This is probably one of my worst nightmares. I've experienced this diagnostic anchoring bias before, but I always try to ask the patient to describe any different symptoms compared to their recent/last ED visit. Without physically seeing this patient, I don't know if I would have repeated a CT scan two days later. I'd be interested in her SIRS criteria, just to see how the bandemia played out.
Agree, I think most docs can point to a time that they fell victim to diagnostic anchoring. The scariest thing about it is that you don't realize it's happening while you're experiencing it, its often only apparent in hindsight.
A huge amount of time too I can the CT results from scans done at the outside hospital, if this patient had a scan that read normal 2 days ago that I could see, sure it would be documented in my MDM and I probably would've gone down the exact same pathway
To be bluntly honest, I had never even heard of RPAs until I read your comment and looked it up. Do they sign the charts themselves or does a physician review it and also sign it?
This is not the first time I get that reaction re: RPAs, and I'm always surprised! Isn't it nice to live on the cutting edge of midlevel independence?
Yes, I am a resident at a community hospital but it's the only one serving an entire county, 400 beds, and is directly owned by a large, world-famous health system. It's not like I'm in some small out of the way HCA. The RPAs sign the read and a physician cosigns it, but I've reached the point where I can tell if it's RPA-read or MD/DO-read before I reach the bottom of the read. I have a habit of opening every image and radiopedia before the read now as well, but who am I kidding as an IM physician really? At best I usually disagree with the editorialized reads making clinical diagnoses, but that's because it's usually an RPA comitting one of the cardinal sins of radiology and practicing IM from the basement.
I know that in IM/psychiatry, *all* the 'physician co-signed' charts are really just rubberstamp approval. I don't expect it to be any different for radiology where we have 1-2 MDs in-house and 1-2 RPAs.
I definitely think there's liability here, but as usual, I have a couple gripes:
- If ED2 doc is liable (and I think that's a big "if"), no way this is a $4 million dollar mistake.
- Moreover, how do you put a price tag on this? Medical costs, certainly. Pain/suffering arguably. But if functional and neurological outcomes are good, how is a 7-figure price tag being justified?
I guess this just strikes my usual nerve with malpractice cases: the price of a mistake just seems preposterous. Yes, the radiologist screwed up, and the patient was harmed. But should that put the radiologist on the hook for 15 years' worth of their salary?
Keep in mind that the 4 and 7 million dollar numbers are just the opening of a negotiation. It's easy to put a price on how much the medical care cost, but pain and suffering is totally subjective.
I had a recent patient with bandemia, ended up admitting them though i had to push the hospitalist to do so. Did a deep dive on it, apparently it is a high positive predictive factor for also having positive blood cultures and septicemia. It is not an absolute red flag to admit, but it is a yellow flag to give pause and consider septic causes.
no, they had elevated wbc and pylo, but were young and healthy, if not for the bandemia then i would not have admitted them. My supervising physician agreed with me though that it is better to be cautious in these types of cases. from what I understand bandemia greater than 10 percent should give you pause to be concerned.
and so it continues, it would be real important to see who evaluated this person, was a general surgeon consulted? Ob gyn? I am so glad i never have to go to the ED again.
There may be some unicorn surgeon somewhere that would come into the ER to do that but I haven’t met them. They’ll do inpatient routine consults but not ER unless actually emergent.
just an old timer here, practiced in a small town, everyone knew everyone and little fell between the cracks. in reality we were on 24/7 for our friends and community. Oh how the world has changed . I appreciate your comments.
This is why I scan. The risk of me missing something is more to me than the risk of them getting cancer…
This is probably one of my worst nightmares. I've experienced this diagnostic anchoring bias before, but I always try to ask the patient to describe any different symptoms compared to their recent/last ED visit. Without physically seeing this patient, I don't know if I would have repeated a CT scan two days later. I'd be interested in her SIRS criteria, just to see how the bandemia played out.
Agree, I think most docs can point to a time that they fell victim to diagnostic anchoring. The scariest thing about it is that you don't realize it's happening while you're experiencing it, its often only apparent in hindsight.
A huge amount of time too I can the CT results from scans done at the outside hospital, if this patient had a scan that read normal 2 days ago that I could see, sure it would be documented in my MDM and I probably would've gone down the exact same pathway
My hospital has RPAs read over 20-30% of CTs, CTAs, and even a good chunk of MRIs.
And a recent study shows primary care PAs order 6x more CTs than their physician counterparts; for less complication patients.
Expect way more of this to happen as volume increases and less trained people read images.
(Even knowing that in this case, an actual MD read this.)
To be bluntly honest, I had never even heard of RPAs until I read your comment and looked it up. Do they sign the charts themselves or does a physician review it and also sign it?
This is not the first time I get that reaction re: RPAs, and I'm always surprised! Isn't it nice to live on the cutting edge of midlevel independence?
Yes, I am a resident at a community hospital but it's the only one serving an entire county, 400 beds, and is directly owned by a large, world-famous health system. It's not like I'm in some small out of the way HCA. The RPAs sign the read and a physician cosigns it, but I've reached the point where I can tell if it's RPA-read or MD/DO-read before I reach the bottom of the read. I have a habit of opening every image and radiopedia before the read now as well, but who am I kidding as an IM physician really? At best I usually disagree with the editorialized reads making clinical diagnoses, but that's because it's usually an RPA comitting one of the cardinal sins of radiology and practicing IM from the basement.
I know that in IM/psychiatry, *all* the 'physician co-signed' charts are really just rubberstamp approval. I don't expect it to be any different for radiology where we have 1-2 MDs in-house and 1-2 RPAs.
And this is why I don’t sleep at night 😳🤯
I definitely think there's liability here, but as usual, I have a couple gripes:
- If ED2 doc is liable (and I think that's a big "if"), no way this is a $4 million dollar mistake.
- Moreover, how do you put a price tag on this? Medical costs, certainly. Pain/suffering arguably. But if functional and neurological outcomes are good, how is a 7-figure price tag being justified?
I guess this just strikes my usual nerve with malpractice cases: the price of a mistake just seems preposterous. Yes, the radiologist screwed up, and the patient was harmed. But should that put the radiologist on the hook for 15 years' worth of their salary?
It sometimes terrifies me to work in this field.
Keep in mind that the 4 and 7 million dollar numbers are just the opening of a negotiation. It's easy to put a price on how much the medical care cost, but pain and suffering is totally subjective.
I had a recent patient with bandemia, ended up admitting them though i had to push the hospitalist to do so. Did a deep dive on it, apparently it is a high positive predictive factor for also having positive blood cultures and septicemia. It is not an absolute red flag to admit, but it is a yellow flag to give pause and consider septic causes.
Did they have a normal white count? I thought this case was odd because they didn't have a leukocytosis at first, but did have bandemia / left shift.
no, they had elevated wbc and pylo, but were young and healthy, if not for the bandemia then i would not have admitted them. My supervising physician agreed with me though that it is better to be cautious in these types of cases. from what I understand bandemia greater than 10 percent should give you pause to be concerned.
and so it continues, it would be real important to see who evaluated this person, was a general surgeon consulted? Ob gyn? I am so glad i never have to go to the ED again.
Lol consult an obgyn for an ovarian cyst or a general surgeon for abdominal pain in the setting of “normal” imaging and see what happens
remember when the "grey hair" came in and completed their own physical examination and diagnosis made despite "normal imaging".
There may be some unicorn surgeon somewhere that would come into the ER to do that but I haven’t met them. They’ll do inpatient routine consults but not ER unless actually emergent.
just an old timer here, practiced in a small town, everyone knew everyone and little fell between the cracks. in reality we were on 24/7 for our friends and community. Oh how the world has changed . I appreciate your comments.
"I am so glad i never have to go to the ED again."
That sounds very "unsinkable ship," no?