September 26, 2007
I guess I order a lot of CT scans.
It’s my reputation anyway. According, so I’ve heard, to the radiology techs and nurses. And I know at least one of the docs in my group feels this way. Sometimes he’ll ask me my opinion on a patient he’s seeing. “I know you’d scan this patient,” he’ll say, “since you love ordering them so much.”
I shouldn’t let this kind of thing bother me. Why should I care what the techs and nurses think? Let them walk a mile in my shoes. They’re not held accountable if they miss a head bleed or PE or small bowel obstruction or neck fracture. I am.
But still. I don’t want to be known as the guy who scans everything. The implication is you’re weak. Or stupid. Don’t believe me? Ask Nurse K (here and here).
Part of it, I think, is the docs I work with. They’ve all been practicing a minimum of ten years, most a lot more. It doesn’t matter how book smart you are, there’s no substitute for laying hands on tens of thousands of patients and the clinical wisdom that comes with it. Not to mention when they were in training it apparently took an act of Congress to order one, and the image wasn’t even that great.
In the end, you can’t worry about any of that stuff. You just have to do what you think is right for your patients. And I stand behind every scan I’ve ever ordered.
So anyway, the other night I figured out a way to see how many scans each doc ordered over the last month. And I’m not even leading the group. I’m definitely firmly entrenched on the right side of the bell curve, but I’m not the crazy outlier I’ve been led to believe.
Not that it ever mattered anyways. But still, ha.
September 26, 2007 at 9:37 pm
Oh, don’t worry. Order away! American tax dollars are vast and never-ending. Insurance premiums have already hit a ceiling and can’t go any higher! Oh wait, yeah they can.
Yeah, we don’t have the liability, but if I chart my assessment and you chart your assessment and neither one has an indication for the exam and you don’t order it, how can they sue you?
What pisses me off personally (other than the lobby back-up that is created when scan-happy doctors are on) is when a doctor won’t tell the patient they’re having a scan (some won’t even warn the patient about the $5000 or whatever MRI scan they ordered) and I don’t think there’s any indication for it. It’s like they want me to defend their stupid scan. Nope. Sorry.
September 27, 2007 at 4:06 am
If there’s no indication, I don’t order it.
I don’t do any of that stuff.
September 27, 2007 at 10:04 am
Two words: Defensive medicine
September 27, 2007 at 11:21 am
“Yeah, we don’t have the liability, but if I chart my assessment and you chart your assessment and neither one has an indication for the exam and you don’t order it, how can they sue you?”
Because the bar is so low to sue, and the risks so high. Hell, if the patient/victim looks sympathetic enough, that’s all you need, no science required.
September 27, 2007 at 6:22 pm
Regardless of how many scans you order, you will still be sued. Unfortunately it is simply a part of our life. You can not prevent lawsuits from being filed. But, you can help prevent yourself from losing them.
If the scan is not indicated, and you have met the standard of care, you will likely win the lawsuit. Practicing in fear of your first, or next suit, is a miserable place to be.
September 28, 2007 at 5:21 pm
I never fault an ER doc for a scan. To me, you guys have it the hardest. You have no relationship on which to base the patient (non-complainer vs. cry-wolfer), you have no opportunity for followup, and you have immense time pressures and other patients waiting to be seen.
For my patients whom I know well, sometimes it’s appropriate to follow conservatively and scan if not better in 24 hours. That would be tempting fate (and a lawsuit) for you.
I speak for primary care when I say that we don’t fault you guys for scans. After all, what do we say when we don’t know what the hell is wrong, and it’s looking bad?
“Go to the ER…”
September 29, 2007 at 10:53 am
It seems like some of the practice of ER medicine seems to relate to confidence. If docs are confident in their assessment skills they don’t seem to order as much. Thats what it seems like to this nurse anyway. As an ER nurse I know exactly which doc will order lots of tests, which won’t. I gotta tell ya we dread working with the overorderers.
September 29, 2007 at 11:05 am
Nice to see that nurse K is so empathetic. As many plaintiff lawyers themselves point out, they themselves want as much testing as humanly possible because as far as they see it that is the best medicine and are we really going to fight lawyers. If you can’t beat ‘em, join ‘em….
September 29, 2007 at 9:18 pm
You know, the point of the post is that I don’t order a ton of scans. But whatever.
September 30, 2007 at 8:18 pm
You probably managed to tick someone off. Maybe only once, probably at least a couple more times than that.
What I find interesting is that you didn’t blow off the allegation. You found a way to determine whether or not it was justified.
As you said, Ha!
I don’t want the ER doc who does unjustified scans - or the doc who doesn’t do justified scans. I want someone closer to the center of the curve than either of those. Sounds like you are.
What I most want, though, is someone who will explain (briefly)what has been ordered and whet he/she expects to find/rule out with that test. Doesn’t have to be very specific and if I come in with a headache, I don’t need be told that you’re ruling out a brain tumor when you do the head CT. In fact, I’d really rather NOT hear that, because I know it’s on the differential.