Bradley M. Tipler, MD

I have an elderly, demented aunt in California for whom I am the responsible decision maker. Up until a few years ago, Aunt Doris was an intelligent, powerful, and forceful woman. Picture Nurse Ratched in 

 and you will be pretty close, although Doris was never so insidious. After a stint as an Army nurse, serving near the front in the European and Philippine campaigns of WWII, she was a head nurse in the VA psychiatric hospital outside San Francisco for 20 years. Ken Kesey was an orderly there for a year before writing 

. In typical Doris fashion, when I asked about him, her summary was “Good for nothing, lazy SOB.”

Every night I see scores of exams on elderly patients. Last night I read an unenhanced head CT, perfusion scan, and CTA head/neck on an 80+ patient. The clinical summary given was “history of dementia, confused tonight.” Three thousand dollars to prove the brain looks like a hybrid of Swiss cheese and a dried walnut.

If we are ever going to control healthcare costs, people will have to accept that dying is part of our life cycle, and those in authority will need to incorporate this understanding into our healthcare system. Doris, when she was lucid, understood this well, and did everything possible to document that she wanted to die in peace, not in an ICU bed with tubes in every orifice and vessel. And still, the system works against her.

We enroll her in hospice with a failure-to-thrive diagnosis, but if she gains any weight, her insurance company takes her out of hospice. Then she gets sick again and is transferred from the nursing home to the hospital and treated intensively until I can contact her doctors and explain her wishes. She goes back on hospice and the cycle starts again. Recent changes in California law may be ending this cycle, but very few states have significant laws related to-end-of-life options.

Why does our system make dying so hard, and why can’t we fix it? Like most tough questions, the answers are complicated. Our culture has made discussions of death difficult for doctors and patients. Some religious and political groups view such forums as death squads. I guess the logic here is, if we don’t talk about it, it doesn’t happen. Sounds like the military’s “Don’t ask, don’t tell” policy.

Financial factors also play a significant role. In the span of my lifetime, American healthcare has evolved from a profession based on personal relationships into a behemoth modeled on a corporate structure. While corporate America likes to espouse noble ideas and goals, the bottom line always wins. One third of Medicare expenses come in the last two years of life, about $66 billion a year. Hospital organizations know imaging and high-tech surgery/procedures are the golden geese, so how hard will they lobby for limits? Ditto equipment manufacturers. Publicly held companies and private investment funds are becoming major players in radiology. How much do you think these large, for-profit companies will spend lobbying Congress to rein in medical expenses, and bring rational limits and decision making into end-of-life care?

For years I have felt our nation needs an Oregon-style Death with Dignity law. Recent experiences with my Aunt Doris have only reinforced that belief. As a radiologist, I am on the receiving end of the current situation, but as a physician I see the waste, futility, and near cruelty involved. I support organizations like Compassion and Choices, which work to change this mess. It remains to be seen if corporate medicine will support such a concept, and the hit on their bottom line. I suspect they will sit back and ride the status quo all the way to the bank, while doctors and patients remain frustrated here in the cuckoo's nest.

Articles

I have an elderly, demented aunt in California for whom I am the responsible decision maker. Up until a few years ago, Aunt Doris was an intelligent, powerful, and forceful woman.

We spend on end-of-life care at expense of patients

I enjoy historical novels. Three of my favorites are 

. One of the details I enjoy is the names. Tom Builder and John Mason leave little doubt what these men do for a living.

Names like Tipperwink and Justindoodle make you chuckle every time you read them. You have to wonder how those names originated. I assume Tipler says something about my ancestor's social proclivities.

Alcohol is a prominent part of life in much of the world. In the U.S., it plays a large role in healthcare. Like tobacco, it directly causes a number of diseases. Unlike tobacco, it also indirectly affects medical care, especially in the ER.

 written on imaging requests from emergency rooms. It comes in an amazing array of contexts. Four simple letters are used to convey a wide range of clinical scenarios, imply an etiology for myriad problems, and explain away a textbook full of imaging shortfalls.

I wonder sometimes if such a lack of specificity is a good thing to have in the medical record. Not that we don't understand exactly what the situation is, but are we giving ammo to plaintiffs' attorneys? Given the Charles-Manson-likefervor The Joint Commission and hospital suits have for clear communications, I am surprised this is tolerated.

From across the country I see requests that say “AMS, etoh.” To me this translates as “altered mental status-the patient is drunk- we have no way of discerning if there is anything else going on in addition to his/her being drunk.”

Often I get an exam, usually a head CT, with motion artifact. The request will have some variant of “repeated scan, etoh.” To me this reads as “the patient is drunk and would not hold still for the exam. I tried talking to him and repeated the exam, but he still moved.” I think most radiologists would get the same message, and I think the communication is usually accurate in this setting.

Maybe it is my own personal bias, but sometimes I get the impression that there is an underlying attitude, an implied message, that the patient is not really ill, just drunk.

There is an undercurrent of maddening frustration that comes from having done everything right and someone else then screwing up your work. It is hard to put a finger on, perhaps the way it is phrased, or even the emphatic handwriting used on 

Still, many times a night, I get the feeling I am dealing with frustrated technologists who are trying their best to get good images on an uncooperative drunk who probably just needs to sleep it off. They do their best, working hard to get diagnostic exams, which often still turn out less than optimal. We all understand this. The trouble is, as a resident once told me “Even turkeys get sick.”

What happens when an intoxicated patient has a real illness, the imaging and physical exam are compromised by his actions, and the diagnosis is missed? Who is to blame? My own bias is toward personal responsibility. However, I think our legal system has gone to an extreme in the opposite direction, and that is where these questions are ultimately answered. This is my problem with 

. Does it in any way imply less than 100% effort by the caregivers?

 adds no information. In my mind it implies many things, but includes no facts. If the patient doesn't, or can't, cooperate for a scan, that should be written in the record, not etoh. If you repeat a scan for motion, that is what the record should say, not etoh. The first line of all my reports is the history written on the request, minus any reference to 

I leave the etoh for the days when I am not working. Mine is a hard name to live up to, but I'm trying.

I enjoy historical novels. Three of my favorites are London, The Forest, and Pillars of the Earth. One of the details I enjoy is the names.

Name my poison? ‘etoh’ in emergency room requests

I live on an organic farm. Not that I'm a huge believer in organic farming, but my wife is. We have cows, chickens, dogs, cats, and more species on the way. In the past decade I have learned about animals, organic farming, and organic solutions around the farm.

If you visit our farm, you will notice partially filled baggies of water and a penny hanging in front of every door of our house. This is an organic method of keeping flies out of the house. Scientific explanations for this method hinge on the fly’s dislike of water, and the fact that their eyes split images into thousands of parts, so one little baggie of water looks like an ocean. Makes sense-too bad it doesn’t work. Fortunately, it has the hidden benefit of making a nice house look like a mobile home, so we are less likely to be robbed.

It strikes me that medicine and organic farming are much alike in this respect. We do a lot of things because that is the way someone told us to do it. We develop elaborate scientific explanations for why it works, and then we continue to do it based on anecdotal support, even when national consensus says it is not the best way of doing things. Since I joined Nightshift Radiology, I have been exposed to the wide variations in practice patterns across the U.S.

If you look up vertigo in the ACR appropriateness criteria, the highest rated test (if you need one at all) is an MRI with and without contrast. CT is not quite so high. What is being done around the country is a little bit of everything. I cover some hospitals where coming to the ER “dizzy” will get you a CT head with CTA head/neck in a heartbeat. At some hospitals with 24/7 MRI coverage, you will have an MRI/MRA of the head and neck before you sit down in the ER. I was taught all you need in the ER is a noncontrast head CT to exclude blood and mass effect, a shot of Vistaril, and an appointment with a neurologist. How can there be so much variation in approach to one problem?

Organic farming techniques go back thousands of years, while “modern” farming only starts with the industrial revolution. Organic farmers will proselytize at length about the life-affirming qualities of their methods and the horrors induced by chemicals in farming. They are oblivious to the fact that since the development of modern farming techniques our lifespan and our food productivity have increased dramatically. They long to go back to the good old days when people died at 50. And they can give you compost piles of anecdotal evidence to support their favored methods.

When I talk to ER docs, it seems to me the most powerful influences on decision-making are how they were trained to do something originally and their most recent “oh my god” case. A diagnosis of pulmonary embolism used to require much more clinical judgment, and the diagnosis was often difficult. These days ER docs are ordering chest CTA at the drop of a hat. The threshold for the test changes every time they are surprised by a positive result with low pretest probability. They’re like organic farmers: If it worked once, it must be the way to go.

What is the best way to do this medicine stuff? The government wants and thinks it can all be standardized, which may happen, up to a point. But our personal experiences influence our judgment, which is the crux of medical decision-making. Applying ACR appropriateness criteria and the numerous published clinical scales may bring some national conformity. But what we really need is an absolute rule, similar to the one governing me and organic farming: “If mamma ain’t happy, ain’t no one happy.”

I live on an organic farm. Not that I'm a huge believer in organic farming, but my wife is. We have cows, chickens, dogs, cats, and more species on the way.

Is why we do what we do reason enough to do it?

Recently, there has been some debate in the radiology literature about the demise of general radiology, and with it people like me: general radiologists. The future of radiology is subspecialization, they like to say. “They,” coincidentally, are always subspecialists.

. “I want to say one word to you. Just one word: plastics.” The screenwriter hit the nail pretty squarely on the head. We use ever increasing amounts of plastic in our lives.

I bought a new Mazda, which is 99% plastic. Great for gas mileage, but turned out to be not so The car is when my wife hit a curb at 5 mph and destroyed the front end. Like plastic, subspecialization is ubiquitous in medicine. But also like plastic, it is not synonymous with quality.

There are definite advantages to subspecialization, which subspecialists love to point out. By limiting your field of expertise, you can concentrate your study and CME on that area. This is particularly helpful if you lack the will or capacity to stay abreast of radiology in general. Zing.

The corresponding clinical subspecialists find rapport with you more easily because you all speak the same language. Of course, if either you or they encounter a problem outside your narrow field, you would want to consult the appropriate subspecialists in that field and let them communicate precisely with one another. When that third problem arises you will need a committee meeting.

Or-here is a novel idea-why not have someone who talks all these languages and integrate the problems, a super subspecialist? Patients have a funny way of showing up with more than one problem, or one problem that affects several organ systems at once. We could call this new guy the multi–organ-system subspecialist, or MOSS for short.

The creation of MOSS radiologists has some other, less obvious, advantages. Academic departments could establish new subsections, thereby creating new job opportunities for younger radiologists. Whole new avenues for getting journal articles published, which is so important to many subspecialists and clearly makes you a better doctor, would be available.

Other radiology subspecialists would be able to communicate with MOSS radiologists without fear of stigmatizing themselves by associating with inferior beings. This new field, by combining a broad knowledge of radiology with the ability to integrate the total clinical picture and the total imaging spectrum, would be adding a unique value to the patient's care. This is especially important because value added has always been one of the best ways to assess the practice of medicine.

As we move closer to the corporate model in medicine, I foresee large healthcare organizations employing MOSS radiologists as chairs and central coordinators of imaging departments. Patients admitted to hospitals might have their imaging optimized and initial exams done by a MOSS radiologist, and, when necessary, additional studies could be preformed or interpreted by other subspecialists.

Large outpatient and emergency centers might use MOSS radiologists, comfortable as they are with the myriad of patient presentations, to initially read exams and then determine the course of subsequent imaging and appropriate subspecialty referral. MOSS radiologists would be a central, critical part of the radiology spectrum.

I have been a general radiologist for 25 years. The entire time subspecialty radiologists from various fields have been predicting and promoting my demise. In that same 25-year span I have never heard a single general radiologist call for the end of subspecialization within radiology. Why is that? Sure, you see my mistakes, but I see yours. Part of the problem may be you see more of mine than you see of your own, because you are not second reading your own work. Every general radiologist I know, myself included, has always seen a role for subspecialists in radiology and values their contribution. The difference between us may be an ego thing, like those two plastic surgeons on TV. Do some subspecialists consider themselves the rock stars of radiology?

Recently, there has been some debate in the radiology literature about the demise of general radiology, and with it people like me: general radiologists.

Bradley M. Tipler, MD

Articles

We spend on end-of-life care at expense of patients

Name my poison? ‘etoh’ in emergency room requests

Is why we do what we do reason enough to do it?

What's old is new again, and the world rolls on