Here are a couple of interesting MSNBC articles....one about over-testing, and the other about over-treating. Both articles claim that we waste billions of dollars every year by over-testing and over-treating patients. Well....no shit Sherlock! Here are my takes on the subjects.
Part 1 OVER-TESTING:
Yes....we over-test a lot. It is called defensive medicine. But it is not JUST because we are afraid of getting sued. Nobody wants to get sued. I am sure it totally screws with your head. Just having to present in M&M conference in residency would fuck up my head for weeks. No doctor, especially ER doctors, want to miss something. In the ER you margin of error is supposed to be zero in the few minutes you have with a patient.
I am in a tort reform state, and lawsuits being capped has not slowed me or any of my colleagues down in our testing. We don't think..."Oh well, now I can only get sued 200k for this patient so I might as well send him home and risk it." No....its that WE DON'T WANT TO GET SUED PERIOD. We don't want to screw up. We don't want to miss things. There has to be a balance in the testing. But it seems as soon as we don't order that "unnecessary" test...we get screwed.
---side note...why do other docs (not me b/c I don't), order so many damn UAs??? You don't have to order a urine test for every ER patient guys).
Patients want to be tested. I don't know how many times I have heard, "But you aren't going to test my blood?" from a patient. No genius, I don't need to order blood work to see that you have cellulitis. I don't need a CXR or blood work to see that a 35 year old patient with no fever and who looks good has bronchitis. But try explaining that to a patient. They will either doubt you, or you will explain it soooooo many times throughout your practice that you will get so sick of explaining it and just order the damn tests.
So if you want to lower costs...don't just give us tort reform BUT protect us from being sued period (unless it involves complete breaching what a reasonable physician would do or if we act outright dangerously). THEN we can practice evidence based medicine. But you are going to have to protect us first.
-ER Doc
5 comments:
But seriously, can I please have an acute asthma exacerbation without getting a chest x-ray? Why, dear lord, why? Asthma attacks are not fun. Coughing uncontrollably in between not breathing adequately is not fun. Attempting to stamp completely still while holding one's breathe, very shortly after things have started improving, is sheer torture. Ok, so it's not THAT bad. But it ain't fun, and it's completely pointless. It's a freaking asthma attack.
Last time I didn't even go for the asthma attack, I went in twelve hours later for concerns about medication side effects. Didn't escape the chest z-ray. When I was there for potential electrolyte imbalance following the asthma attack. Wth?
I once had four chest x-rays in one month, with zero abnormalities. Two ER, one pulmonologist, one GP.
Doesn't the fact that I had a severe asthma attack last week and was exposed today to a major asthma trigger and am now having every symptom of an asthma attack which resolve fairly quickly following steroids and bronchodilators possibly strongly suggest that I'm having perhaps an asthma attack?
Ok, same anonymous as above, but with my lawyer hat on. Two comments:
One, there are already rules against frivolous law suits. The issue is finding good ways to deem as frivolous a suit that involves complex information. The other issue is enforcing rules against and sanctions for filing frivolous suits.
Two, it's a matter of time. In my state, tort reform is in place and suits are still filed, but the number of law students planning to practice med-mal here can probably be counted on the fingers of one foot. Tort profs actively dissuade students from seeking careers in med-mal. It may well be a dying field. As the costs of the litigation rise and the award caps drop, the possibility of making a living at med-mal keeps shrinking. Give it time. Tort reform will likely change legal culture, but like any culture change, it's going to take time.
Anon,
You are right about the CXRs. In a normal asthma exacerbation that is improving with treatments, there is no need for a CXR or antibiotics for that matter. Sometimes these unfortunately get ordered in triage. Others just routinely get it like they get UAs for everything. Personally, I don't order CXRs for standard asthma exacerbations in healthy individuals. Next time, feel free to refuse the XR or discuss holding off on it with your ER doc
-ER Doc
I have thought that myself for ages. We need to change the culture of medicine in our country - not just the MD's but the public! People need to learn to NOT expect everything and anything. They need to realise there is not a pill or a test for every complaint. They need to realise that many conditions are self limited! They need to realise we can't figure out every diagnosis! Ah, how I yearn sometimes to be practising in the late 1800's....
Yes please cut back on ordering needless UA's. I don't know how many absolutely normal urines I have to look at in a night because patients want to feel like their doc is physically doing something about their problem.
-crazy medtech
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