The continuing battle between the emergency department and radiology


I overheard a disappointing phone call while supervising a radiology resident recently. I could tell that the resident was struggling in a conversation with an emergency department physician, so I asked him to switch over to speakerphone. Eventually, I heard the emergency physician say, “Listen. This is how it works. A patient points to what hurts. Then I have that part scanned, and you tell me what is wrong.”

Disheartening as it sounds, patterns like these have worsened in recent years. I try to teach radiology residents and ordering providers alike what the most important imaging tests are given clinical concerns, yet the amount of information given to the radiologist declines, and the number of scans continues to grow while the payment for these studies has leveled off or decreased in some cases. I even find out that providers are sometimes dishonest in the history provided just to get a study performed. The county hospital I am affiliated with has a large number of patients who can’t pay. Not only does the system eat the cost, but many of these studies involve potentially harmful radiation.

I have read tales of many physicians upset over their inability to order tests that they feel patients need, as insurance companies control access to most tests outside of the hospital. I tend to side more with the insurance companies in questionable cases, as a large number of studies cross my computer every day that are not appropriate for the clinical indication provided. Hospitalized patients can bypass insurance preapproval because such patients are deemed to have emergent testing needs, hence access to the testing driving utilization inside the hospital rather than the actual necessity for the tests. I have seen physicians have their relatives admitted to the hospital to facilitate testing in some cases. In the meanwhile, hospitals tend to pack their daytime imaging schedules with preapproved outpatients because hospitals can charge more than outpatient imaging centers charge. Everyone is thus clamoring to use hospital scanners while outpatient imaging centers are quiet.

You may ask why radiologists don’t prevent abuse of the system. A better question is this: Why does the system not integrate radiologists into the process? As it goes, radiologists are placed at the mercy of the system. In most cases, they cannot order imaging tests, and denying tests only buys them more liability or places their employment contracts in jeopardy. I have said on many occasions that if an insurance company wants to save money, it need only hire a radiologist to evaluate imaging requests before they are performed.

As a result of technology, radiologists are now expected to read hundreds or thousands of images on the spot in many scenarios, and they face interruptions at a level unmatched by most other doctors because people assume that what they do is easy. I ask what would happen if a doctor called a surgeon in the middle of a surgery to ask him or her to stop operating and discuss a separate patient. This is laughable because the surgeon is busy and wouldn’t even take the call, yet it is pretty standard for radiologists to be stopped in the middle of a patient encounter to discuss another patient. Radiologists have been encouraged to welcome such interruptions or else have their contracts threatened by offsite radiology companies.

The escalation of emergency imaging appears to make sense from an optimization standpoint. Any corporate efficiency expert will tell you that standardization is key to streamlining a process. Understaffed emergency departments thus benefit when everyone coming in with a headache gets a CT scan of the head, for example, because it eliminates the step of examining the patient. In some large hospitals like mine, specialized consultants are quickly called when there is any hint of uncertainty on the part of the evaluating provider. The patient is then subject to multiple physician bills for a single diagnosis.

It is much easier to go straight to the scanner than examine the patient. Such scans provide a massive amount of information, the least of which is typically whether the patient really has an emergency. However, scans often lack precision in making diagnoses. This precision drops further when the radiologist is not given enough clinical information.

A large problem is that patients go to the emergency room for answers, but the purpose of the emergency room is to treat whatever emergent condition you have and not deal with a chronic issue. As a result, patients leave the emergency room unsatisfied with a large bill, a bill that the emergency department provider is not accountable for. This is why commercial insurance providers typically charge a much higher deductible when the emergency department visit does not result in admission. What’s more, additional imaging or clinical follow-up may be indicated, and without a primary care provider, the patient may never get appropriate care. It is a broken system for sure, a system that favors emergency care because the charges for emergency services are often higher than similar services provided in the primary care office. It is no wonder that the number of training positions for emergency medicine physicians has skyrocketed in recent years.

In my idea of health care reform, we need to find a way to keep people from using the emergency department for primary care. As a radiologist, I often don’t get paid for an exam that is not indicated. If emergency medicine providers went uncompensated when the patient doesn’t have an emergency, they wouldn’t be able to collect for most of their services.

In the meanwhile, the battle between the emergency department and radiology continues. At the end of the day, too many radiologists are broken down by the system. It is simply easier to do the wrong exam than spend minutes or hours on the phone arguing. We can’t fix health care until there is an incentive to do the right thing for the patient.

Cory Michael is a radiologist.

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