You are a bank teller. Someone points a gun at you and demands all the money in your drawer. You're going to give that person all the money—unless you're Bruce Willis, in which case you say something cocky and take the gun away. Doctors (with the possible exception of a few surgeons I've known) are seldom that stupid and would do as they are told rather than die protecting someone else's money.
Over the past few years, there has been an outcry from the government and insurance companies lamenting the overuse of imaging, especially CT scans. Seldom does a week go by without some article mentioning the “overuse” of CT in U.S. emergency rooms. The same forces that created the current system are now complaining about it. I'm reminded of the daily struggle getting the boys ready for school, followed by the whining when they have to walk into school late.
By not supplying universal coverage, payers and the government have turned ERs into national walk-in clinics. In our hospital, the true emergencies are probably outnumbered by faux emergencies 10 to one. At the same time, the government has mandated that anyone who presents to the ER is an emergency. He or she cannot be transferred or handled routinely.
The Joint Commission on Accreditation of Healthcare Organizations and similar groups use wait times in the ER as a measure of quality, demanding that all these self-defined emergencies be assessed promptly. Chronic problems demand a complete diagnosis simply because the patient chose to visit an ER instead of a primary care provider.
These same government and private entities, with the enthusiastic support of the legal profession, have created an artificial expectation of perfection. All mistakes, oversights, and misdiagnoses are subject to the retrospectoscope, with serious consequences. Because of an upcoming job change, I have been filling out credentials forms from a lot of hospitals. Every one of them asks if you have ever been accused of malpractice, been investigated by your medical staff or quality review committee, or had any investigation into your work by any organization. Tolerance for mistakes is not a hospital byword.
We may have a small problem with overuse of imaging by emergency physicians. But we have a big problem with overuse of emergency rooms and conflicting demands on physicians.
Every day, about five million people with headaches and/or abdominal pain walk into our ER. Only a small percentage of them have serious maladies warranting the term emergency. By virtue of walking through that door and climbing onto the gurney, however, they all assume the importance and the liability of a true emergency. The ER doc knows how to sort out true emergencies from routine problems on a clinical basis with reasonable accuracy. But reasonable accuracy is not what the powers that be expect. Besides, the time required to make such an assessment is considered unacceptable. What would you do?
I would get a CT scan on all of them. The system virtually demands it. We did not create this system; it has been thrust upon us. And the one true emergency in 100 patients might have grounds for a suit due to delay in diagnosis.
With the misguided goals of efficiency and economy, those controlling the purse strings have created a system requiring excess utilization of expensive ER services and medical imaging. Now they are generating more expenses and wasted staffing trying to decrease utilization without addressing the real issues. If the U.S. hopes to control healthcare costs and CT utilization, it needs to lower the guns aimed at physicians or start training a lot of Bruce Willis wannabes.
