Transcript Risk avoidance - Jacobi Emergency Medicine

Risk
Or, Hippocrates was wrong
P. Mukherji
Primum non
nocerum
-HIPPOCRATES
First do no harm
 FIRST:
implies that this is a cardinal
and overarching tenet of medicine
 The
statement also implies that this is
possible.
Better motto:
 Please
try and kill as few patients as
possible, while hopefully healing and
helping as many as possible.
 Please
stop me
 Please interrupt
 Please look it up
91 yo WM s/p trip and fall
 +head
injury: abrasion
 NT head/spine, full ROM
 No concerning sx, no ASA/Coumadin
 CT?
RULES to help us?
 Canadian
 NEXUS
 New
Head CT
II
Orleans Criteria
To scan or not to scan?
0%
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a
...
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..
0%
in
b.
Spin em all and let
God sort em out
Nope, he might
get a brain tumor
Sp
a.
CT shows small SAH
...
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IC
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H
b.
SDH is more
common in trauma
Epidural is more
common in trauma
He has an aneurysm
He needs ICU time
He needs a monitor
SD
a.
Pt. admitted for observation
 Falls
off the bed(!)
 When transferred back to stretcher
stops breathing
 Regains VS, is transported to CT
 Stops breathing again!
CT shows?
 C-spine
 CT

is crumply at C2
head is clean
Attending read later finds initial CT
finding to be motion artifact
Did we do wrong?
 Pt.
was admitted for his own safety
 Harm came to patient
 Admission led to harm
 Should

we change practice?
CO- vs. O-MISSION
Would you do it differently next
time?
0%
H
ow
d
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T
ab
ou
t
pl
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...
0%
ea
b.
Head CT please
How about just
good instructions
H
a.
Doctors are biased*
 Routinely
overestimate benefits of
intervention
 Routinely minimize risks of
intervention
*Surgeons!
House of God?
 FAT
 “The
MAN’s RULE #13
delivery of good medical care is
to do as much nothing as possible”
But it’s not just about doctors
 We
all routinely underestimate
everday risks

High frequency, unlikely events
 We
tend to demonize and
overestimate rare events

Low frequency, very unlikely events
Did you ever fall?
 Over
your lifetime, falling is a
significant risk
 Falls
in the elderly are a problem,
should you be attentive to it already?
What’s most likely to kill ya?
ll
Fa
u
Fl
RS
A
M
k
ta
c
d.
at
c.
25% 25% 25% 25%
ar
k
b.
Shark attack
MRSA
Flu
Fall
Sh
a.
Actual lifetime odds of dying
 Sharks:
 Falls:
1 in 218
 MRSA:
 Flu:
1 in 60,453
1 in 197
1 in 63!
Risk vs. Benefit
 We
accept the risk of anaphylaxis
when prescribing antibiotics,

AS LONG AS
 We
think there is some benefit to the
antibiotics for the pt.
Overutilization?
is defined by multiple
federal overseers and review boards
as:
 Overuse

Testing for which no (or minimal) benefit
to the patient exists
Who has prescribed Abx?
 …for
sinus pressure?
 …for cough/bronchitis?
 …for sore throat?
31M with fever and sore throat,
has exudates, tender ant.
nodes, and no cough
a.
b.
c.
d.
e.
Bicillin shot!
Z-pack
Rapid strep, Cx if
neg
Rapid strep, do
what is says
Suck it up, wuss
It’s cool, you haven’t killed
 (Probably)
 But
you haven’t helped
 …and
you might have killed
Sore throats
14 million visits in U.S./yr.
 Steroids/NSAIDS >> Abx
 NO evidence that it helps abscess
 ONLY evidence on rheumatic heart from
worst military outbreak ever

NNT? 40,000
 NNH? 5 minor rxn, 6 to recur, 2500 major

Smartem.org, David Newman, AEM 2010
Let’s talk about
 Our
cognitive errors
 Assessing
and communicating risk
 Balancing
risk and intervention
Unintended Consequences**
 Interventions
ALWAYS have the
potential to create unanticipated and
unforeseen events

Perverse

Every intervention/test carries RISK and
UNCERTAINTY
 RULE #1


LAW of UNINTENDED CONSEQUENCES
We are expected to detail these risks to
our patients

Informed consent: risk/benefit- uncertainty
on both ends
Risk assessment
 We
suck at this
 Probability
of Occurrence x
Impact of Risk Event
We suck at probability, too.
 Statistics,
 You
anyone?
test a bunch of people for HIV
 1 is positive
 Likelihood of true positive?
Math!
 Test
is 99.99% sensitive AND
specific
 Out
 So
of 10,001 men, 1 has HIV
what do you do with your positive
guy?
Sir, your rapid test was positive,
you need a repeat test but…
ro
ng
ly
ab
Pr
ob
Pr
ob
ab
le
,
ry
ve
s
It’
w
un
bu
t
li.
.
...
.
e.
..
lik
ry
d.
ve
c.
25% 25% 25% 25%
s
b.
It’s very likely
correct
It’s very unlikely
to be correct
Probable, but
could be wrong
Probably wrong
It’
a.
Great for negatives (screen)

One pt. with HIV will be positive.

One other pt. will have a positive test.

50% chance that this is a true positive**
 PPV = 50%
(RULE #2)
Testing?
 On
low prevalence groups leads to
higher rates of false positives**
 RULE
#2
Screening
 Hgb
A1C
 Mammography
 PSA
PSA
 Screening
PSA will result in an
absolute mortality reduction of 33%
PSA
 17

of 100 men will get a dx of CA
3 will die if untreated
 Treatment
will save the life of 1 of 3*
 Treatment will kill 1 of the 17
 10 of the 17 will be incontinent and/or
impotent
How you present the data
matters
 “98.5%
safety from a particular
disease”
 That
is exactly 1 in 63, the odds that
you’ll be killed by flu in your lifetime.
How likely are you to pass the
inservice?
%
20%
99
%
20%
98
%
20%
95
e.
%
d.
20%
90
c.
20%
%
b.
50%
90%
95%
98%
99%
50
a.
You did not grow a brain that
likes small or huge numbers
 All
your brain sees is either a really
high (98%, 99%) likelihood and
rounds up
 or
a really low (1%, 2%) and rounds
down
Probabilities are percentages
 But
real numbers work MUCH better
RULE #3: USE REAL NUMBERS
 Want someone to go home?
 “98% you’re ok!”
 Want someone admitted?
 “1 out of 50 you’re dead!”

How do some docs manage
risk?
 TESTS

We’re even told that pts. WANT tests.
 Testing

does not reduce legal action
and might increase it
Every test is an additional
intervention** RULE #1
 Failure
to follow up
 Failure to interpret correctly
 Failure to pursue to the correct test
 Alteration of the presenting frame
 Incidentaloma
 Radiation
Prevalence of incidental findings in
trauma patients detected by
computed tomography imaging
 >3000
pts.
 990 (32%) had Type I findings
 1274 (41%) had Type II findings

631 incidentalomas concerning for
nodules, masses
Incidence and Predictors of
Repeated CT-PA in ED patients
 Longitudinal
study of 675 pts.
 33% had repeat CT-PA
 5% had >5 repeat CT-PA
 75% had some CT scanning
 Limitations:
possible under-reporting
Don’t just stand there…
 Inherent
 Lack
predisposition to intervening
of tolerance for uncertainty
 Errors
of comission and omission are
treated differently
Testing does not transfer risk
 Most
“high utilizers” are not driven by
litigation fears
 Most
cite diagnostic concerns, “best
for the pt.”, “don’t want to miss
anything”
 “Not
missing anything”
Implies need for diagnostic certainty
 Relays fears of sudden unexpected
morbidity

 Outcome

based practice
Low risk patients may not get a dx
Who’s the most conservative
Jacobi attdg?
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b.
Perrera
Gruber
Corciari
Haughey
Jones
Sufai
Pe
a.
Most clinically cowboyish?
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d.
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c.
17%
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a
b.
Perrera
Gruber
Corciari
Haughey
Jones
Sufai
Pe
a.
 What
if all the cowboyish guys
worked fasttrack and main?
 And
the most conservative attdgs
worked resus/trauma?
Poker, anyone?
 Know
thyself
Questions?
 We
a low level of comfort with
uncertainty; it makes us want to do
stuff
 Testing low risk groups has problems
 Discussion of risk and benefit (to
whom and of what) is ongoing.
Minimalists will win this discussion.
Take home
 We
should expect much clearer
thinking about risk to our pts.
 We
should accept that we are
responsible for both our actions and
inactions, and tailor approach to pt.
Thank you
Dr. Schriger, UCLA
Dr. Gallagher, Montefiore
Dr. Newman, Sinai
choosingwisely.org
TheNNT.com
bestbets.org
Cochrane Review
@ercowboy