I am working in a dedicated trauma center this month, an entire hospital built specifically to manage the injured. And if you are badly injured, you want to be at this place. But most of our patients are not badly injured.
I recently saw a 22 year old lady who flipped over her honda civic and was transported by helicopter (of course) to our fine facility. Although there were no obvious injuries, she was really freaked out. That’s understandable. This freaking out however made it difficult to examine her, as everywhere I touched her hurt, even places that were obviously uninjured. This is a fairly common problem in an emergency department, and it doesn’t take long to figure out how to deal with it: you have to adjust your threshold for calling a point on the body tender, much like you do with a scared two year old. You touch a scared two-year old’s hand, and he screams, the wrist makes him scream, the elbow, more screams, but then you move the shoulder and he really screams.
So I applied the same principle to this lady, and I came away with the impression that there wasn’t much wrong with her. I asked for a CT scan of the head and neck, which are low-radiation tests. The nurse asked why I didn’t also scan her chest and belly, which are high-radiation tests, and I told her that I didn’t think she needed those tests, and I went back upstairs to join my team, who were rounding on our admitted patients. A few minutes later our boss, Dr. J, was paged, and told us that he had to go downstairs, but we should keep rounding. A few moments later, he was paged on the hospital-wide overhead, so I went back down, thinking something of interest was happening in the area where new patients are seen. Dr. J was standing at the bedside of my patient, feeling her belly, and she was screaming. The nurse said, can we do a full-body scan? Sure, he said. Thank you, the nurse said, looking at me quite satisfied.
Later on that evening, I examined another young lady who I didn’t think needed any tests after her car accident, and Dr. J asked me to get another full-body scan. As I put the requisition in, I thought about the nazis who, when asked to explain how they could kill innocent people, claimed they were just following orders.
Why is it that so many people at this institution are needlessly irradiated? Let’s look at the incentives.
1. The physicians. Much has been said about how today’s legal environment leads to extra testing, I won’t rehash it. It’s clear that the way we deal with bad medical outcomes, which is harmful to everyone involved except the lawyers, needs to be changed; the problem is that the people who make the laws that determine how we deal with bad medical outcomes are lawyers. So for now, we’re stuck with physicians being incented to overtest, and we hear a lot about the fiscal result of this. But a much more dangerous consequence of the shift from the patient needing to prove that she needs the test to needing to prove that she doesn’t need the test is that the culture of medicine more and more embraces tests, medications, and other interventions. Tests, however, are in and of themselves bad, and so are medications, to say nothing of surgeries. When you’re torn about whether to test or treat, the answer is always no. Contrast this with the first rule of managing trauma, according to the manual I was given at my orientation, which states that one should always assume the worst. This makes sense in a patient who is unwell, but, again, most of the patients we see are fine and assuming the worst does not help them, it hurts them, even if they don’t know it. Ordering an unnecessary CT scan is painless assault.
2. The nurses. The nurse’s goal is to only bring the patient to the CT scanner once, because moving patients is extra work. Therefore the nurses are incented to scan every inch of the body on the first trip.
3. The patients. Most patients not only don’t realize that tests are bad, they happily absorb radiation and say thank you doctor, can I have another. In fact I have found that the more tests you order, the more grateful the patient. If I keep a patient six hours and order 20 tests, the patient thinks she has received a high level of care, not knowing that the son that she has in ten years won’t be able to do long division because I zapped her ovaries today. If I keep the patient six hours and just observe her to make sure her pain gets better and not worse, she’s pissed.
And where are the incentives not to test? Do we reward doctors who order fewer tests, but do just as well for their patients? Do we protect doctors from ambulance-chasing lawyers? And what would become of the resident who tells his boss that he doesn’t think the test is indicated, and if you want it, you can order it yourself? Let me tell you about the incentives for me not to do that. See you in Nuremberg.