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Demystifying Medicine One Week at a Time

C.T. This

How and when do new medical technologies become the ‘standard of care?’

A recent study showed that the use of CT scans in hospital emergency departments rose sixteen percent between 1995 and 2007.

Looks a bit like a medieval torture doughnut.

The only thing that surprises me about this is that it’s not more.

Way more.

I remember the first time I actually ordered a CT scan on a patient all by myself, in 1997. I remember signing the order in the patient’s hospital chart, and feeling with some trepidation that I had just moved from the sidelines of the medical world into the main arena–the one floored and wallpapered with health care dollars.

Back then, quaint as it seems, we used to really deliberate about ordering tests like CT scans. They were deemed expensive and inconvenient, and in the [paradoxically-named] internist’s armamentarium, it was a sort of holy grail of diagnostics–it lets us see your insides. [Quaint, too, in light of all the hoopla about airport body scanners.]

One of the faculty doctors who trained me had the following shtick that has stuck with me:

“Know what the most expensive thing is in health care?” he would mischievously ask.

MRIs?

Open heart surgery?

ICU care for moribund elders?

“The doctor’s pen,” was the answer, whereupon he’d pull out a Mont Blanc fountain pen and flash it around with panache.

The implication of future wealth coupled with fiduciary-medical responsibility was unmistakable.

Somewhere along the way, our collective reticence at using such “big guns” like CT scans and MRIs have fallen by the wayside. As the technologies have become faster, better, and more detailed, they have become altogether more commonplace, such that they are darn near routine.

In the ER with a headache? You’re likely to get a CT scan. Abdominal pain? Belly CT, you betcha! [I don’t mean to pick on the ER. Come to my office and there’s a good likelihood the same fate awaits.]

Partly it’s the legitimate fear of missing something, of being a bad doctor, and of course the fear of a lawsuit. It’s also partly because patients have come to expect imaging tests because they’ve read about them, seen them on television, had their loved ones go through them. Heck, you can even get your own screening CT scan with no doctor’s order necessary. [Please note the preceding link is just for illustrative purposes, and in no way an endorsement. In fact, I think screening CTs are overall a bad idea. So there. Fodder for a future post…]

Well, we’re through the looking glass now. When everybody gets exposed to the amounts of radiation in a CT scan, bad side effects start getting reported. [These horror stories mostly occurred in the setting of improper use and repeated CT scans, mind you.]

I guess my point is, before asking for/being asked to get a CT scan, ask your doctor to really think through the need for the test “like they did in the old days.”

3 Comments

  1. As an ER doctor for the last 31 years, I don’t know to which study you refer, but, in my emergency department, the number of CT”s and MRI’s that we order has gone up way more than 16% in the last 15 years. I would bet they have almost doubled. Why? Physicians have become averse to uncertainty. It used come with the job and we accepted it.

    When I trained, back in the 1970’s, CT scans and MRI’s didn’t exist. Ultrasound was new and limited. We were comfortable with risk. It was OK to say, “I’m not sure. Why don’t we see what happens over the next 24 hours?” Actually, with some common sense a good judgment, most of the time we did the right thing with little excess morbidity. Today that is unacceptable, driven by patient expectations, fear of liability, and constraints of time. It takes less time and is way less stressful to order a test than it is to have a difficult conversation with the patient about why I would order this test for my wife… then add the important disclaimer that many or most ER Doctors would simply order the (stupid) test instead of having this painful conversation.

    How much of this is driven by fear of liability? Hard to know. If you look at any of the recent studies on how much malpractice insurance and fear of malpractice drive excess costs in health care, you find that they trivialize the problem to about 2-4% of total health care costs. Ask any old timer, and they will say that is nonsense. Over the last 10-20 years, physicians in training have learned to practice to a “standard of care” into which the fear of liability is built. If you ask them why they are ordering the CT scan on the 12 year old boy who has abdominal pain for 5 hours, who as already has had an ultrasound on which the appendix was not visualized), the young doctor will say it’s the “Standard of Care”. They have no insight into the extent to which the fear of liability has been built into everything we do.

    If I were only taking care of friends and family in the ER, the average total bill would probably be 10-30% less… and I am a minimalist already. Can you imagine how much less it would be for some of my younger colleagues? When it comes to ordering excess tests, for a variety of reasons, we are completely out of control and it’s not just fear of liability that drives this. Another contributing factor is the disappearance and marginalization of primary care providers in the care of inpatients. But that’s the topic of a different rant.

    That’s my story and I am sticking to it.

  2. I’m a senior radiology resident at a busy hospital, and I can’t tell you how disheartening it is to get the MANY requests for CT interpretation (on call in total I may read 80-100 studies n a night) for patients who have only been seen/evaluated by a triage nurse. Chest pain in a 19-year-old? Let’s get a CT angiogram! Monthly pelvic pain in a menstruating female? Better rule out ovarian tumor — don’t worry, they always order an ultrasound AS WELL, which sometime ends up being done second because the triage nurses are so fast with their computer orders!!!

    A number of these studies are truly necessary, and I feel like I’ve been able to make some great diagnoses that have very much made the difference for some patients. But in the vast majority of cases, I’m just on a general hunt for “anything” as the patients haven’t yet had a good physical exam, and to tell you the truth, I am unfortunately obligated to report things like pulmonary nodules, likely adrenal adenomas, and renal cysts — all of which may just get your primary care doctor to continue the cycle of followup testing…

    So I highly recommend being an educated consumer in the ER; when my own 3-year-old son needed to be evaluated for “swelling” in his neck, you better believe I rejected outright a CT with anaesthesia, immediately suggested by the ER and peds surgeon. Guess what? An ultrasound is GREAT at looking for abscess.

    It’s scary out there. We all need to be part of the solution.

  3. excellent post and discussion

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