Emergency physicians and the choice of overtesting or lawsuits

Emergency physicians are in a dilemma.  Risk missing a diagnosis and be sued, or be criticized for overtesting.

Regular readers of this blog, along with many other physicians’, are familiar with the difficult choices facing doctors in the emergency department.

The Associated Press, continuing its excellent series on overtesting, discusses how lawsuit fears is a leading driver of unnecessary tests.

Consider chest pain, one of the most common presenting symptoms in the ER:

Patients with suspected heart attacks often get the range of what the ER offers, from multiple blood tests that can quickly add up in cost, to X-rays and EKGs, to costly CT scans, which are becoming routine in some hospital ERs for diagnosing heart attacks …

… and the battery of testing may be paying off: A few decades ago insurance statistics showed that about 5 percent of heart attacks were missed in the emergency room. Now it’s well under 1 percent, said Dr. Robert Bitterman, head of the American College of Emergency Physicians’ medical-legal committee.

“But you still get sued if you miss them,” Bitterman added.

The AMA’s idea of providing malpractice protection if doctors follow standardized, evidenced-based guidelines makes sense in these cases. Furthermore, it can also help reduce the significant practice variation that health reformers continually focus on.

Combine that with patient demands for tests. As the Angela Gardner, president of the American College of Emergency Physicians notes,

“Our society puts more weight on technology than on physical exams. In other words, why would you believe a doctor who only examines you when you can get an X-ray that can tell something for sure?”

Refusing those demands creates unhappy patients. And concern that unhappy patients will sue remains the elephant in the emergency room.

Patients can help by asking whether the proposed test is really necessary, and what the risks are if the test isn’t done. Better yet, specifically asking how the test will change a doctor’s treatment plan can be a way to start a meaningful dialogue about the pros and cons of testing.

I understand that that may be difficult to do in the harried setting of an ER, but taking a few minutes to come up with a shared decision may help reduce unnecessary tests, and perhaps, a physician’s malpractice risk.