If emergency department (ED) physicians could spend less time thinking about getting sued, they might order fewer radiology tests for their patients.
The practice of defensive medicine—where clinicians order testing or make referrals primarily to avoid litigation—is prominent in every service line and clinical setting. Ordering imaging in the ED is no exception.
In 2006 the Massachusetts Medical Society found that ED physicians had high rates of ordering scans for defensive purposes: X-rays at 23 percent; CT scans at 30 percent; MRIs at 19 percent; and ultrasound tests at 19 percent. All told, defensive medicine cost the state of Massachusetts $281 million in 2006, with imaging across the ED and other specialties accounting for $181 million. While reliable estimates are scarce, according to one study the annual costs of defensive medicine in the United States may exceed $45 billion.
Inside and outside the ED, patients are being overexposed to radiation. “Many physicians have given up the stethoscope and physical exam in favor of an echocardiogram and a CT scan,” says Kevin Campbell, MD, a cardiologist at Wake Heart and Vascular in North Carolina. Campbell notes a CT scan is nothing to take lightly: “The survivors of the atomic blasts in Japan were exposed to the equivalent radiation to two CT scans.”
Aside from raising the risk of radiation-induced cancer, unnecessary tests often result in incidental findings that cause anxiety to patients and lead to more tests and spiraling medical costs. Further compounding the problem, in-patients who receive unnecessary tests are forced to stay in the hospital longer to await results, which heightens their risk for adverse events such as infection or falls.
In many cases fear of litigation drives tests that may be clinically necessary, but shouldn’t be conducted in the hospital. For example, Katie is being treated for pneumonia and then complains about a pain in her knee. After conquering the pneumonia, rather than keep Katie another night to get a knee MRI and wait for the results, the attending physician could discharge her from the hospital and refer her to a specialist for imaging. The goal should be to get Katie out of the hospital at the appropriate time while ensuring she receives needed treatment. But often, defensive medicine leads to just the opposite.
It would be easier to combat defensive imaging if everyone’s priorities were aligned, but that’s not the case. Insurers are the only ones clearly motivated to reduce imaging overuse (one study found that $8.2 billion could have been saved in one year alone by eliminating redundant lab and radiology tests). Common sense would suggest most patients want to avoid unnecessary tests. But in fact, many patients demand imaging tests despite the doctor’s best advice. And in the current fee-for-service world, providers, especially hospitals, often are incentivized to give patients more of what they want.
Caught in the middle of these competing interests are harried ED physicians. “I find myself exasperatedly trying to talk patients out of the scans they think they need,” wrote a New Orleans ED physician in response to a New York Times article on imaging overuse. And a Toronto surgeon suggested how being sure of diagnosis can easily trump doing what’s right: “The more evidence a physician has to prove that a diagnosis was not missed, the sounder he or she sleeps at night.”
Combatting defensive medicine in radiology will require work on many fronts. While some stakeholders are focusing on tort reform, the Choosing Wisely campaign is educating patients on the benefits and risks of tests and how to discuss imaging decisions with doctors.
But real change will come about only when health systems apply a standard to radiology care and incentives are aligned to bring the full expertise of radiologists to bear. Radiologists are highly trained to know when and which types of scans to use in order to achieve an accurate diagnosis. They can help ED physicians make the right ordering decisions.
By enabling direct communication with radiologists and access to evidence-based guidelines 24 hours a day, health systems can ensure that ED physicians have expert diagnostic radiology advice at their fingertips. Having radiologists take on a more consultative role will protect patients from undue harm while helping ED physicians improve patient care—and at the same time reduce the chances for litigation. Physicians will choose the best scan (which could be none at all) for optimum patient outcomes, and they’ll have the extra ammunition to say to patients, “These experts agree that you don’t need a CT scan.”
As the value-based care model gains traction in the United States, radiologists will be able to contribute more of their knowledge to improving patient care. And patients, more knowledgeable and better cared for, will be less likely to sue.
Shower — before or after
Javier Beltran, MD