Defensive medicine as the cost of an aggressive tort industry | RangelMD.com | 10.19.04
Another example is the high rate of cranial CAT-scans of children in the emergency department following head injuries. Every year thousands of children receive minor head injuries as a result of typical play and sports but every year thousands of these children receive CAT scans despite the fact that they have normal neurologic exams and normal mental status (i.e. no indication of serious intracranial injury).
As a result, thousands of children are exposed to very high levels of radiation despite the fact that there is no data that aggressive scanning changes head injury outcomes and very few of these scans show any intracranial pathology. One of the reasons many of these physicians give for ordering one of these scans is because of “pressure from worried parents”. The real reason for these excess scans is that ER physicians don’t want to sit in a court room and try to explain why they didn’t order a CAT scan for a child who is now dead or severely disabled. A single CAT scan can cost over a thousand dollars. This certainly adds to the costs of medical care.
Great article (as always)—but then I got to these paragraphs (supra) and I just had to comment. In my practice of Emergency Medicine (now into my 15th year post-residency), my threshold for getting a head CT with isolated pediatric head trauma has gotten lower. I trained in a Level I trauma center and certainly saw the entire spectrum of head trauma (both isolated and in association with multi-system trauma) in adult and pediatric populations. Most of my practice has become more conservative—is it defensive, sure to a point. But it is also the natural course of training tempered by experience. It is also practice and experience tempered by practice realities. One of the most significant drivers for the need for head CT (along the lines of parent expectations) is the scripted responses from the advice nurse, which many health plans offer—planting the seed of need for a head CT. Or the call to the primary care provider (PCP)—who says go to ED immediately, the child needs a head CT… I’m placed in a no win situation, my hands are tied, and I order the test. Defensive? Yes, but not of my own doing. I’m sure many of my fellow emergency physicians can echo how our hands are tied by the seeds of expectation that are planted by those calls or those “front-desk” office visits with their PCPs (”you’re too sick to be seen here, go to the ER;” “we don’t take that insurance anymore go to the ER because you need a CT;” “you don’t have insurance, the ER can see you and do the tests,” or the barely legible scrawl on a presciption pad that says “patient is sick, please evaluate”). A reasonable history and physical would have disspelled any notion of a need for any testing.
With regards to the “cost” of the head CT, that is an artificial argument—because it really isn’t a cost argument, it is a “charge” argument—what is this particular patient going to be charged based upon their particular health plan. The marginal cost of that singular scan is quite small.
With regards to the “radiation” exposure, well that seems to be a much more significant argument, and certainly must be placed in the balance.
Finally, I practice on the tip of the emergent healthcare spear, some aspects of my practice are defensive in terms of thwarting future litigations; but also defensive because of the need to block the offenses of my fellow healthcare colleagues. My clinical agenda is many times set by the defensive agenda of my clinical colleague, and many times completely beyond any backfield maneuverings.
4 Comments
I have extremely active and adventurous children who’ve had more than their fair share of accidents. Most, typical kid stuff, some absolutely absurd and one, stupidity of the supervising adult.
My 2 sons, have been to the ER for head injuries a total of 5 times. Each time we were told by the on call doctor to take them to the ER to SEE IF they needed a CT scan.
With the exception of the stupid supervising adult event, we didn’t call the doctor, we went straight to ER.
When we got to the ER, the first time, the doctor was going to order the CT scan but I could just tell something was up, and I asked him why he seemed hesitant. He explained that not all head injuries really NEED a CT scan, but to be on the safe side … and I realized he was doing a CYA proceedure reluctantly.
I told this doc … hey, if youd on’t think he needs one, give me the instructions to watch for. I don’t want to put my kids through unnecessary testing! I can’t even imagine demanding putting my kids through a CT scan if the doctor wasn’t sure he needed one!
From then on, when we’d take them in, I made sure the ER doctor made sure he knew that we understood that we were there for an evaluation to SEE IF he needed a CT scan, not to have a CT scan. (and get stitches when necessary
..)
The last event, when we didn’t call, no one even questioned it, they took him striaght from triage to CT and asked us why we hadn’t called an ambulance …because …we didn’t have a cellphone was our answer.
He was going to the pool with another family, the MOTHER let him ride on the TRUNK OF THE CAR!!!!! He slid off and landed on his head!! ARGH!!!!!!
She never followed us to the ER, she just took her kids to the pool. Took her 2 weeks to even come check on my son!! No, my kids don’t play over there anymore.
I have extremely active and adventurous children who've had more than their fair share of accidents. Most, typical kid stuff, some absolutely absurd and one, stupidity of the supervising adult.
My 2 sons, have been to the ER for head injuries a total of 5 times. Each time we were told by the on call doctor to take them to the ER to SEE IF they needed a CT scan.
With the exception of the stupid supervising adult event, we didn't call the doctor, we went straight to ER.
When we got to the ER, the first time, the doctor was going to order the CT scan but I could just tell something was up, and I asked him why he seemed hesitant. He explained that not all head injuries really NEED a CT scan, but to be on the safe side … and I realized he was doing a CYA proceedure reluctantly.
I told this doc … hey, if youd on't think he needs one, give me the instructions to watch for. I don't want to put my kids through unnecessary testing! I can't even imagine demanding putting my kids through a CT scan if the doctor wasn't sure he needed one!
From then on, when we'd take them in, I made sure the ER doctor made sure he knew that we understood that we were there for an evaluation to SEE IF he needed a CT scan, not to have a CT scan. (and get stitches when necessary
..)
The last event, when we didn't call, no one even questioned it, they took him striaght from triage to CT and asked us why we hadn't called an ambulance …because …we didn't have a cellphone was our answer.
He was going to the pool with another family, the MOTHER let him ride on the TRUNK OF THE CAR!!!!! He slid off and landed on his head!! ARGH!!!!!!
She never followed us to the ER, she just took her kids to the pool. Took her 2 weeks to even come check on my son!! No, my kids don't play over there anymore.
Your comments reflect the real world dilemma many ER physicians face, we would like to be completely straightforward about the diagnosis and what should be done based upon our clincial evaluation. But, by time the patient arrives the advice nurse or primary care provider may have been called or even the triage nurse has given an opinion about what should happen that our hands are tied in terms of patient (or parent) expectations.
There are two levels of expectations, those of the patient (and parent) and those of the referring agents (physician, mid-level, advice nurse, etc.). In a sense, we must be mindful that a “successful” encounter must address both sets of expectations. The irony here from the third party advice nurses is that we may get a letter about our quality of care if we don’t get a CT based upon their telephonic interview.
Your comments reflect the real world dilemma many ER physicians face, we would like to be completely straightforward about the diagnosis and what should be done based upon our clincial evaluation. But, by time the patient arrives the advice nurse or primary care provider may have been called or even the triage nurse has given an opinion about what should happen that our hands are tied in terms of patient (or parent) expectations.
There are two levels of expectations, those of the patient (and parent) and those of the referring agents (physician, mid-level, advice nurse, etc.). In a sense, we must be mindful that a “successful” encounter must address both sets of expectations. The irony here from the third party advice nurses is that we may get a letter about our quality of care if we don't get a CT based upon their telephonic interview.