Comments on: CT scans in the ER, are emergency doctors ordering too many tests?

By: Anonymous ER Doc

Anonymous ER Doc — Sat, 03 Oct 2009 11:53:44 +0000

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.

By: Jake MD

Jake MD — Sat, 24 Jan 2009 15:07:00 +0000

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.

By: Jake

Jake — Sat, 24 Jan 2009 15:05:00 +0000

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.

By: Edwin

Edwin — Thu, 22 Jan 2009 02:52:00 +0000

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

By: Anonymous

Anonymous — Wed, 21 Jan 2009 14:35:00 +0000

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.

By: Anonymous

Anonymous — Mon, 19 Jan 2009 20:11:00 +0000

“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”.

By: Anonymous

Anonymous — Mon, 19 Jan 2009 16:23:00 +0000

"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.

By: Mike

Mike — Mon, 19 Jan 2009 15:43:00 +0000

“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.

By: Anonymous

Anonymous — Mon, 19 Jan 2009 13:53:00 +0000

Does anyone know if ordering more tests does reduce your exposure?

By: Anonymous

Anonymous — Mon, 19 Jan 2009 11:59:00 +0000

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.