tests that we choose to run, but those lawsuits are tricky.

I dislike the idea of defensive medicine, but I guess it's unavoidable in first world countries such as America. But it's harmful to patients of poorer countries in the sense that it drains them financially. In the long run, these patients won't have enough money to maintain their health. Which is why a lot of med schools here teach us to rely more on history and pe and to be cautious when ordering tests, taking into consideration the financial status of the patient and to order the tests only when necessary.

It just irritates me when I see other doctors order ct and mri left and right without first considering the history and PE properly...

[Ledgem]

Originally Posted by Pink Cow

I dislike the idea of defensive medicine, but I guess it's unavoidable in first world countries such as America. But it's harmful to patients of poorer countries in the sense that it drains them financially. In the long run, these patients won't have enough money to maintain their health. Which is why a lot of med schools here teach us to rely more on history and pe and to be cautious when ordering tests, taking into consideration the financial status of the patient and to order the tests only when necessary.

It just irritates me when I see other doctors order ct and mri left and right without first considering the history and PE properly...

It's very expensive here in America as well. Even if most of our patients are covered by insurance, that money doesn't come out of thin air. If the insurance companies have to pay for more tests then they simply raise the rate on everyone in the insurance group. It may not bankrupt the individual receiving the tests (although we do have plenty of cases of people entering bankruptcy over medical problems), but it represents a massive drain on society.

There is another element that might be different between the US and the Philippines. It partly has to do with litigation as well: we document everything. Compared with the way that medicine used to be in the "olden days" an increase in documentation was needed, but we have reached ridiculous levels such that physicians spend more time charting than they do working with patients. And that's really all that it is; few physicians have the time to read through much of what is written in the chart, instead looking for particular highlights and updates.

Getting a thorough history takes time. Talking through things with the patient takes time, getting to know the patient and earn their trust takes even more time. Plenty of patients are unreliable historians, too. It's more time-efficient to get a brief history, schedule the patient for imaging and labs, and then move on to the next patient. It isn't right or ideal, but it's a limitation that we have to work with.

[GDB]

So, I'd like some opinions on this. Lately, I've noticed my left eye's had this weird twitching/pulsing feeling under the eye. Closing the eye usually makes the feeling go away, as does putting my finger under the eye (as if I were to wipe a tear from the inner duct without touching the eye itself).

For a while, while it worried me, I thought it was just a feeling and not something actually happening. Then a week or two ago, it started happening while I was in the bathroom, so I decided to check the mirror and noticed there was actually a visible pulse going on under the eye (think those cliche anime pulsing veins). This sort of freaked me out.

I checked online and it looked like the three main causes are inadequate sleep (I do have some degree of insomnia, usually takes 30-60 minutes to fall asleep and the past couple of weeks I'd only gotten about 6 hours a night on average at best), stress (definitely been getting that at work), and eye strain. The last one is the one that I'm most curious about, as I do work with computers all day, but I also got new lenses in my glasses in May. I cannot recall when this twitch started happening, but I at least know it wasn't happening before January.

Anyone ever have something like this happen? It's getting more frequent, so not sure if I should consult an optometrist, check to make sure they didn't screw up my left lens, or if this is an issue for a general practitioner.

[Ledgem]

Originally Posted by GDB

Anyone ever have something like this happen? It's getting more frequent, so not sure if I should consult an optometrist, check to make sure they didn't screw up my left lens, or if this is an issue for a general practitioner.

I've had it twice in my life, and both times were during periods of high stress and lack of sleep. I would suggest attempting to find ways to de-stress as much as possible and to get onto a healthier sleep schedule. Even if those don't fix your spasms they're healthy changes to your life that will benefit you regardless. I don't know what the official data says (if there is any) but even after fixing my sleep schedule it took at least a few days, perhaps up to two weeks, for the spasms to go away.

There's always the possibility that it's eye strain but I doubt that it's the case here. How many hours per day do you wear your glasses? If they were a source of eye strain then my guess is that you would have noticed within a week of the lens change (both that your eyes felt fatigued and that the spasms were present).

[GDB]

I pretty much wear my glasses at all times other than showering and sleeping. I figured that was the less likely reason, but I did see that it was a potential cause so I listed it.

[SummeryDreams]

Originally Posted by GenjiChan

I think it depends on the location of the cyst.... I got a patient who went for surgery 8x because of a cyst regrowing under his eyelid.... It was never serious though it irritates his vision... I myself got a recurring cyst in my earlobe but it was never malignant.... The explanation was the blood vessel continues to pour to the region...

Cyst on the breast and ovary are pretty not to be ignored whether its benign or malignant (what more if its malignant LOls)

Really? It was explained to us the reoccuring cysts have higher chances of being malignant the time it will return.. Either way, no matter what it is, it is still not good to have that and sometimes life threatening even if it's just a cyst.. Depends on the location though..

[NoemiChan]

Originally Posted by SummeryDreams

Really? It was explained to us the reoccuring cysts have higher chances of being malignant the time it will return.. Either way, no matter what it is, it is still not good to have that and sometimes life threatening even if it's just a cyst.. Depends on the location though..

That's my opinion but based on what a doctor said to me... Besides... I never heard a case of malignancy on earlobes or eyelids....

[MeoTwister5]

I have blepharospasms myself on my left upper eyelid. Usually afte4 stress.