There are many demands in the emergency department, some of which come from patients and their families. This post in the Art of Medicine series looks at those situations in which patients/parents are requesting – nay demanding specific tests.
As I noted in a previous post in this series the ED is an emotionally charged environment. Often parents are seeking an answer as to why their child is ill. That answer may come in the form of a specific diagnosis or further elucidation as to the reason for particular symptoms. I’m sure that many of you have encountered a parents asking for a “test” to tell them what’s wrong with their child. Perhaps they’ve even asked for it by name. “I just want a CBC.” or “She needs an MRI.” Let’s explore this conundrum in a little more depth, shall we?
Why are they demanding a test?
Because they are scared. Sense a theme here? Coming to the ED is oftentimes a frustrating, terrifying experience. Uncertainty drives many a visit, and in order to mitigate concerns parents are seeking answers. In many ways we have been taught to seek out objective evidence. In an era where any test is possible parents may be conditioned to think that the only path to a diagnosis is through a confirmatory test. Empiricism this is not. So before getting that test explore why the parent is “demanding” it in the first place. I’ve found that it is frequently possible to convince the parent that your diagnosis is justifiable based on H&P and clinical reasoning alone. All that this takes is time. Before ordering any test you should answer the following questions:
- Is it justifiable based on the clinical scenario?
- Is it justifiable from a billing standpoint?
- Will it make a difference in the patient’s clinical care?
- Is the risk worth the potential benefit?
Don’t they trust me?
Unless they explicitly say so the answer to this one is no. Many patients have been to multiple providers/had multiple visits before coming to the ED. Keep that in mind, and you will better empathize with a certain degree of skepticism that surrounds select encounters. Also, know your limitations. It’s cliche for sure, but trust is earned. You should always be honest with the family about what you think is going on and why you need/don’t need to pursue testing.
What if the referring physician said they should get a test, but you disagree or feel that a different test would be better?
Let’s consider the example of a belly CT for abdominal pain. Sure, it’s a great imaging modality, but the risk of exposure to ionizing radiation is great. Remember that to work in the ED is to work in a place where the worst case scenario should be considered and ruled out. This begins with an appropriately thorough H&P and selection of the best tests to aid in situations where the diagnosis or next course of action is still uncertain. Lot’s of things hurt inside of the belly. You don’t need imaging in a child to diagnose pancreatitis – so if the amylase/lipase are abnormally high skip that CT.
Also, you should always call the referring physician in any instance where a child has been sent to the ED. Perhapsthe referring provider has only spoken to the family on the phone. It’s quite possible that they said to the mother of a child with a barky cough - “Sounds like croup. The ED might have to give a breathing treatment or get an XRay.” Consider for a second that all a frightened parent might have heard is “My son needs an XRay to tell me why he’s coughing so bad.” Pretty different than leaving the room with the mindset that “Dumb PMDs don’t know what they’re doing – asking for XRays in a well appearing child with croup.” Telephone medicine is hard!
What should I do if the parent won’t leave without a specific test?
This is where your skills as a negotiator can help. But, if the family absolutely, positively won’t leave without a test then think about the risks and benefits. A test like a rapid strep is a no-brainer. The risk (unless you count sputum in the face) is small. The downsides of sending a CBC include pain from the venipuncture, and the chances that you’ll have to account for some aberrant results (false positive in the well appearing child). This could lead to more testing in the future. Plain radiographs are unlikely to cause harm and in my view are OK to order in these circumstances, but still don’t serve as a substitute for a thorough explanation of diagnostic though processes and clinical reasoning. I don’t think that one should be ordering CT scans, MRIs or performing more invasive tests (like lumbar puncture) just to placate a parent.
Should I document that I disagree with the ordering of the test?
No, because you shouldn’t been ordering something that is unnecessary in the first place. If you’re not sure ask a colleague or more experienced provider for help.
So, in summary I urge you all to address patient and family concerns head on. Find out why they want a specific test. This will help you better understand their thought processes and concerns and allow you to provide better, more informed care that is evidence based and likely to educate.