It’s easy to think ill of ER docs ordering unnecessary tests. But they face similar pressures: satisfaction surveys, government guidelines, malpractice threats.
As I sit on the receiving end of the Emergency Department’s imaging work, my mind goes from “What are they thinking?” to “Are they even thinking?” In medicine it is easy to get into an “us versus them” state of mind. The whole Ivory Tower thing implies that we aren’t even in the same medieval edifice but in opposing armed camps.
Much of the reason for my confusion relates to the limited information we receive as the reason for the exam. While radiologists like to think that an imaging request is a consultation between equal colleagues, in fact, an imaging request is just another “test” being ordered. No one writes out a detailed clinical summary when they order a CBC. Newsflash: A total body CT is just another test just like a CBC. Instead of being the consultants we would like to be, we are really just lab techs.
It is easy to think evil thoughts regarding the motives of ER docs who order seemingly unnecessary CT scans on straightforward broken bones, CT stone studies on patients who get scans on a regular basis for obvious recurrent stone disease, MRIs for infected fingers, and - my personal favorite - the head CT for a confused 90-year-old. Can’t we just accept that any 90-year-old who is taken to the ER in the middle of the night is going to be a little confused? Heck, when I get the call in the middle of the night, I’m more than a little confused.
I realized, however, that I was being unfair. There are, after all, two sides to every story, so I sat down with the director of one of our local hospital ERs and asked him to help me understand. He was very gracious about answering my questions and actually seemed glad to talk about it. He was also not very happy about the state of modern healthcare in the US and his feeling of powerlessness was eerily familiar.
According to him, the ER physicians are also caught in the middle of an impossible situation. They must cater to the expectations of the patients as well as satisfy the patient’s primary physician or the specialist who will be taking over care of the patient. The wobbly third leg of this stool is the need to practice defensive medicine. He told me that at any one time there are at least a dozen outstanding malpractice suits in the ER.
Many patients come to the ER expecting to receive a certain drug or imaging procedure. Ultimately, patient satisfaction surveys can affect the way an ER physician practices or even gets to keep the job. How likely is a drug-seeking patient who is denied the drugs he or she wants to rate the service they received as good or excellent?
On the consultant side, the ER physician relayed the story of a teenager with a simple wrist fracture who had already been casted and was in a wheelchair heading to check out, when the orthopedist on call, who had not even seen the patient, called in an order for a CT of the wrist. No reason given and none discernible by the ER physician, but course correction and off to CT.
The ER physician, who like me has many years of experience, shares my concern for the next generation of physicians. They are trained to order tests and many lack the judgment or experience to really practice good medicine as it was taught to my generation. I used to joke that CT was becoming the physical examination for some doctors but I’m no longer laughing. The government is taking over control of medicine and dictates what constitutes good medical care. Combining these factors there seems no solution to the struggle between the quantity and quality of care.
Wouldn’t it be great if doctors could take care of patients in the ER without having to answer to patient satisfaction surveys, government guidelines, or the threat of malpractice suit - at least for those who still remember how? I bet reducing the number of head CTs on confused 90-year-olds would save at least a billion dollars a year at our hospital alone.