When you first make the step from school to practice, pocket cards are (sometimes literally) a life saver. The pocket cards contain the most important treatments for the most common diseases in short sentences and flowcharts. In my field, neurology, we have at least ‘the acute cerebral infarction’, ‘the status epilepticus’, ‘mild traumatic skull-brain injury’ (two versions, for children and adults), ‘bacterial meningitis’, ‘intracranial haemorrhage’ , ‘subarachnoid hemorrhage’ and the phone book in your pocket.
Now that I have about five years of experience in neurology, there is little on the cards that I don’t also know by heart. Yet I still reach for it in stressful situations, routinely. When a bad patient comes in and the reception is hectic, with all kinds of doctors and nurses in the room, it’s nice to see your own idea about the next step confirmed on a piece of laminated paper.
It is therefore with enthusiasm that I open an email at my work address with the promise of a new pocket card. However, the subject appears to deviate from my current collection. The pocket card does not offer advice for a treatment, but an overview of the costs in clinical and outpatient neurological care in the Netherlands. For example, I read that a brain CT costs 162.64 euros and an epidural 205.06 euros.
I find the really large amounts in treatments for multiple sclerosis, oncological admissions, operations and genetic research. The purpose of the pocket card is to make healthcare providers more aware of the costs of their diagnosis and treatment, in the hope that other choices will be made. Thinking carefully about the yield of a particular test, looking at cheaper alternatives and requesting tests in stages is encouraged.
I understand this sentiment. Healthcare is expensive, too expensive, and the current way of working is probably not future-proof. However, I find it difficult to leave the decision to individual doctors. I am being trained in an academic center where scarcity – especially when it comes to requesting and receiving radiological examinations in a timely manner – is the order of the day. Thinking about sensible care is always an integral part of our work. A ‘steer away scan’ (imaging that is performed purely to reassure the patient, while the doctor actually has no suspicion of pathology) is rarely requested here.
Considering the costs even more when you are sitting in front of a patient is very difficult. You are afraid of doing someone short, of not being the best doctor, or of making the right diagnosis too late. Cost savings are necessary, but in my opinion should be implemented nationally and in protocols and should not be the burden of individual doctors in the consulting room.
In my left pocket are my reflex hammer, stethoscope, and neurological tuning fork. In the right pocket are the pocket cards with the most important clinical pictures for my field. The cost card is in my mailbox and on the hard drive of my computer, but it doesn’t get a place in my white coat.