Unnecessary testing needs more than tort reform to cure

Recently, while covering for one of my partners on a weekend, I was consulted by a physician to do a procedure.

The doctor wanted his patient to undergo an EGD, which is a scope test that examines the esophagus, stomach and first portion of the small intestine called the duodenum. We gastroenterologists do this test routinely to search for an explanation for a patient’s symptoms, or to determine if these organs might be harboring a lesion that is silently bleeding.

Gastroenterologists are obligated to perform procedures for sound medical reasons. I have already confessed publicly on this blog why physicians like me have performed medical tests for the wrong reasons. The medical universe is not ideal, and neither are its players.

Nevertheless, we want our care to make sense and not to waste dollars. For example, if a patient is suffering an acute headache, it would be hard to justify ordering a CAT scan of the abdomen, which would be unlikely to explain the symptom. One reason that wrong tests are done is because physicians ask colleagues for a specific procedure, and not for their cognitive advice.

For example, when we order a radiology examination, such as routine x-rays, CAT scans, MRIs, etc., we are not requesting the radiologist’s opinion on the medical issue, only that the test be performed. For ordinary readers who are on the sidelines of the medical arena, here’s how it works.

• A doctor like me decides that a patient needs a CAT scan.
• I order it.
• The radiologist does it.

Personally, I think this is a serious failing in medical practice. Radiologists have the deepest expertise in the procedures they do, yet they are not routinely consulted in advance. If they had knowledge of the particular patient, they could advise us if our intended test is the best option. Perhaps, a different radiology test would clarify the clinical issue better. Or, perhaps, we ordered the proper test, but it should be performed using special technique.

In general, radiologists are not treated as true consultants, but as technicians. By doing so, clinicians like me who take care of patients are squandering an opportunity to practice better medicine.

Of course, there are many times that physicians and radiologists do confer to optimize the diagnostic approach. But, in my experience, these important conversations are exceptional. Physicians who order imaging studies on their patients likely feel that they have enough knowledge to choose the right exam. Some do, and some don’t.

I have never liked serving as a technician gastroenterologist, but I am often asked to do so. Like every other gastroenterologist, I have performed requested procedures that were reasonable, but that I would not have personally recommended if my advice had been sought. The patient referenced at the top of this post was in a different category. This was not a ‘gray area’ issue.

This particular patient was having some minor rectal bleeding. He had already had the pleasure of a full colonoscopy this past November, when hemorrhoids were discovered. No additional testing was necessary for the current minor bleeding, as hemorrhoids were the likely culprit. The request for an EGD was nonsensical. The ordering physician had no economic conflict of interest in ordering the test; only the gastroenterologist would benefit financially. An EGD here was like ordering a foot x-ray on a patient with a sore throat.

I will now risk outrage from my medical colleagues by sharing a dark secret with the public. I will divulge two pieces of confidential medical code, and trust you all to protect me from vengeful physicians who will accuse me of breaking sacred medical omerta.

At the very bottom of my consultation report, I wrote: ‘will discuss with you’. This is standard medical code for, your request is nuts and I won’t put in writing what I really think. When a doctor uses this phrase, it means that a private conversation between the consulting and referring physician will soon follow. Ask your own doctor what the phrase ‘will discuss with you’ means, but be prepared for garbled gobbledygook seasoned with a dash of doublespeak.

Later that day, my partner continued the discussion with the physician and gently asked for his rationale for requesting the EGD. Here comes secret code #2. The referring physician wanted the EGD ‘for completeness’. When a doctor uses this phrase, as we all have done, it means, the test makes no sense and is totally unnecessary.

So, what happened? Monday morning, the gastroenterologist who was originally consulted assumed care of the case. The EGD was done.

Fear of litigation results in overutilization of medical care. I know this personally. But, there are other reasons why we physicians pull the procedure trigger. This vignette illustrates that our profession has its own healing to do. Tort reform can’t cure it all.

While I didn’t perform the EGD, am I an accomplice by not standing up to the referring physician initially? Can I rightfully still consider myself to be an ethical practitioner? Radiologists don’t refuse to do CAT scans that make no clinical sense. Should the standard be different for other medical procedures, which have very low risks of complications? What would you have done here? Would you have refused the physician’s request, which would likely result in the loss of this physician’s future referrals?

Would you rationalize the unnecessary test knowing that if you didn’t do the EGD, that someone else would? Do private pracitioners view this scenario differently than employed physicians? Should they?

Do you have similar vignettes from your own practice or experience that you can share?

Michael Kirsch is a gastroenterologist who blogs at MD Whistleblower.

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