Recently my primary computer began to act sick off and on. I took it to the folks behind the tech support bar at the corporate store who were eager to help. They ran a bunch of diagnostic tests that were inconclusive. They couldn’t be sure whether it was a hard drive or a software issue, so they reloaded a clean copy of the software and wished me luck. They warned me that the hardware was too old for them to work should the problem recur.
Well, it did. So on a rainy weekend afternoon, I found myself visiting the independent computer mechanic who had been recommended. After a half an hour of running some more tests and a bit of head scratching, he stood up, leaned over the computer, and put his ear against the back of the panel for about a minute and a half. "I could do a bunch more tests tomorrow, but when the hard drive in these babies begins to fail, they make a different sound," he said. He told me I needed a new hard drive. I got one, and was soon back in business.
Two articles reinforce what I relearned during my visit with the computer doctor: A well-trained ear is a valuable tool, and more testing often doesn’t result in a more accurate diagnosis. Nor does it correlate with better quality care.
Dr. Todd A. Florin and his fellow investigators found that emergency departments that used more tests to diagnose and manage community-acquired pneumonia had higher hospitalization rates and were no more likely to experience revisitations than were lower utilizing EDs (Pediatrics 2013;132:237-44).
In the other study, Dr. Jane F. Knapp and her associates observed that pediatric-focused EDs used significantly fewer chest x-rays to diagnose asthma than did general EDs (Pediatrics 2013;132:245-52).
Neither of these groups examined the factors that might have influenced the differences in utilization that they observed. It is unlikely that standard lab and x-ray resources are any less available at the kind of institutions they were studying. Could it be that physicians practicing in pediatric-focused EDs somehow feel more insulated from the threat of a malpractice suit? Are they "better" trained? And if so, what was it about that training that allowed these physicians to rely more on their history taking and physical exams to arrive at a diagnosis? Or is there some test-ordering virus that has infected the culture of certain hospitals while sparing others?
Of course, one of the explanations may be that physicians who limit their practices to children are more likely to acquire a comfort level with diagnosing community-acquired pneumonia, because it represents a higher percentage of the volume of illness that they see. If a physician is well mentored, familiarity can breed competency.
I suspect that if the investigators in these studies had examined the relationship between physician age and resource utilization, they would have found that older physicians ordered fewer lab tests and x-rays. Forty or 50 years ago, physicians were more likely to practice in settings geographically separated from hospitals, and as such were less likely to have ready access to lab and x-ray equipment. Out of necessity, they had to become comfortable using their eyes and ears to make a diagnosis. As physicians huddled together in groups and/or became extensions of hospitals, diagnostic equipment became more available. And when it gets built, it will get used, particularly if it can provide some income.
Community-acquired pneumonia is usually not a difficult diagnosis to make. If I hear crackles in a febrile child, do I need to know his exact temperature or his white count? If the x-ray is normal, will I withhold antibiotics? Not if I know that x-ray images can lag behind reality.
However, if there has been a recent choking episode or the child looks sick enough to hospitalize, I would like more information before I treat. Or if a phone call from my office staff the next day isn’t reassuring, it may be time for some tests. But one phone call is cheaper than a complete blood count and emits far less radiation than a chest x-ray.
Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He is the author of "Coping with a Picky Eater: A Guide for the Perplexed Parent" and several other books. E-mail him at pdnews@frontlinemedcom.com.
Updated: 10/8/2013