Last post, I mentioned that we work in a system that can encourage unnecessary testing. I then went on to see a patient that really hammered this point home for me.
A young insured high schooler tripped and fell, hitting his head against a window sill and knocking himself unconscious with seizure-like activity for about ten seconds. His dad found out about it the next day, talked to his wife who had a friend who knew a nurse who told them he could have a brain bleed and that’s the story of how we ended up meeting.
It was now almost 24 hours after the fall. I talked to him and looked him over and decided that he had not had a seizure, only passed out (not that it really made any difference) and that everything about him was completely normal.
There were no outright expectations of a CAT scan, but real concerns had been placed over a possible head bleed and so I started to give the talk I give to allay those fears.
As I did so, I reflected on my situation. Why the heck was I advising against a head CT? The family wanted one to prove nothing’s wrong. The hospital wanted one to make some money and increase patient satisfaction while decreasing liability. The radiologists I’m sure are more than happy to read and bill for an easy young normal head CT. And why was I spending time trying to convince these people to forgo a test when I gain nothing but increased risk?
Because unnecessary testing is wrong — it wastes money and resources and in the specific case of a CAT scan increases the lifetime risk of cancer by some small percentage. The family ended up being reasonable and saw the logic in what I was saying and everyone seemed satisfied without any further testing.
Still, it was a reminder: while the justification to withhold testing tends to be nebulous and distant, the reasons to just go ahead and order the scan are anything but, surrounding me in the ER. And while no one has ever thanked me for not ordering a test, failing to order one on the wrong patient would result in people lining up to publicly speculate as to how I could possibly practice such bad medicine.
June 10, 2008 at 11:38 am
Interesting reflection. Sounds like you are fighting an uphill battle – like recycling. It’s a very noble cause but probably won’t make a difference in our lifetime. (I always look forward to reading your posts – keep ‘em coming!)
June 10, 2008 at 2:22 pm
Very insightful and interesting!
June 10, 2008 at 4:23 pm
And you were absolutely correct.
June 10, 2008 at 5:24 pm
Wow, an example of a doctor NOT practicing “defensive medicine” for a change! Very refreshing! Good job!
Love reading your blog!
Jeremiah
June 11, 2008 at 12:35 pm
Hi, Ten!
I’m Julio from Brazil.
I’ve seen your blog in wordpress.com and liked it very much. It’s the first time I’ve read a “Medblog”.
It’s so surprising see that a ER doc has time to write a blog and even to laugh about his life! I’ve subscribed your RSS and have become your fan!
I have a personal blog in portuguese about my everyday thougths. Maybe you go there and don’t understand anything, but at least stare at the pictures, lol. And comment, anywhere, please!
See ya!
http://pensaria.wordpress.com
June 11, 2008 at 12:44 pm
Excellent observation. I sympathize with ER docs who *do* feel cornered into ordering more tests. The level of health care literacy among patients tends to extend up to the point of knowing which tests are available, but not when they are indicated. I think most of us face difficulties when someone approaches us and requests a CT scan, Lyme serologies, MRI of the c-spine. It takes a long time to get the relevant history and explain risks/benefits of testing, including the risk of any incidental finding that a) does not answer the patient/doctor’s question and b) requires more studies to follow-up. Thank you for the post.
June 11, 2008 at 8:23 pm
Unfortunately you are put in that situation where yes, for all the reasons you mentioned, you have to order the scan. And then the bill goes up, and the insurance company gets charged more, and the bills are passed to us, and our insurance policies become expensive and out of reach…until we no longer can order the scan because we have no way to pay for it. The whole system needs rethinking.
Scalpel’s comment (#10) is a good start
June 11, 2008 at 8:51 pm
I hope that if I ever get end up in the ER, I’d get a doctor such as you – the one who actually discussed the test with the patients rather than just order it. I for one, don’t want unnecessary tests.
June 11, 2008 at 8:53 pm
Hmmm – I thought you were going to talk about a more typical situation – a person with a totally minor head injury and no LOC expecting or demanding a CT. Your case at least could have some justification medically to order it since there was LOC and once and a blue moon there are delayed subdurals. I find it easier to fight the “you don’t need a CT” battle with the TOTALLY bogus minor cases.
Whenever I talk people out of a test, there is always a moment leaving the room when I think wow I really hope the don’t end up having something wrong. Agreed you can justify a scan here but he was far enough out that he clearly didn’t have the life-threatening epidural, and he sure didn’t act like he had a subdural, and even in the unlikely event he did I figured he looked so good they’d just watch him anyway and even relayed all this info to the family to help them make a decision. All of which just proves my original point — it takes a lot less thought and effort to just order the scan.
June 11, 2008 at 10:18 pm
I think we should be able to charge a higher evaluation and management fee for using our clinical acumen instead of ordering a bunch of tests. If you were able to bill an extra $50 – $100 for deciding the patient did not need a CT scan (therefore saving the patient/insurance company a couple of thousand bucks), the incentives would be proper and useful to all parties.
Unfortunately, the opposite is true.
June 12, 2008 at 2:57 pm
I am surprised that seizure activity would not indicate a higher risk of significant injury.
I like your reasoning on this patient.
Scalpel recognizes the problem of fee for service, that ignores the use of critical judgment as a service.
June 14, 2008 at 12:18 am
Certainly a tough situtation, especially when you’re dealing with expectations from a family. I think it would be fair to draw a parallel here between the pressure to order an unnecessary CT scan and the pressure we all face on a daily basis to prescribe unnecessary antibiotics. What an uphill battle that is!