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The Cost-Effectiveness of Family Physicians — Work Up New Symptoms in Stages

September 29, 2013

I took the longest time off from posting on this blog site that I ever have since I launched it in 2010. I had a good reason. I spent a week in England learning more about their National Health Service. I’ll share some of those experiences later. Plus, I’m working on some articles for the mainstream media.

For now, I’d like to go back to the cost-effectiveness of family physicians. The next concept of how they behave different from other physicians is that they are more likely to work up new symptoms in stages.

All of us know that there are perhaps 89 causes of chest pain. But if a physician sees a patient with a new symptom of chest pain, should he or she order 89 tests to cover all 89 possibilities?

Family physicians clearly say that the right answer is no. Judgment should be applied based on the underlying disease probabilities of the specific patient situation. A 69-year-old smoking diabetic patient with 2 hours of crushing sub-sternal chest pain should have different tests than an 18-year-old girl with sharp right-sided chest pain that lasts for seconds and only occurs when she takes a deep breath.

This is an example of the culture of family medicine that differs from the culture of U.S. medical schools and the broader medical establishment. How many pimping sessions from some egotistical ologist in medical school revolved around the trainee not ordering enough tests to cover some extreme zebra disease? It happens a lot.

Perhaps our definitions of medical error need to change as well. We need to be more tolerant of what some would call the error of the delayed diagnosis. The only alternative is to order every possible test at the first opportunity. This is not only wasteful, it is harmful as well. Labeling an episode of care as resulting in a delayed diagnosis assumes that an earlier diagnosis would have changed the outcome, which is most often not the case.

At least most family physicians understand this. Too bad most of the other American physicians, regulators, the legal system, and the bureaucrats don’t.

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