OK....gotta get this off my chest cause it bugs the crap out of me....Over 85% of ED physicians feel there is too much dx testing in their Depts.....and 97% admit to personally ordering unnecessary tests....doesnt that mean there should be at least 97% who believe there is too much testing? I mean 97% admit that they themselves are ordering unnecessary tests????? I also want to point out I believe the push over the past decade of "Patient satisfaction" Reimbursement based on pt satisfaction surveys etc have a lot to do with the extra testing as well. I know I feel that pressure. Now I know it sounds like a great idea to do "shared decision making" with our pts on the utilization of tests...but I remain more then a tad bit skeptical that we can make much of a dent this way. Thats because in 19 years of ER practice I still have trouble convincing DOCTORS we dont need testing/treatment.....Here are a few examples of areas that I have continued to battle for most of my career WITH OTHER DOCTORS(presumably more medically savy then the typical ER patient).....Why I do not need to bring down the asymptomatic BP of 200/100 sent in from the PCPs office for ED eval...why I actually dont need to do anything but shabaam return serve right back to the PCP(usually w the recommendation they find a better one). I still get weekly a patient sent in by a doc w no sx at all but high blood pressure. Not only do many feel I need to normalize that pressure stat, they often feel a CT brain should be done or an EKG or labs...when in reality that MAY need to be done in the next few weeks, but certainly doesnt need to be done today. 2. Why I dont need to CT every syncope admits head...most hospitalists(presumably doctors) believe this is key. Why I dont need an ABG .....EVER! A VBG is fine, and how I can manage a severe RAD w/o an ABG, or DKA w/o an ABG, or tx PNA w/o blood cultures....Why the isolated WBC means essentially nothing in the eval of acute abd pain, why the Hgb of an acute massive bleed is irrelevant(Ob's first question with the pt who will need a D and E..."whats the crit?" ....uh I dont give a crap! I could go on and on...but if we can't convince doctors of these well researched issues with robust EBM to back it up...how are we really going to convince more then a smidgeon of our ED pts they dont need that MRI for their sciatica today?
That being said I do have success in shared decision making when a topic has gotten some national attention....use of opioids for one. I can convince at least parents more now that their child should not need oxycodone for their whiplash injury by invoking the national medias coverage of rx opioid related deaths...also CT scans and radiation exposure has gotten national attention so again, for minor head injuries in kids and early appy eval and kidney stones, I recommend no Cts often explaining alternative approaches(usually obs) and scan in 12 hours or 24 if sx persist and most of the time pts(particularly parents) generally go with the reduced testing /less radiation exposure route. However I believe it takes national media scrutiny on the issue to make this conversation viable.
I agree patient satisfaction leads to unnecessary testing. I want to specifically comment on the fact that tort reform doesn't decrease testing. I practice in a state with tort reform, but anyone can file a lawsuit. There is not a formal review process in place to screen potential suits on their validity. I don't care if I have a very low risk of loosing a suit if I can repeatedly be filed on. Plus forever more I have to report that I was named in a suit only to be dropped 4 months later. In addition to tort reform, I believe a review board screening cases for validity on the front end would decrease anxiety about missed diagnoses and litigation.
I have one additional point to make about overtesting. Some of the problem comes with the training of students in general. From early on in training, meaning grade school, high school, and college, we as future physicians were driven to be right all the time. Getting straight A's. When we did not, we felt bad and felt some consequence, like feeling we were going to get into medical school. Then we again were sensitized to being right with tests like the ACT, SAT, MCAT. Finally in medical school we are pushed to be the best, to get into the right residency, and to get the best grade on the USMLE. Residency tends to try to break this , but again the boards still want you to be right. So the uncertainty of not being right can be a difficult thing to break. This I think is more central to the over testing. Yes, the fear of malpractice is cited, but I think there is an internal issue of not wanting to be wrong.
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Quality Review Gets SepticFull episode audio for MD edition252:40 min - 352 MB - M4AEM:RAP 2015 Août Résumé en FrancaisFrançais62:21 min - 57 MB - MP3EM:RAP 2015 August Canadian EditionCanadian31:42 min - 29 MB - MP3EM:RAP 2015 August Aussie EditionAustralian58:17 min - 53 MB - MP3EM:RAP 2015 Agosto Resumen EspañolEspañol76:59 min - 71 MB - MP3EM:RAP 2015 August MP3306 MB - ZIPEM:RAP 2015 August Summary1 MB - PDFEM:RAP Español Agosto 20152 MB - PDFEM:RAP 2015 August Board Review Questions223 KB - PDFEM:RAP 2015 August Board Review Answers239 KB - PDF
Sean G., M.D. - August 6, 2015 8:43 AM
OK....gotta get this off my chest cause it bugs the crap out of me....Over 85% of ED physicians feel there is too much dx testing in their Depts.....and 97% admit to personally ordering unnecessary tests....doesnt that mean there should be at least 97% who believe there is too much testing? I mean 97% admit that they themselves are ordering unnecessary tests????? I also want to point out I believe the push over the past decade of "Patient satisfaction" Reimbursement based on pt satisfaction surveys etc have a lot to do with the extra testing as well. I know I feel that pressure. Now I know it sounds like a great idea to do "shared decision making" with our pts on the utilization of tests...but I remain more then a tad bit skeptical that we can make much of a dent this way. Thats because in 19 years of ER practice I still have trouble convincing DOCTORS we dont need testing/treatment.....Here are a few examples of areas that I have continued to battle for most of my career WITH OTHER DOCTORS(presumably more medically savy then the typical ER patient).....Why I do not need to bring down the asymptomatic BP of 200/100 sent in from the PCPs office for ED eval...why I actually dont need to do anything but shabaam return serve right back to the PCP(usually w the recommendation they find a better one). I still get weekly a patient sent in by a doc w no sx at all but high blood pressure. Not only do many feel I need to normalize that pressure stat, they often feel a CT brain should be done or an EKG or labs...when in reality that MAY need to be done in the next few weeks, but certainly doesnt need to be done today. 2. Why I dont need to CT every syncope admits head...most hospitalists(presumably doctors) believe this is key. Why I dont need an ABG .....EVER! A VBG is fine, and how I can manage a severe RAD w/o an ABG, or DKA w/o an ABG, or tx PNA w/o blood cultures....Why the isolated WBC means essentially nothing in the eval of acute abd pain, why the Hgb of an acute massive bleed is irrelevant(Ob's first question with the pt who will need a D and E..."whats the crit?" ....uh I dont give a crap! I could go on and on...but if we can't convince doctors of these well researched issues with robust EBM to back it up...how are we really going to convince more then a smidgeon of our ED pts they dont need that MRI for their sciatica today?
Sean G., M.D. - August 8, 2015 2:46 AM
That being said I do have success in shared decision making when a topic has gotten some national attention....use of opioids for one. I can convince at least parents more now that their child should not need oxycodone for their whiplash injury by invoking the national medias coverage of rx opioid related deaths...also CT scans and radiation exposure has gotten national attention so again, for minor head injuries in kids and early appy eval and kidney stones, I recommend no Cts often explaining alternative approaches(usually obs) and scan in 12 hours or 24 if sx persist and most of the time pts(particularly parents) generally go with the reduced testing /less radiation exposure route. However I believe it takes national media scrutiny on the issue to make this conversation viable.
Joshua A. - August 24, 2015 3:22 PM
I agree patient satisfaction leads to unnecessary testing. I want to specifically comment on the fact that tort reform doesn't decrease testing. I practice in a state with tort reform, but anyone can file a lawsuit. There is not a formal review process in place to screen potential suits on their validity. I don't care if I have a very low risk of loosing a suit if I can repeatedly be filed on. Plus forever more I have to report that I was named in a suit only to be dropped 4 months later. In addition to tort reform, I believe a review board screening cases for validity on the front end would decrease anxiety about missed diagnoses and litigation.
Craig K. - September 1, 2015 9:45 AM
I have one additional point to make about overtesting. Some of the problem comes with the training of students in general. From early on in training, meaning grade school, high school, and college, we as future physicians were driven to be right all the time. Getting straight A's. When we did not, we felt bad and felt some consequence, like feeling we were going to get into medical school. Then we again were sensitized to being right with tests like the ACT, SAT, MCAT. Finally in medical school we are pushed to be the best, to get into the right residency, and to get the best grade on the USMLE. Residency tends to try to break this , but again the boards still want you to be right. So the uncertainty of not being right can be a difficult thing to break. This I think is more central to the over testing. Yes, the fear of malpractice is cited, but I think there is an internal issue of not wanting to be wrong.