And as a FP I will freely admit I order unnecessary tests. At least half the x-rays I do are done more for patient concern than mine. And it’s done for reasons similar to what Doctor Centor outlined: patient expectation, the less than 0.1% chance. And for reasons outlined by some of the ER docs above: exceptionally poor historians(just because they are in my office doesn’t mean they are my long-term patient and if the cardiologist sent me zippo related to their recent cath then I don’t know anything about it, and heck the EMR data dumps are unreadable anyway), and inability of patient to allow a decent physical exam for whatever reason.

SO yes you do unnecessary testing. And you know it. So do we. So does every specialty. Maybe he should have painted with a broader brush. But the basic point remains.

I suffered from a severe Crohn’s Disease flare last year that ultimately ended in needing surgery.

In the time frame between establishing that I needed surgery and the actual surgery, I was not ill enough to stay admitted in the hospital nor was I well by any means. As a result, I ended up in the ER a good number of times due to severe pain which only could be helped by IV pain medication (believe me that this was not someone over reacting to pain as I was told by both ER nurses and doctors that it was obvious I really needed help and if my pain medications at home weren’t helping, it was probably a good idea that I be evaluated in case that was the day that something further did go wrong).

After establishing that I didn’t have a fever and sending test to check against infection (and the one time I did, I had micro-abscesses and was immediately scanned and admitted), I was always given a physical exam. Most of the time these two things combined with medication to treated my pain and nausea were enough to determine that it was safe for me to go home and talk to my gastroenterologist the next day. I only was imaged in the ER before my Crohn’s disease was diagnosed and the other time when I was going to admitted anyway because of the initial symptoms of infection and the ER wanted to check how severe things were in case I was a more dire case than I appeared.

What I had going for me though was that I could give a clear and concise history of my Crohn’s disease and also provide a full list of medications and information about treatment during previous ER visits. There was a time or two when I was asked, “Do you want a CT?” and I was able to give an intelligent answer that include information about the last time I was scanned and reasonable answers to questions about my history of pain and my worsening condition. I understand that this is not the typical situation and that many people can’t provide detailed medical information but still expect a doctor to be able to fix them. Once when I was admitted directly by my gastroenterologist and not through the ER, I had prepared a list of medications and dosage information and the internal medicine resident who evaluated me was practically drooling when he saw the list and that he was going to have to waste time slowly getting this information out of me.

Overall, I’d say that the gastroenterology department was a lot more interested in over-imaging me than the ER. But every doctor I saw (in the ER or not), gave me a thorough abdominal exam (great to have lots of doctors poke you in the area giving you extreme pain) and a good general once over for anything else that could be problematic. While some of the ER docs I met were better than others — and one or two might have been not very good at all in the bedside manner dept. — I did always leave knowing that nothing had dangerously changed and sure in the knowledge that there was no need to be admitted to the hospital on that occasion.

I want to be on the one that evaluates internists who don’t follow their own JNC 7 guidelines for severe asymptomatic hypertension and instead just panic when they see the numbers and send that pt. to the ED.

Or the one for surgeons who dismiss altered mental status and belly pain and order a contrast CT. Then rush the pt to the OR 6 hours later when they see the pneumatosis intestinalis on CT.

Or the one for the OB/Gyn docs who told me to transfuse 2 units of PRBC’s for the lady that was bleeding heavily and hypotensive post hysterectomy and then told me to send her home for follow-up tomorrow (apparently in their autopsy clinic).

Or the one for the FP guys who prescribe Zantac to the pt with unstable angina, then I see that same pt a week later with an STEMI.

We see everyone’s screw-ups in the ED, don’t forget that. I am willing and able to start casting stones at everyone else.

We do police our own in the ED. DB, how about you mind your own beeswax? Or come up with a better solution? Trust me, we often talk about saving on the healthcare dollar. Clean your own house first.

You don’t need a bunch of internists to question it, but somebody should be. It seems, again, as a casual observer and from what I’ve heard, that our administration does no such thing. It’s different to say “hey did you really need to image that one guy” vs “why are you MRI-ing all/most of your knee sprains?”

It seems too that the emergency residency-trained physicians have a method to determine who does and does not need a scan based on some sort of learned criteria that seems to be rather consistently followed vs. a more random approach from some of the non-emergency residency docs at my work.

If you’re trying to push physicians to change their practice, and you’re pissing off 100% of your intended audience, you’re doing it wrong.