Begin At The End

A fictional king once advised: “Begin at the beginning, go on till you come to the end: then stop.”

Notwithstanding this helpful bit of guidance, I learned at some point during my maze-solving childhood that it could actually be quicker and easier to solve puzzles or problems by starting at the goal and tracing a path back to the starting-point.

Take, for instance, a recent piece in the New England Journal of Medicine about usage of ultrasound versus CT for the ER workup of urolithiasis. The study casually included bedside ultrasound (performed by ER docs) as a separate category from radiologist-conducted sonography. I won’t bore you with the details here (if you don’t have a paid subscription to NEJM, a quick look on the AuntMinnie.com discussion forums will decently apprise), but suffice it to say the piece gave surprisingly poor statistics to CT and surprisingly good stats to sono. And an additionally surprising lack of reported difference between sono performed by ER versus radiology.

Surprising, I say…well, not if you begin with the end of the story, which is that ER staff are often far from shy about claiming that they are capable wielding transducers, and should be given the equipment, credentialing, and (of course) reimbursement for doing so. As the expression goes, “follow the money.”

The agenda in academic clothing doesn’t always have dollar-signs so directly visible at the finishing-line. Sometimes it’s about control, or even convenience. For instance, whether contrast is necessary or even useful in body CT scans on ER patients. Emergency-medicine write-ups of the matter seem to differ from many radiologists’ firsthand experience, not to mention more scholarly sources including the ACR Appropriateness Criteria. The disparity might seem puzzling…unless you start with the endpoint that cutting out contrast improves the ER holy-grail of throughput. (Notwithstanding the hours patients typically spend sitting around in the ER waiting to be seen before and after their CTs occur.) Removing the possibility of contrast also neatly turns the ER’s body CT ordering into much less of a thought-requiring process.[[{"type":"media","view_mode":"media_crop","fid":"28215","attributes":{"alt":"","class":"media-image media-image-right","id":"media_crop_486475719524","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"2835","media_crop_rotate":"0","media_crop_scale_h":"0","media_crop_scale_w":"0","media_crop_w":"0","media_crop_x":"0","media_crop_y":"0","style":"height: 76px; width: 200px; border-width: 0px; border-style: solid; margin: 1px; float: right;","title":" ","typeof":"foaf:Image"}}]]

Lest interspecialty sniping attain too much of the focus, it should be noted that the practice of cobbling data to arrive at a preconceived desired conclusion is far from new or unique to medicine. Further, our increasingly socialized healthcare system routinely sets such a tempo in much larger scale demonstrations of starting with a concrete goal and then ham-handedly getting there no matter how flimsy and unjustified the mechanism turns out to be. Here’s an old chestnut we’ve seen repeatedly:

Goal: Cut reimbursements. Method: Set “quality” metrics necessary to avoid penalties, or even get a bonus. Modified method: Retroactively move the metrics when too many docs and/or facilities are in compliance and reimbursements aren’t being cut enough. Re-modified method: Conduct audits to claw back even more money.

What does seeing through such flimflammery accomplish? Well, that all depends on what entity you’re dealing with. If it’s a used car salesman proffering a lemon, or a stockbroker with a bogus “hot tip,” there are options - like diminishing or eliminating your dealings with the individual.

But if it’s someone with more leverage, like another hospital-department with more clout than yours or a governmental agency that hesitates not at all to void its metaphorical bladder on your boot and tell you it’s raining…is there a benefit to knowing that you’re being sold a bill of goods when you can’t do anything about it?