Skip to content
  • About
  • Contact
  • Contribute
  • Book
  • Careers
  • Podcast
  • Recommended
  • Speaking
  • All
  • Physician
  • Practice
  • Policy
  • Finance
  • Conditions
  • .edu
  • Patient
  • Meds
  • Tech
  • Social
  • Video
    • All
    • Physician
    • Practice
    • Policy
    • Finance
    • Conditions
    • .edu
    • Patient
    • Meds
    • Tech
    • Social
    • Video
    • About
    • Contact
    • Contribute
    • Book
    • Careers
    • Podcast
    • Recommended
    • Speaking

Unnecessary testing needs more than tort reform to cure

Michael Kirsch, MD
Conditions
July 17, 2010
110 Shares
Share
Tweet
Share

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.

Submit a guest post and be heard.

Prev

Why general internists are quitting clinical medicine

July 16, 2010 Kevin 12
…
Next

ER visits rise because of prescription drug abuse

July 17, 2010 Kevin 1
…

Tagged as: Hospital-Based Medicine, Malpractice, Specialist

Post navigation

< Previous Post
Why general internists are quitting clinical medicine
Next Post >
ER visits rise because of prescription drug abuse

More by Michael Kirsch, MD

  • AI-driven diagnostics and beyond

    Michael Kirsch, MD
  • The surprising truth behind virtual visits

    Michael Kirsch, MD
  • Drawing the line on unnecessary medical tests

    Michael Kirsch, MD

More in Conditions

  • Epigenetics and our inheritance to future generations

    Vishruth Nagam
  • COVID-19 unleashed an ongoing crisis of delirium in hospitals

    Christina Reppas-Rindlisbacher, MD, Nathan Stall, MD, and Paula Rochon, MD
  • Emergency care nightmare: the urgent need for experienced nurses

    Rachel Basham, RN, CCRN
  • Debating the role of psychiatric assessments in medical decisions

    Christian Youssef & Francisco M. Torres, MD
  • 5 things to know about weight from a bariatric surgeon

    Maria Iliakova, MD
  • Physician autonomy and patient interactions in corporate health care

    Michele Luckenbaugh
  • Most Popular

  • Past Week

    • Reigniting after burnout: 3 physician stories

      Kim Downey, PT | Physician
    • The erosion of patient care

      Laura de la Torre, MD | Physician
    • Inside the grueling life of a surgery intern

      Randall S. Fong, MD | Physician
    • 1 in 5 doctors will become disabled. Are you prepared?

      Amarish Dave, DO | Finance
    • Assertiveness in health care [PODCAST]

      The Podcast by KevinMD | Podcast
    • Misinformed claims and the offensiveness of discrediting COVID-19 vaccine development

      Angel Garcia Otano, MD | Conditions
  • Past 6 Months

    • Medical gaslighting: a growing challenge in today’s medical landscape

      Tami Burdick | Conditions
    • I want to be a doctor who can provide care for women: What states must I rule out for my medical education?

      Nandini Erodula | Education
    • Balancing opioid medication in chronic pain

      L. Joseph Parker, MD | Conditions
    • Reigniting after burnout: 3 physician stories

      Kim Downey, PT | Physician
    • Mourning the silent epidemic: the physician suicide crisis and suggestions for change

      Amna Shabbir, MD | Physician
    • I’m a doctor, and I almost died during childbirth

      Bayo Curry-Winchell, MD | Physician
  • Recent Posts

    • Assertiveness in health care [PODCAST]

      The Podcast by KevinMD | Podcast
    • Epigenetics and our inheritance to future generations

      Vishruth Nagam | Conditions
    • Practicing medicine with conviction

      Arthur Lazarus, MD, MBA | Physician
    • The power of memory in shaping human identity

      Emily F. Peters and Sandeep Jauhar, MD, PhD | Physician
    • How Tratak yoga reshaped my USMLE Step 2 prep

      Dr. Nikita Mehdiratta | Education
    • Transforming primary care for physician well-being [PODCAST]

      The Podcast by KevinMD | Podcast

Subscribe to KevinMD and never miss a story!

Get free updates delivered free to your inbox.


Find jobs at
Careers by KevinMD.com

Search thousands of physician, PA, NP, and CRNA jobs now.

Learn more

View 29 Comments >

Founded in 2004 by Kevin Pho, MD, KevinMD.com is the web’s leading platform where physicians, advanced practitioners, nurses, medical students, and patients share their insight and tell their stories.

Social

  • Like on Facebook
  • Follow on Twitter
  • Connect on Linkedin
  • Subscribe on Youtube
  • Instagram

CME Spotlights

From MedPage Today

Latest News

  • FDA Relents, Approves Novel Antidepressant After Many Rejections
  • OSHA Comes in for Both Praise and Harsh Criticism at House Hearing
  • New Insight Into Hyperglycemia Risk With PI3K Inhibitor for Breast Cancer
  • Oktoberfest Doctor: Not the Wurst Job You Could Have
  • Blue Shield of California Has Fix for MA Enrollees Worried About Co-Pays

Meeting Coverage

  • New Schizophrenia Treatments Are Coming: Don't Panic
  • Loneliness Needs to Be Treated Like Any Other Health Condition, Researcher Suggests
  • Stopping Medical Misinformation Requires Early Detection
  • AI Has an Image Problem in Healthcare, Expert Says
  • Want Better Health Outcomes? Check Out What Other Countries Do
  • Most Popular

  • Past Week

    • Reigniting after burnout: 3 physician stories

      Kim Downey, PT | Physician
    • The erosion of patient care

      Laura de la Torre, MD | Physician
    • Inside the grueling life of a surgery intern

      Randall S. Fong, MD | Physician
    • 1 in 5 doctors will become disabled. Are you prepared?

      Amarish Dave, DO | Finance
    • Assertiveness in health care [PODCAST]

      The Podcast by KevinMD | Podcast
    • Misinformed claims and the offensiveness of discrediting COVID-19 vaccine development

      Angel Garcia Otano, MD | Conditions
  • Past 6 Months

    • Medical gaslighting: a growing challenge in today’s medical landscape

      Tami Burdick | Conditions
    • I want to be a doctor who can provide care for women: What states must I rule out for my medical education?

      Nandini Erodula | Education
    • Balancing opioid medication in chronic pain

      L. Joseph Parker, MD | Conditions
    • Reigniting after burnout: 3 physician stories

      Kim Downey, PT | Physician
    • Mourning the silent epidemic: the physician suicide crisis and suggestions for change

      Amna Shabbir, MD | Physician
    • I’m a doctor, and I almost died during childbirth

      Bayo Curry-Winchell, MD | Physician
  • Recent Posts

    • Assertiveness in health care [PODCAST]

      The Podcast by KevinMD | Podcast
    • Epigenetics and our inheritance to future generations

      Vishruth Nagam | Conditions
    • Practicing medicine with conviction

      Arthur Lazarus, MD, MBA | Physician
    • The power of memory in shaping human identity

      Emily F. Peters and Sandeep Jauhar, MD, PhD | Physician
    • How Tratak yoga reshaped my USMLE Step 2 prep

      Dr. Nikita Mehdiratta | Education
    • Transforming primary care for physician well-being [PODCAST]

      The Podcast by KevinMD | Podcast

MedPage Today Professional

An Everyday Health Property Medpage Today
  • Terms of Use | Disclaimer
  • Privacy Policy
  • DMCA Policy
All Content © KevinMD, LLC
Site by Outthink Group

Unnecessary testing needs more than tort reform to cure
29 comments

Comments are moderated before they are published. Please read the comment policy.

Loading Comments...