KevinMD on; oh, and a bad example of defensive medicine

Defensive medicine is indeed a problem. This isn’t the example that tells that story. Oh, and Kevin looks pretty good on TV.
Defensive Medicine: Cautious Or Costly RICHMOND, Va., Oct. 22, 2007(CBS)

It started as a simple stomach ache, but Alexandra Varipapa, a sophomore at the University of Richmond, decided to go to the emergency room.

There, doctors ordered a full CT scan, a radiation imaging test, which found a harmless ovarian cyst. She never questioned the CT scan, CBS News correspondent Wyatt Andrews reports.

Wow, she walked in and just got a CT scan! Oh, wait, she also got a history and a physical exam, but you wouldn’t know that from the slant of the article.

But her father did – when he got the $8,500 bill, $6,500 of which was that CT scan.

“I was pretty flabbergasted,” said Robert Varipapa, himself a physician.

Varipapa says his daughter’s pain could have been diagnosed far more easily and cheaply with a $1,400 ultrasound.

“A history, a pelvic examination and probably an ultrasound,” he said. And he would have started with the ultrasound.

Aah, a doctor relative with a retrospectoscope. Stepwise testing works just fine in the clinic, but in the ED we need to do a lotta things in a hurry:

  • rule out the horrible thing
  • get a diagnosis, or exclude the killer diagnosis
  • get the patient out of the ED to make room for the next patient

But the hospital defends the CT scan, saying an ultrasound might have missed something more serious.

“It would not have ruled out appendicitis obviously, it would not have ruled, necessarily, out a kidney stone,” said Dr. Bob Powell, ER medical director of Bon Secours St. Mary’s Hospital.

Varipapa agrees, but asks why not start simple – and do the CT scan only if necessary?

“Well it’s my opinion this is defensive medicine,” Varipapa said.

Well, you may be right that it’s defensive medicine, but that doesn’t make it incorrect, or bad medicine. A better question would be the 6K charge for a CT scan, but bashing the ED is a lot easier. Frankly, this is not a terrific example of defensive medicine, but is a good example of a) the different thought processes between clinic and EM doctors, and b) a cautionary tale of current ED costs.

Kevin looked very reasonable and professional (and wasn’t wearing his pajamas)! Here’s his CBS video. I recommend it, mostly to see Kevin before he moves to Hollywood.

Update: TBTAM weighs in, on the side fo the ED!


  1. I saw that the abdominal and pelvic CTs were charged separately in the video–is that normal? Over 3K for each one separately?

  2. Joseph J. Neuschatz M.D. says:

    The Non-Hypocritic Oath

    I swear:
    To obey the law and practice medicine to the best of my knowledge and according to my local judges, medical malpractice lawyers, jury decisions, mandatory second opinions, liability insurance companies and HMO limitations.
    If abortions remain legal, I will or I will not produce them, depending on my own personal beliefs, on the number of abortion clinics burned in my immediate vicinity, and on the number of anti-abortion people picketing the local hospitals.
    I will give no deadly medicine to anyone if asked, nor suggest any such counsel. Unless, of course, a euthanasia law is finally passed and I will then make such desperate decisions case by case.
    Whatever in connection with my professional practice, or not in connection with it, I see or hear, in the life of men or women which ought not to be spoken of here or abroad, I will not divulge, as reckoning that all such should be kept secret.
    Unless of course, their charts are subpoenaed by medical liability attorneys, requested by Medicare or Medicaid, checked by the hospital peer review committees or investigated by the department of Health.
    While I continue to keep this Oath unviolated, may it be granted to me to enjoy life and the practice of the Art of Defensive Medicine.

  3. Joseph J. Neuschatz M.D. says:
  4. sultan of swage says:

    The patient had abdominal pain that was so severe that she sought emergency medical attention yet the CBS producers would like us to believe that she was just thrown onto a CT for what was ultimately a “harmless ovarian cyst?” Tintinalli and Rosen both teach that an unruptured cyst that is not torsing the ovary should not be the go-to diagnosis for severe abdominal pain, and the clinician should continue to pursue other diagnostic probabilities based on the H&P, but what do I know…

    CBS has a responsibility to itself and that was made pretty clear by this piece. Is the CT defensive when it catches the early appy the afebrile patient thought was just a bad piece of chicken?

    Newsflash to all the non-ED docs and armchair clinicians out there: patients-either by accident or design-do not always give the best histories in the ED and their physical exams aren’t always as reliable as they are during their visits to their PCP for an annual check-up. What we do is different from what you do and just because you don’t understand it does not make our practices “defensive.”

  5. Thank you for further underscoring the ridiculousness of any policy changes of any kind based on “defensive medicine”. The docs can’t even agree what it is and they purport to tell us how much it costs?

  6. Joseph J. Neuschatz M.D. says:

    My dear Sultan,

    Please lets slow down with the use of abbreviations.
    It is enough that CC once meant “chief complaint” and now it means “closed captioning,” LOL meant “little old lady” and now it means “laughing out loud” etc., etc.
    Why invent ED when we have ER ? For me ED will always be “erectile dysfunction” and never “emergency department.”

    And by the way: what does your PCP stands for ? Pneumocystis carinii pneumonia ? Phencyclidine ? Something else ?



  7. sultan of swage says:

    cjd: I’m sorry…what do you mean?

    jjn: Point taken.

    LOL, BTW…In the ED/ER now and have a CP and possible CVA that may need TPA to attend to ASAP so I will have to blaze so, SYL.

  8. Joseph J. Neuschatz M.D. says:

    OK, SOS !

    IMHO I better reply in French: MDR !
    I will return q6H prn for N&V, until HS.

  9. Just the ER doc says:

    Of course it was just a cyst, unless it was early appendicitis, or, heaven forbid, a young woman with an asymptomatic ovarian cyst and appendicitis that gets missed because you just did an ultrasound and found something asymptomatic but your improper conclusion confuses things even more. Then when the pain persists and even worsens, she doesn’t come back because she knows it is from her cyst. A few days later, it really hurts so she comes back in with her ruptured appendicitis. You think a CT is expensive, how about prolonged treatment of a ruputured appendicitis which requires surgery and drainage of multiple intra-abdominal abscesses followed by chronic abdominal pain, adhesions with recurrent bowel obstructions, and lifelong dyspareunia from the scarring? This doesn’t sound like defensive medicine, it sounds like good medicine.

  10. elizabeth says:

    If she had abdominal pain severe enough to seek emergency treatment (and likely she spoke with her father physician before going to the ER) it was reasonable for her to get a CT scan. Just imagine the media blitz doctor daddy would have stirred up if a ruptured appendix were missed. But, in the end it was really about the bill he was stuck with, not the test done.


  1. […] Kevin, you looked great! (But CBS, I have to agree with GruntDoc here, that was a lame excuse for an example of “defensive medicine.” Hindsight’s […]

  2. […] GruntDoc says nice things about Kevin (as he should) but argues the show used a bad example of defensive medicine. […]