One of my biggest pet peeves in medicine is when a patient tells me what tests I should order for them. I am sure it is one of yours, too. We did not go into medicine for the purpose of being told by our patients what tests they would like to order.
Unfortunately, our years of medical training and experience are trampled by the patients that arrive with internet research in hand and a society that relies heavily on testing, rather than experience and a thorough examination.
In school, we learned lots of different criteria for what warrants an x-ray. The Ottawa Ankle Criteria is a perfect example of how to determine whether or not a patient needs an x-ray of his or her ankle. I love the Ottawa Ankle criteria. Unfortunately, I don’t practice it.
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What I didn’t realize in school is that, particularly in the emergency department (ED), patients aren’t coming to have you evaluate if they hurt their ankle — they are more so coming for the x-ray. You can explain the Ottawa ankle criteria over and over again, but some patients are not going to be satisfied until they get their x-ray.
There is the rare instance where you can convince a patient that they do not need the x-ray and they should really wait and see if there is improvement before they come back, but in our society and with the cost of medicine, patients are less apt to return and pay an additional copay when they could just get the x-ray while they are already there.
I used to push for patients to forego the x-ray, explaining that it would not change the treatment course or it might increase their hospital bill, but then I started putting myself in their position. If I myself, even with all of my medical knowledge, went to the ED for ankle pain, I would want an x-ray. I would not want to go all the way to the emergency room to get an ace wrap and some crutches and to be told I did not need one. In short, the only reason I would be going would be to get an x-ray, because I am too nosy of a person not to know exactly what is going on inside of my ankle.
After putting myself in my patient’s shoes, I realized that I would be doing the exact same thing they are doing. Therefore, if a patient comes in and asks for an x-ray, and there is a slight chance they may have a fracture, I am more apt to order it. In this instance, you are not only giving them an x-ray, you are also giving them piece of mind. Hence, the idea of the therapeutic x-ray.
This is not to say that I have become completely soft when it comes to allowing special tests. I will never order a CAT scan if I feel it is not warranted. And if a patient’s extremity appears totally atraumatic and he or she is using it without difficulty, I will give you a full on explanation as to why I don’t think you need an x-ray.
The more I work, the more I realize how much of medicine is treating both a person’s mind and body, and how much society has affected our patients’ minds. But I too am a member of society, and I too would be doing the exact same thing.
Jillian Knowles, MMS, PA-C, is an emergency medicine physician assistant in the Philadelphia area.
