Reviewing the Great ER Caper: Just to be sure.

Kevin, MD linked to this, and I really must comment.

Here’s the abstract, and I hope you’ll read it all:

200910290120.jpg For years I’ve heard friends describe experiences of being caught in a web of excessive and unnecessary medical testing. Their doctors ordered test Z to investigate a seemingly incidental finding on test Y, which had come about because of a borderline abnormality on test X.

I often wondered why test X was done in the first place. As a primary care physician, I would have treated them for the likely diagnosis and done diagnostic tests — especially a series of diagnostic tests — only if they didn’t respond as expected….

Naturally, I’d express sympathy or outrage, whichever the speaker seemed to expect, but internally I’d pat myself on the back. I felt fortunate that there was absolutely no way I’d ever be stuck in such a scenario. After all, I’m not only an experienced physician but also an advocate — in fact, a teacher — of standard-of-care practice. When I get sick, I told myself, they’ll have to do it by the book.

That was before last Easter.

Short version: Easter Sunday an experienced physician realized he was breaking out with shingles on his face, and decided that instead of bothering his internist with it he’d go to the ED. What he got there was, to put it mildly, terrible. After the obvious diagnosis (which the patient no doubt gave everyone from the triage nurse up, he’s smart and knew the problem):

“Before you go,” my colleague mused, “just for completeness’ sake, maybe we should have an ophthalmologist and a neurologist take a look at you. What about it, just in case?”

“I don’t know . . . I don’t think so . . . well, okay . . . maybe it’s a good idea.”

No, it turned out to be a terrible idea. Acquiescence to this obvious weakness on the part of the EM doc resulted in two senseless consultations (three if you add in the residents’ time) and a pointless MRI, then read as abnormal, though there was no significant abnormality.

Eventually the patient went home with the correct medications, but with a 9,000 dollar bill. Which was, and is, terrifically stupid.

After an EM doc’s period of contemplation, here’s my opinion:

First, if you have a regular doctor, call them (especially of you are a doctor and know what the problem is. Rx called in, see me Monday, problem solved). However, as most people aren’t, and my patients don’t have regular doctors…

Second, I’m at a loss to explain the actions of the EM doc. All the blame lies with them. Yes, I’m taking issue with the EM doc.

I’m of two minds about this weird consultology on the part of the EM doc. Right diagnosis, sounds like a thorough exam, so where’s the problem? Either it’s fear of suits, or it’s a junior EM doc taking care of a Senior doc.

Fear of suits: New York is rated “F” by the ACEP EM Report Card for their medical liability climate. That’s not an excuse, but a reason. I personally am guilty of getting tests for my lawyer (which were also medically indicated). Mea culpa.

The Junior doc taking care of a Senior doc is also at work here, and is magnified at an academic center (where there are always more tongues clucking about the idiotic decisions / misses in the ED). Add in any perception that the ED is a scapegoat, and there’s going to be a tremendous amount of testing on ‘one of their own’ to preclude an awkward and embarrassing Morbidity and Mortality meeting. Trust me, docs will go a long way to stay away from that spotlight.

I have no idea which drove this horrible decision. I hope everyone involved, especially the EM doc, learned a lesson.

By the way: “Just to be sure“. Therein lies half the evils in medicine. Get a test, just to be sure. Get another test, a consult or two, and admission, just to be sure. Look, if you’re unsure, then fine, do what it takes to care for the patient. Just to be sure, though, is the path to ruin for our profession, and our country.


Comments

  1. I guess one of the benefits of our NHS is that, from personal experience, you have to be practically dead in order to qualify for “further tests”. When my daughter broke her arm at 2yo and then fell on the cast 2 weeks into healing, the ED were sceptical about taking an x-ray to check if there’d been any movement in the pin. She had some pain, but full movement and circulation in her fingers, so they decided not. As it happens, it had moved…but they discovered this 2 weeks later when they x-rayed prior to cast removal. 5 years later she had to have another major operation to correct the move.
    It’s difficult for me (a non-medico) to know if an x-ray when she fell would have resulted in any kind of intervention by the orthopod, thus negating the need for the second major surgery. Of course, when I asked, no-one was answering that particular question! On the upside though, the benefit of the NHS – to me personally – was that I didn’t have to pay a bean for ANY of the treatment. I do however, wonder how much the NHS saved by not running an x-ray and then later having to pay for 1 major procedure plus 3 days in hospital and a month later a minor procedure plus 2 days in hospital. For me, I’d have prefered a “just to be sure” x-ray at the beginning rather than have to spend 5 days in hospital, which for me, was torture.

  2. I think in general when I consider testing or a consult, I try to ask myself, “what am I going to do with the information I get from this? Will it change management?” If not, then why bother? I can’t imagine any testing for shingles being helpful. Either you know what shingles looks like or you don’t, and this should be a basic competence of an ER doc.

    I’ve had many a conversation with ER docs with the idea of a consultation being brought up, realizing that there was nothing else for me to do, and urging them to simply refer back to the primary MD, emphasizing the importance of follow up, and the folly of traveling around to consultants.

  3. Sounds like Dr. Coulehan wanted fries with that, he just didn’t bother to find out what the cost was. And probably couldn’t have found out — hospitals in particular are notorious for fantastically overcharging cash/insurance payers, to pay for those that don’t, without ever indicating up front what those charges will be.

    Sure, particularly in an ED, there are cases where you simply can’t stop to inquire what they are willing to buy — those are the emergencies. In this story, though, you have a sophisticated customer offered a variety of additional services, and he buys them all without any consideration of the price. It’s not until he sees the bill paid by his insurer that he’s scandalized. Do you think he’d have a different answer if asked, “an MRI costs $X; do you want one just to be sure that there’s no mass?”

    I forget if you’re at Harris or JPS, but if I called the ED of either today and asked how much it would cost to get an MRI of my head, could I get an answer? I’m actually curious. Would I also have to ask if there was a separate charge from the physician or radiologist to look at it?

    I suspect that if I could get an answer, it would be a hugely inflated number, with the hospital figuring they could always negotiate down, but can’t raise it later, and that it wouldn’t include a host of additional costs (sorry, that’s another $16 for a band-aid). I also suspect that if there were “menu” pricing for additional services, then there would be a huge drop in revenue for the hospitals as the people who would otherwise have the means to pay simply decided not to purchase — I think the only reason that doesn’t happen now is that nobody sees the cost up front, and has no clue until they get a bill and/or an EOB. If they did, there wouldn’t be any $90 saline drips or $130 boxes of facial tissues.

  4. Aerospace Genius says:

    As GruntDoc said earlier, “Market, please.”

  5. The doc at issue here probably should’ve known better. But as Jabulani pointed out, its hard for someone without medical training to know whether the test is necessary.

    I have insurance, but it’s a high deductible. I have to pay the first $3500 before insurance starts to kick in. When they want to do tests, a few times I’ve inquired about the cost. I’m told “we don’t worry about that, we’re going to do everything that is necessary” – necessary for diagnosis or necessary for avoiding lawsuits.

    I’d rather get full information about cost, what they’re looking for, how knowing that information vs. not knowing that information will change future treatment, and then decide whether I want to take the risk. Let us sign a waiver that if we don’t do that that test and suffer negative consequences we won’t sue. But don’t guilt us into it if we don’t really need it..

  6. “Fear of suits: New York is rated “F” by the ACEP EM Report Card for their medical liability climate. That’s not an excuse, but a reason.”

    Is it? Texas is ranked #2 on that “Report Card” and it doesn’t seem to have reduced the testing there:

    http://www.boston.com/bostonglobe/ideas/brainiac/2009/07/mcallen_texas_h.html

  7. “Fear of suits: New York is rated “F” by the ACEP EM Report Card for their medical liability climate. That’s not an excuse, but a reason.”

    Is it? Texas is ranked #2 on that “Report Card” and it doesn’t seem to have reduced the testing there:

    http://www.newyorker.com/reporting/2009/06/01/090601fa_fact_gawande

  8. Yes, McAllen they found because it was such an outlier, not because it was representative.

  9. Well, is there some representative evidence that because we cap pain and suffering damages at $250,000, doctors perform fewer tests? Surely after 30 years of tort reform in some of our biggest states, the savings can be documented.

    There doesn’t seem to be much correlation with damage caps on a per capita basis on spending:

    http://www.statemaster.com/graph/hea_tot_sta_hea_car_spe_percap-state-care-spending-per-capita

    Nor does there seem to be much correlation with damage caps when you consider access (physicians per capita). That seems to be more tied to the rural/urban divide:

    http://www.statemaster.com/graph/hea_tot_non_phy_percap-total-nonfederal-physicians-per-capita

    You say McAllen is an outlier – how did you reach that conclusion? Hopefulness?

    Frankly, the whole “we will test less because you cap pain and suffering damages at $250K” doesn’t make much sense. Unless you’re dealing with a child, or a really, really old person, you have no idea what their economic damages would be, so you could still be popped with a million dollar judgment. If that’s your fear, then why would it change?

  10. nurse 1961 says:

    As a “nurse” in this fight. I see many doctors order tests because they don’t know what is wrong with the patient. The shot gun approach is used to CYA. If they find something abnormal, that was the cause. If they don’t they send them home with atypical . . . . (Yes, you may know who these doc’s are). Assessment, orders for lab, x-rays, Ct-scan, IV, pain meds, and then you sit and wait for two to three hours. Oh yea, I forgot nausea medicine and since it has been two to three hours another dose of pain med.

    Then we have the doctors that walk in the room listen to the patient do an assessment and walk out knowing what is wrong with the patient and have plan of care decided. They have . . . . and write up the diagnosis and prescription if needed. These doctors are complained about because they didn’t run test and rack up thousands of dollars in care. (Yes, we have a few of these too). Patients in and out in 30 minutes and my waiting room is empty.

    Personally, I like the “treat and street” for many of our urgent care patients. They could have gone to their private physician but don’t have one. After all it is easier to go to the ED, than to go to the doctor’s office.

    As to Matt, the cost for a CT is $1200 to $1600 depending on the number of avg. slices (Head 28-36, Chest 40-48, and Abdomen 30-38)(Inpatient/ED costs more than Outpatient). No this doesn’t count the Radiologist, the ED physician, or the Facility Charges. They are all billed separately.

  11. The first Matt says:

    Thanks, Nurse. It’s not that I really need to know how much — I’m curious as to whether it’s even possible to get a meaningful number in advance. And while $1600 is a base number, it doesn’t let a consumer know anything when you don’t know the professional fees for the physician and radiologist, or the facility charges. Facility charges, I suspect, is a completely arbitrary number — might as well have an “additional overcharge” line item.

    Is it possible to get at least a reasonable estimate of total cost for such a service, including all the required additional expenses? I can’t think of any other business that could get away with telling you or implying that some service might be necessary — and indeed your very life might depend on it — but not telling you what it’s going to cost you.

  12. I wrote about excessive ER care and took white heat for it from ER colleagues. http://bit.ly/UqTkP I stand by the post. Agree that phrases ‘just to be sure’, ‘just for completeness’, ‘just to be on the safe side’ should prompt a rush to the door.