Internist Robert Centor provides some suggestions to fix health care.
On one point, he calls out emergency physicians, saying because of high exposure to malpractice claims, “technology trumps the history and physical examination.” Often times, “when in doubt, they image.”
This draws a sharp rebuke from Texas emergency physician GruntDoc, who points out that “ED care was 3.5% of the total healthcare budget. Squeeze out all the negative imaging studies and it’d be less, but getting a margin out of 3.5% to make a dent in total healthcare expenditures would be difficult to say the least.”
Is Dr. Centor being “dismissively arrogant,” or does he does he rightly point to a significant driver of health care spending?
Related posts:
- Increasing radiation exposure to patients from CT scans and other imaging tests
- How many more scans are doctors ordering today?
- Ordering tests for other doctors
- Are doctors ordering the right tests?
- Why doctors should reconsider ordering a CRP to screen patients for heart disease
- Unable to provide proper patient care, emergency doctors are suing the state of California
- "Running doctors out of the emergency room"
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{ 12 comments }
Specialists want this. See Emergency Physicians–When in doubt, they image?
The point is that we all need to come together on standardized tort reform as a part of healthcare reform. We need to make it known that we as physicians will make or break any healthcare reform that is passed and unless it contains significant measures to reform the tort system, we should make any policy they enact go down in flames when put into action.
I’ve read other ER bloggers who’ve said –
“We’ve considered installing the CT-scanner in the doorway and just scanning everybody who comes in but the EMR teams are concerned about their repeated exposure so we don’t”
While this was an in-jest comment I do get the feeling it’s the way they do business, at least with the insured.
Does anyone know if ordering more tests does reduce your exposure?
“Does anyone know if ordering more tests does reduce your exposure?”
good point…it’s one of those things that is always thrown out there and unchallenged. But you can’t find any real data for.
“While this was an in-jest comment I do get the feeling it’s the way they do business, at least with the insured.”
Actually, I am much more likely to scan the crap out of the uninsured person because they won’t or can’t get follow up for their condition and so while they are still “captive” I try to rule out what I can. As far as liability goes I am the only one holding the bag. An insured person has follow up and liability and responsibility can be spread around to their PCP, health plan, etc.
I don’t make a single cent on ony imaging study I order whether the patient is unsured or uninsured.
grumpy ole ER doc.
“it’s one of those things that is always thrown out there and unchallenged. But you can’t find any real data for.”
Kind of like trying to figure out what procedure is or is not “defensive medicine”.
Grumpy Ole ER Doc,
I wish you were MY doctor. I applaud you. I remember, a few years back, when I found myself employed but without health insurance. I went to get medical treatment and I was treated like a second-class citizen. Keep doing what you are doing. You sound like one of the true “good” docs that are still out there.
I have to admit, we image a lot in the emergency department. There are many reasons. As Grumpy Ole ER doc says, sometimes it’s because we have the one and only chance to figure out the problem. Sure, we can refer the uninsured for further care and evaluation, but they won’t be able to get it because the specialist won’t see them. Often, they can’t even get in to see a primary care doc without insurance. So, we look and look and look.
Likewise, try this exercise. Call a surgeon about abdominal pain and ask if he’ll come and evaluate the patient. Answer? Possibly, if you do a CT scan and there’s something on it that merits his ministrations. If it’s negative, he’ll say ‘what do you want me to do? It’s a normal scan!’
OK, moving on. Try the hospitalist. Try the neurologist. Try the urologist. Try anyone you consult, except perhaps the psychiatrist (though they’ll ask for one eventually as well.) Everyone wants imaging for 1)completeness 2)malpractice avoidance and 3) the possibility that it might reveal an entity that will direct the patient away from them, or towards someone else.
Finally, in our educated, high-expectations culture, people want them. And isn’t that the point now? Customer service? Customer is always right? Doctors are just withholding good care? Doctors need good patient satisfaction scores?
It’s all comi-tragic. We want to reduce health-care expenditures? We can’t even reduce CT scans in the ER.
Edwin
this is simple. TAKE THE INCENTIVE , FINANCIAL AND OTHERWISE , out of all these tests and ER doctors can return to previously honed diagnostic skills and observation wards.
the perfect example is all the imaging done these days for a routine Appendicitis! oh , come , on really? this is third year med school dx.
I agree with Edwin about doing scans for specialists. I may know perfectly well that the patient has appendicitis, but there isn’t anything I can do about that because I can’t operate. No surgeon will touch the patient (unless they are very old-fashioned and amazingly patient-friendly) without a CT diagnosis. By the way, Jake MD, my reimbursement is in no way tied to the number of tests I order. I get paid a straight salary and my patients receive the same treatment no matter their insurance status (except, as was pointed out, those who need me to make all of their diagnoses because I am the only doctor they can see). There may be some groups that practice such that they are directly reimbursed for their labor, but it is not the norm. Most ED physicians have no direct financial tie to their ordering — they do it for many reasons as Edwin pointed out, but getting paid doesn’t typically factor in. In fact, the less insurance, the more scans, as was also pointed out. I don’t care whether they can pay or not — only that I do what I can to help.
You can sign me up for a country with uniform access to health care, even if my salary goes down. If most doctors (with the exception of primary care providers getting driven out of business) can’t live on their salaries of over 150,000, they need some serious lifestyle revisions.
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