Midwestern State University DB To Scan or Not to Scan Clinical Case Discussion After reading this article, write a 3-4 paragraph discussion of the article.

Midwestern State University DB To Scan or Not to Scan Clinical Case Discussion After reading this article, write a 3-4 paragraph discussion of the article. Should the cost of medical imaging influence the decision of whether or not to perform an expensive exam? Should other alternatives be explored first? Could taking cost into consideration compromise the patient’s treatment and outcome? You may do outside research for your post. Be sure to cite your sources properly and include an APA formatted reference list at the end of your post. You may not read other posts until you have made your own post.You will participate in four discussion boards. In the first three discussion boards you will be asked to read a health care situation which raises an ethical dilemma. You will then write a post that is 3 – 4 paragraphs long where you will discuss the situation. The fourth discussion board will ask you to comment on another student’s post from one of the first three discussion boards. Please read the instructions for that discussion board.You should briefly address both sides of the situation. It would not be a dilemma if there was not more than one solution. Be sure to discuss them both.Then state what you would do and why. When you tell us what you would do, be sure to tell us which ethical theory you are using to make your decision. Utilitarianism, deontology, rights-based ethics, justice-based ethics, virtue-based ethicsYou are expected to do outside research to write your posts. You should use at least two peer-reviewed articles. You can find information about peer-reviewed articles under the module “Course Project”. Your post should use proper APA in-text citations. There should be an APA reference list at the end of your post Virtual Mentor
Ethics Journal of the American Medical Association
March 2006, Volume 8, Number 3: 135-137.
Clinical Case
To Scan or Not To Scan?
Commentary by Marion Danis, MD
As a fourth-year medical student planning a residency in internal medicine, Rose
Simmons enjoyed her rotation in the emergency room and saw it as a chance to learn
practical points about patient management. She purposely chose Percy Hospital because
of its diverse patient population.
One evening Rose was working with Dr Charles, a respected attending who had been at
Percy for almost 10 years. Dr Charles handed her a chart. “Twenty-two-year-old male
with abdominal pain, Rose. See him in Room 15 and then present him to me.”
Fifteen minutes later, Rose returned with her note and a radiology order form in hand.
“Twenty-two-year-old male, no previous medical history, presents with abdominal pain
that started this morning as crampy and diffuse and localized to the right lower quadrant
over the past 2 hours,” she reported to Dr Charles. “He’s febrile to 102, slightly
tachycardic, with rebound tenderness in the right lower quadrant. His white blood cell
count is 16 000 with a left shift. Sounds exactly like the patient with a possible
appendicitis that we sent to CT this afternoon; want to sign this order form so I can
send him too?”
Dr Charles hesitated. “What does this gentleman do for work?” he inquired. Rose
replied that he worked as a cashier in his family’s grocery store. “Does he have
insurance?” Now it was Rose’s turn to hesitate: “He mentioned that he didn’t, but I
reassured him that we would make sure that he gets the medical care he needs.”
“I’ll take a look at him to confirm your findings. Then, why don’t we call the surgeons
and tell them that this patient needs to go to the operating room?” offered Dr Charles.
He looked up from another patient’s chart to meet Rose’s confused stare. “CT can be
helpful for the diagnosis of appendicitis, but it’s not the standard of care. This kid’s
family would have to swallow the cost; $1500 is a lot of night shifts at the grocery—or
an uncompensated loss for the hospital. We can save the family the trouble—and save
ourselves a potentially inconclusive scan—by trusting our clinical intuition and calling
the surgeons now.”
Commentary
This scenario describes 2 different approaches to the diagnosis and management of
insured and uninsured patients with similar symptoms. The juxtaposition leads to
valuable insights.
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Virtual Mentor, March 2006—Vol 8
135
Dr Charles has ordered an abdominal CT scan for an insured patient with suspected
appendicitis; later in the day he suggests managing the care of an uninsured patient with
suspected appendicitis without a CT scan. The delivery of a parsimonious plan of care
for the uninsured patient may well be among the best strategies one could offer. By
avoiding excessive and expensive diagnostic tests in clear-cut cases of appendicitis and
proceeding to provide necessary treatment, the attending physician in this story may be
providing the most cost-effective and affordable care possible.
One could argue that by offering frugal care, Dr Charles is being both prudent and kind
to this uninsured patient. Whereas insurance allows those of us who have it to pool the
financial risks of being sick, the uninsured patient must carry the financial burden of his
or her medical care alone. For the uninsured patient, illness often imposes both sickness
and poverty. By thinking about the financial burden for this patient, the doctor has been
attentive to the social context of illness.
As we consider this scenario carefully, we notice that Rose Simmons, the medical
student, perceives the disparity in care offered to the insured and uninsured patients and
infers that the care of the insured patient reflects the standard of care. Yet we, and the
student, should be cautious in making this inference. Often insured patients get
excessive interventions merely because reimbursement is available. This may well be the
case for the insured patient described here; CT scans are not always warranted because,
despite their sensitivity and specificity, they have not led to a reduction in unnecessary
operations [1-3].
Aside from the question of how good the CT scan characteristics are, when the clinical
presentation is classic and clinical suspicion is high, Bayesian logic suggests that one
ought to proceed to treat without the scan [4]. Bayesian logic applied here dictates that,
when the clinically based probability is high enough, a test will not necessarily add to the
verification of a diagnosis; it thus behooves a clinician to proceed immediately to
treatment. If, as the narrative seems to imply, the insured and uninsured patients were
similar in their presentations, the uninsured patient may have gotten the more costeffective approach to care.
This initial interpretation of the scenario may be overly simplified. Appendicitis, or any
other clinical problem, can present atypically, and the diagnosis can often be uncertain.
If that is the case in this scenario, what should the attending do? One option that would
preserve the cost-effective strategy of the physician would be watchful waiting prior to
making a decision about surgery [5]. This option is ethically acceptable because of
concerns about cost. In other words, this would be an ethically justifiable way to ration.
If, on the other hand, Dr Charles is uncertain about the diagnosis and does think that a
CT scan would be the best approach to diagnosing the patient, he faces some tough
options. He can either order it and risk incurring the anger of administrators at his
institution who are intent on avoiding financial losses, or not order it and impose unfair
rationing and the possibility of harm on an uninsured patient. In making this decision,
Dr Charles is choosing whether or not to be complicit with an unfair system that denies
equal access to uninsured patients [6].
136 Virtual Mentor, March , 2006—Vol 8
www.virtualmentor.org
Complicity is an ethical problem we all confront in a morally imperfect world. As
Christopher Kutz suggests, when we live in a complicated world in which the harms
imposed by economic, social, and political institutions affect our relationship with
others, we must sort out whether we wish to participate and the degree to which we are
thereby complicit in these collective harms [7]. His analysis—that to behave ethically we
must each take some responsibility for what goes on—would direct Dr Charles to order
the CT scan if he is in doubt about his uninsured patient’s diagnosis. Of course, Dr
Charles might possibly suffer the consequences of the hospital’s financial loss, but he
would do so while representing the patient’s well-being and interest.
References
1. Goldberg J, Hodin RA. Appendicitis in adults. Available at:
http://patients.uptodate.com/topic.asp?file=gi_dis/20863. Accessed February 13,
2006.
2. Mun S, Ernst RD, Chen K, Oto A, Shah S, Mileski WJ. Rapid CT diagnosis of acute
appendicitis with IV contrast material. Emerg Radiol. 2005;Dec 17:1-4.
3. Flum DR , Morris A, Koepsell T, Dellinger EP. Has misdiagnosis of appendicitis
decreased over time? A population-based analysis. JAMA. 2001;286:1748-1753.
4. Hunink M, Glasziou P, Siegel J, et al. Decision Making in Health and Medicine: Integrating
Evidence and Values. Cambridge, UK: Cambridge University Press; 2001.
5. White JJ, Santillana M, Haller JA Jr. Intensive in-hospital observation: a safe way to
decrease unnecessary appendectomy. Am Surg. 1975;41:793-798.
6. Committee on the Consequences of Uninsurance, Board on Health Care Services,
Institute of Medicine. Coverage Matters: Insurance and Health Care. Washington, DC:
National Academy Press; 2001.
7. Kutz C. Complicity: Ethics and Law for a Collective Age. Cambridge, UK: Cambridge
University Press; 2000.
Marion Danis, MD, is the chief of the Ethics Consultation Service at the Clinical Center and head of
the Section on Ethics and Health Policy in the Department of Clinical Bioethics at the National
Institutes of Health. Her research focuses on finding strategies for fairly rationing limited health care
resources by involvement of the public.
Related Articles
CT Scans in the Diagnosis of Appendicitis, March 2006
The opinion expressed here is that of the author and does not reflect the policies of the NIH, the US
Department of Health and Human Services, or the AMA.
The viewpoints expressed on this site are those of the authors and do not necessarily reflect the views and
policies of the AMA.
Copyright 2006 American Medical Association. All rights reserved.
www.virtualmentor.org
Virtual Mentor, March 2006—Vol 8
137

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