No surprise to regular readers of this blog: “With the malpractice situation, the rules of the road for physicians, quite understandably, are, ‘When in doubt, do the test.’” (via EconLog)
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- Increasing radiation exposure to patients from CT scans and other imaging tests
- PlayStation 3 and medical imaging
- Merry Christmas and Happy Holidays
- My USA Today column on why medical malpractice reform is needed
- CT scans in the ER, are emergency doctors ordering too many tests?
- Tips for convincing your doctor to order more tests for you
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{ 32 comments }
Of course it’s not a surprise – physicians make all kinds of decisions based on a misunderstanding of their risk.
Kevin, ever they lobbyist, left out some of the article:
“Several hypotheses are offered as to why too many tests, or the wrong tests, could be ordered: physician worry about malpractice suits; patient demand for the latest, best exam; doctors who aren’t up to date on the rapidly-developing technology, and doctors who profit from tests because they own imaging equipment.”
Of the 4 reasons quoted above, 3 of them are really defensive:
1. physician woory about malpractice suits speaks for itself
2. patient demand Defensive – on the stand: “Doctor, didn’t Mr. Smith ask for this test that may have diagnosed his tumor?”
3. not up to date? Fear of not doing the latest and greatest and “missing” the tumor (or whatever) – just get an expert on the latest technology to testify for plaintiff
So Kevin, IMO, is not far from the mark.
In my practice one of the main tests that is ordered is a MRI of the brain. Is this necessary for the diagnosis of tension headaches? No. The problem is my partner was just sued for by a patient who claimes that he did not diagnose a menigioma 4 years prior which was in a location that doesn’t cause headaches. Their expert witness said that he should have got a scan and that would have made the diagnosis. So, I and everyone else orders MRI scans. By the way, they are not cheap. As to Eric’s comment above, this is not a misunderstanding of the risk. It is very real and that is why every headache in the er gets a scan.
Or the physician owns the scanner and wants to pick up the technical fee.
Either way.
Know what the Stark law is Apollo and how that fits )or rather doesn’t fit) in what you proposed?
If a patient requests a test, that’s not defensive. That’s him requesting the test – why would you deny it?
So it’s not the desire to be professionally competent that inspires you to stay up to date? It’s defensive medicine? In that case, litigation is working. Would you think it was bad if the only thing that kept the engineer on the bridge you’re driving over up to date was litigation? Is that an argument for less?
Stark does nothing to prevent a cardiologist from owning his own cardiac CT and ordering the test. And it is there that you’ll find the greatest increase imaging costs.
“The Stark law generally prohibits a physician from making referrals to an entity for the furnishing of certain DHS reimbursable by Medicare if the physician (or an immediate family member of the physician) has a direct or indirect financial relationship with that entity, unless an exception to the law is satisfied”
I think that cards might be on thin ice apollo
Maybe. I don’t know. I’m only posting because I’m writing a paper on this right now and in general (I expect Kevin to take umbrage to this) physicians who own their own scanners tend to order far more studies, read them less well than a trained radiologist and even supply studies of a lower technical quality (the images suck).
I just wanted to point out that perhaps the biggest reason for such a rise in imaging costs isn’t so much legal — but greed.
apollonius, i think you are exactly right. Defensive medicine certainly is an issue with cost, but I think FAR less than the cost of:
echo
nuclear stress testing
ultrasound
carotid doppler
I, too, do not understand how cardiologists are able to get away with. There is just no dis-incentive to perform these tests, and cardiologists i have referred patients to, in the past, have openly admitted this informally.
This phenomenon is a major force in threatened medicare reimbursements across the board, and contributes to the decline in primary care on several levels.
Unhappyman,
If you refer a patient to a cardiologist, what do you expect him to do? Shake a bag of bones? read some tarot cards? Perform a chant and then say “Your heart is ok”? Or do you expect them to have some type of evaluation and risk stratification?
If you think it is unnecesarry then why refer them? Do a treadmill or Nuc test yourself if you want.
There is an in office ancillary service exception to the Stark laws and that’s how they get around it. The reason behind it was for patient convenience.
From what I’ve read I think the cardiologist should refer the case to a radiologist and then order surgery/work etc. from that point. There is simply too much financial incentive as the system is currently set up and I think patients suffer for it. It’s a money mill for physicians, the AMA is fighting hard to protect it.
non-cardiologist quips “If you refer a patient to a cardiologist… do you expect them to have some type of evaluation and risk stratification?”
YES, and that doesn’t mean that every patient needs the annual trifecta of echo/stress/holter. CHA-CHING!!!
This happens whether the patient is a 30-yr-old honduran immigrant with a murmur & h/o “rheumatism”, or 85-yr-old with compensated CHF.
I was “unhappyman” but now I feel so much better that you pointed out that I too can bilk the system – I’ll think about that nuclear stress machine lease-to-own, so I too can profit & call it “defensive medicine” (by the way I draw a sharp distinction between that & the PCP or ER doc ordering CT or MRI with no financial incentive, which I realize of course is clearly often defensive medicine).
If a patient requests a test, that’s not defensive. That’s him requesting the test – why would you deny it?
a) It’s not required
b) The patients insurer requires a doctoral dissertation on why it is required, followed by appeal letters and several phone calls.
why should I spend my valuable time obtaining “authorization” for a test, attempting to convince an insurer that an unnecessary test is necessary, just because a patient requested it? Why would I waste time and money getting it done?
No, I am not denying the test. I am refusing to spend $500-$600 of my own money to save the patient’s $500-$600 he/she would have to pay for the test.
The patient is free to go and get the test and pay for it himself. Unfortunately, this is tantamount to not doing the test at trial (just like not dragging the patient to the specialists office is tantamount to not recommending the consult )
If the patient wants it and you believe it’s medically unneccessary and tell him you won’t vouch for him if insurance won’t pay, again, how is that “defensive medicine”? That’s the free market, and it doesn’t sound like you like it much.
If you had first party payers like so many of you claim to want, this would be SOP.
As to what it’s like at trial, you’re basically full of it.
If the patient wants it and you believe it’s medically unneccessary and tell him you won’t vouch for him if insurance won’t pay, again, how is that “defensive medicine”? That’s the free market, and it doesn’t sound like you like it much.
No. Vouching for him in order to get it done is defensive. Not the other way around.
I am currently being sued precisely because I did not ensure that my advice was followed. So I am not full of it.
The biggest waste is having to have films read by a radiologist. I read all of my own films, MRIs and CT scans and rarely does the radiologists interpretation add anything of value to the case. I can diagnose my own Rotator Cuff tears and ACL injuries. The racket is having to pay a radiologist to tell me a patient has a normal Xray.
One study (looking at the interpretation of chest radiographs) compared the accuracy of three groups (board-certified radiologists, radiology residents and non-radiologist physicians) taken from a pool of physicians from private practices throughout North America and Great Britain. These physicians reviewed a standardized clinically confirmed set of 60 posterior chest radiographs. The area under the receiver operating characteristic curve-a measure for which 1.0 is a perfect diagnosis and 0.50 represents a purely random result – was 0.86 for the board-certified radiologists, 0.75 for the radiology residents and 0.66 for the non radiologists. Note this same set of physicians reported being “very confident” in their findings. Similar studies have been repeated time and time again.
Sadly the statistics do not bear your personal observations. In one study that weighted the evaluations of selected radiographs between radiologists and emergency physicians found that the reads of the radiologists were more accurate (74% verses 55%) and more sensitive (62% verses 38%). In this study Radiologists correctly read 82% of cases that were identified by an independent panel as “critical” compared to 48% of emergency physicians. These findings were repeated in a similar study at the same hospital even after concerns were raised from the prior study.
Claim defensive medicine all you want but the numbers don’t lie. Perhaps you’re just as good at reading films but somehow I doubt it. The irony for me is too delicious for words, in pursuit of padding their bottom line doctors are hurting their patients and opening the door for more malpractice lawsuits all the while screaming “defensive medicine.”
Oops. My post above was in reply to this comment:
The biggest waste is having to have films read by a radiologist. I read all of my own films, MRIs and CT scans and rarely does the radiologists interpretation add anything of value to the case.
Thought I had it in there — early. More coffee.
In the third comment, the writer reports his partner getting sued citing not ordering an MRI. He doesn’t report the outcome of the suit. You can get sued everyday for everything you do or don’t do from the moment you get out of bed. That doesn’t mean it is right or wrong. Getting sued is no reason to change clinical management. Losing may be.
One thing mention nowhere in here is HISTORY and EXAMINATION. Here is how one practices medicine boys and girls: You take a history, then you do an examination. That provides actual DATA, which you then analyze and determine what, if any other data is needed, before ordering tests. I contend that much of the increase in scans is due to people not taking histories or examining patients.
That is the answer to the poster who wonders why someone refers to cardiology if he doesn’t want a study. What I want when I refer to card or neuro or any other consultant is for them to perform a HISTORY and an EXAMINATION using their more finely honed skills for that organ system, and then use their superior knowledge of that organ system to ANALYZE that data and make recommendations, which may or may not include a recommendation for further studies.
Why thank you. after 20 years of practice I have not figured that one out yet.
“One study (looking at the interpretation of chest radiographs) compared the accuracy of three groups (board-certified radiologists, radiology residents and non-radiologist physicians)…”
Do you have a link to your quoted study?
Who do you represent? Is your research funded?
Ann Emerg Med. 1989 Aug;18(8):826-30.
Hopper KD, Rosetti GF, Edmiston RB, et al. Diagnostic radiology peer review, Radiology 1991
BE Kouri, RG Parsons, HR Alpert. Physician self-referral for diagnostic imaging: review of empiric literature (most interesting paper I’ve read on the subject)
N Engl J Med 354:26 June 29, 2006
Who do you represent? Is your research funded?
This from an anon? Who are you? Do you self refer? Do you have a vested interest in reading your own films? Sounds hostile doesn’t it?
Either the statement is true or it isn’t. Hoping that I’m funded by a party you dislike or a malcontent doesn’t change the validity of the studies.
I could be a malpractice lawyer but it doesn’t change anything. Just because someone you dislike says something doesn’t make it less true. I’m writing a paper.
I wouldn’t have bothered to respond to Kevin’s post but for the fact he left out one of the largest reasons imaging costs continue to go up. Doctors with x-ray machines, ct scanners, MRs tend to utilizes them at far higher levels than doctors who refer that end of medicine to radiologists (this is paraphrased from the NEJM article mentioned above). To me this means 1 of 2 things, either the doctors that don’t have this equipment are not practicing good medicine and are missing opportunities to diagnose their patients or the doctors with this equipment are overusing them.
“This from an anon? Who are you?”
Your screen-name ‘apollonius’ is just as anonymous since you do not allow access to your profile online. What are you trying to hide? You ooze pure bias.
“Do you self refer?”
I am a specialist surgeon in the military and order large volumes of CTs, MRIs, etc, etc. No self-referral here. Not that there is something wrong with that though. By the way, the 2 MRI scanners here run 24/7 and they are still deferring patients out to civilian MRI centers. There must be some sort of self-referral going on here!! The mere fact that you are not divulging your funding source leads me to believe that you have a bias and likely receive funding from the ABR or the ACR.
“Do you have a vested interest in reading your own films?”
This is an easy one. Yes, I do have a vested interest in the outcome of the patient. Before taking a patient to the operating room, I look at the CT scan. It is called malpractice to rely only upon the radiologist’s dictation, who has no vested interest in the outcome of the patient, to tell me where and what to operate on. Although small, I can remember several cases where the dictation from the radiologist gave the wrong side as to the abnormality. Guess who will be explaining to the jury why the wrong kidney came out? Certainly not the radiologist. Once again, it is malpractice to purely rely upon a radiologist’s dictation prior to surgery. The surgeon should put eyes on the CT scan himself before cutting. I guess you need to credential me to read a CT scan…
It is a pure turf war nothing else.
“Hoping that I’m funded by a party you dislike or a malcontent doesn’t change the validity of the studies.”
That is assuming the studies are valid. Bad data in, bad data out. The article you cited in the American Journal of Roentgenology is automatically biased since it came out of a radiology department and one of the lead authors received funding from the American College of Radiology (“H. R. Alpert was supported by the American College of Radiology”). I can smell a rat!
With the spread of Nighthawk services, you and your radiologist buddies may be looking for a new job soon as more and more Indian and Chinese radiologists read CT scans for pennies on the dollar. I don’t blame you for “sounding so hostile”. The radiologists sealed their fate when they relegated themselves to the status of a highly paid technician with no vested interest in the outcome of the patient.
I have no vested interest in our MRI and reading the radiologists interpretation is a waste of time. I can see where it could be valuable in a Chest Xray, but an extremity Xray. Get real, a radiologist telling me that a hand Xray is normal serves no purpose. I guarantee I see more hairline fractures than the radiologist because I have the power of the physical exam. Show me how these statistics apply to an orthopedist. They don’t Spend anytime with an orthopod in the OR and you will hear. “No tear on MRI, hey look at that Rotator cuff tear right there.”
Last month I read a RUG (retrograde urethrogram) on a patient and he clearly had a 3cm bulbar urethral stricture. The radiologist read the film as normal. I had to relearn the radiologist on the fine points of differentiating between the prostatic and membranous urethra. I guess I need to get credentialed now on interpreting RUGs…
I went to the ER with a radial head fracture.
The ER guy couldn’t find the fracture on the film but from the sail sign and clinical findings, concluded there was one and spinted it and referred me to ortho.
My friend from ortho guy saw me the next morning and took 1 second to spot the fracture and point it out. He provided management and then,
Two days later the radiologist report comes up describing the fracture.
I paid more for the radiologist than both the other guys put together–and it didn’t add a damned thing. It is a racket.
Exactly anon 9:23
“I paid more for the radiologist than both the other guys put together–and it didn’t add a damned thing. It is a racket.”
You hit the nail on the head. CMS is aware of this and the radiologist and ‘apollonius’ is on their hit list…
Radiology is a “racket”???
People need help. Honestly.
extremely interesting dialogue.
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