Incentives promote unnecessary, excessive tests in the ER

A professor of medicine visits the emergency department with a seemingly routine case of shingles, and gets the million dollar workup.

Writing in the Washington Post, Jack Coulehan describes how he was subjected to neurology and ophthalmology consults, several MRIs, and a CT scan. All for shingles, a disease that is diagnosed clinically, and treated with an anti-viral medication, pain relievers, and in some cases, steroids.

Soured from the experience, Dr. Coulehan writes that “I’ve lost the smugness and condescension I often felt when listening to others’ stories about being trapped by the system and manipulated into excessively complex and specialized medical situations. Unlike most of my patients, I actually knew what my diagnosis was and what to do about it, but I learned how difficult it is to remain objective when you’re feeling very sick.”

That’s true. Many patients in the ER won’t dispute or object to tests that doctors recommend they undergo. But not mentioned are the countless times where patients are counseled not to have a specific study, only to have him find another doctor to order the unnecessary test.

There is very little disincentive, for both patients and doctors, to pursue excessive testing. And there’s no hope for cost control until that changes.

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  • Mike

    I think this is a bit misleading. It sounds like the problem he had was with the neurologist. Although the ER did consult neurology for “classic shingles”, maybe he was concerned with the eyelid lag. And I think people tend to test/order more on colleagues as missing a diagnosis in a colleague is tough to deal with.

  • rbalboajrmd

    Am I missing something here? Why on earth would a physician, who admits knowing he has shingles, go to the er for treatment? Was this some type of research project?

  • family practitioner

    This is a great and revealing story.
    He regrets going to the ER.
    Stay out of the ER unless it is a real emergency.
    Call your doctor if you are not sure.

  • Anon

    “My symptoms were confined to the distribution of a single nerve, the ophthalmic branch of the left facial nerve.”

    Rather, he means the ophthalmic branch of the left trigeminal nerve.

  • Hmmm

    Wouldn’t someone have been worried about temporal arteritis? Missing a treatable, preventable (within a narrow window) cause of permanent blindness would be terrible, perhaps worth some investigation to rule out?

  • Mark N. Simon, MD

    Great piece and insight into one of the main reasons for the excessive costs in healthcare. Similar expenses are incurred when pregnant patients go to the hospital for minor complaints. Many times patients want testing done “just to be sure” that everything is okay with the pregnancy. Other times physicians order more tests “just to be sure” they didn’t miss anything. Frequently these patients are sent to the hospital after calling their doctor’s office because the office “wants to be sure” that they have been checked out. This overabundance of caution does nothing to actually help the patient and adds a great deal of cost to the system.

  • http://www.ruckinginsurance.com Kevin Sullivan

    The reason for all the testing: The patient doesn’t have an immediate out-of-pocket cost, and the hospital charges the insurance carrier per test.

    Patient: If I’m not paying for each test, test me all you want.

    MD/Hospital: I get paid by the test, so I’m going to test.

  • Anonymous

    Those ED docs…. Making the poor neurology resident do all their work.

  • No out of pocket? Out of mind

    ER testing is not free for even well insured patients, most of the time (double coverage, or stop-loss provisions might apply rarely); the ER visit is costly, the tests usually have sigificant co-pays. MRI’s, no matter how well-indicated, usually come with a steep price tag for patients – the benefit of insurance is the hospital much stick to contracted fees and can’t bill the patient three times the cost, as they might with an uninsured patient. Blood tests, scopes, ekg’s, ultrasounds, – some are cheaper , some hurt, some have higher risk – tests are not “free” to patients on any level.

    Patients who are there because of sickness want to know what is going on, they want to be well. That’s why they want a test.

    What about that risk of arteritis mentioned above? Why isn’t that worth ruling out? It’s an emergency condition and the consequences of missing a narrow window of treatment is catastrophic.

    If there was an objective sign of neurological impairment, why would even a physician patient be entrusted with the differential? Denial alone could interfere with a proper assessment of his own condition.

  • Nuclear Fire

    That doesn’t sound at all like GCA to this Rheumatologist. Looks like the Ophthalmologist agreed.

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  • http://emergencist.blogspot.com/ Dex

    This is why you don’t want to be a VIP in the emergency room–excessive testing. Go incognito, and try to get treated like it’s routine. If you have a problem with logistical issues, like waiting around for a bed after admission, then its time to make your position known, or call some high-gravity beings to pull for you.

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