Are you a perfect diagnostician? No? Then give your patients a break

Give your patients a break. Nobody is a perfect diagnostician. Not even the best trained physician can determine, with 100% accuracy, which patients have serious pathology. Even with advanced testing, we aren’t close to perfect. However, if you listen to the subtext of breakroom complaints, it seems like we expect patients to be better diagnosticians than we are. “Why are all these patients here with completely trivial issues?!”

As an emergency physician, I hear a similar complaint from radiologists all the time. “You emergency docs order way too many CTs!” They focus on the negative scans, and judge our practice on that single data point. Of course, to be a great emergency physician requires ordering negative CTs; perhaps a large number of negative CTs. I don’t know the appropriate negative rate for a CT angiogram of the aorta. I am pretty happy to have 20 negative scans – or perhaps many more – for every one positive, given how hard the diagnosis is to make. If my negative CT rate is lower than that, I am almost certainly missing aortic dissections. However, the radiologist primarily sees the negative scans, and so they complain. They have already read 10 negative aorta scans today, and so complain to me that “you emerg docs order way too many scans” and “this patient can’t possibly have a dissection”. (Ironically, my rule in rate when a radiologist tells me a patient “can’t possibly have” a disease is very close to 100%). 

Reflect on that for a moment. In emergency medicine, you know that negative tests are an important part of good clinical care. In order to avoid missing dangerous pathology, we need to order more negative tests than positive. Medicine is hard. Even with many years of intense training, interpreting the vague signals from the human body is an imperfect science. We readily accept this when evaluating our own practice. Why then are we so unwilling to extend the same logic to our patients?

A patient’s decision to come to the emergency department is a diagnostic decision based on their (untrained) interpretation of the symptoms they are experiencing. It is their equivalent of ordering a CT scan. If a trained physician is not perfect in interpreting signs and symptoms, should we expect perfection from our patients?

When we mock our patients for presenting with “nothing” or “trivial symptoms” we are acting exactly like the radiologist who complains that emergency doctors order too many CTs.

Might there be a kernel of truth to these complaints? Of course emergency doctors order too many CTs. Of course there are some patients who don’t need to be in the emergency department. But complaining or mocking the individual making the decision doesn’t help.

Emergency physicians don’t like ordering unnecessary scans. No doctor wants to expose their patients to unnecessary radiation. No doctor likes to have more studies to interpret. Extra tests make us less efficient, as we have to spend more time reevaluating the patient after the test is completed. Every emergency doctor has at some point stayed late after a shift because CT results they have been waiting on for hours get reported just as they are about to leave.

We don’t order these tests because we want to. We order these tests because medicine is hard. We order these tests because of societal pressures. We order these tests because doctors are expected to be perfect. We order these tests because malpractice lawyers are always circling.

Likewise, patients don’t want to come to the emergency department unnecessarily. The emergency department is not a fun place to spend time. No one wants to wait 4 hours to be seen by a doctor. No one wants to sit with their child next to a patient tripping on meth. No one wants to spend time in a waiting room far less comfortable than your average airport, with no place to charge your phone, no food, and often not even access to drinking water. Patients don’t choose the emergency department if they have viable alternatives.

They come to the ED because it is the only option. Because their family doctor only works between the hours of 9 and 3, 4 days a week. Or because they don’t have a family doctor at all. Or because, despite having a clear surgical complication, their surgeon won’t see them until the visit scheduled 6 weeks post-operatively. 

We judge these patients. We judge these patients because, retrospectively, after completing our assessments, it is clear to us (with all of our medical training), that there is nothing wrong with them. We judge them exactly like the radiologist judges us (after the CT is already negative, not before). 

We need to shift our perspective. These patients are worried. They could have a serious condition. They need our expertise. It is OK for them to have false positives, just like it is OK for us to order negative CTs.

I don’t know the ideal “positive ED visit rate”, but I know it is not 100%. If we don’t want patients sitting at home with potentially deadly pathology, we need to accept that. Like the radiologist needs to learn to live with the fact that their job involves reading a lot of negative CTs, we need to learn to live with the fact that out job includes caring for the worried well. We should not judge our patients for seeking our care. 

If you want to complain, at least direct your complaints in the right direction. Complain about a system where patients can’t find a family doctor, and therefore feel compelled to seek care in an emergency department for issues they know aren’t emergencies. Complain about the lack of urgent appointments with surgeons for post-operative complications, or the long waits for specialists, or the backlog for imaging, all all of which push patients unnecessarily towards an overcrowded emergency department. Complain about an educational system that fails to teach children basic health literacy. Complain about governments who consistently underfund medicine. Complain about administrators who divert funds away from patient care into endless bureaucracy. 

But don’t complain about patients. They are doing their absolute best within the health system we created for them. We shouldn’t expect them to be perfect diagnosticians, especially considering the utter lack of resources we have provided them with.

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