Malpractice fears spurring most ER docs to order unnecessary tests
Of 435 ER physicians who completed the survey, 97 percent admitted to ordering some advanced imaging scans that weren't medically necessary, the findings showed.
Such scans contribute to the estimated $210 billion wasted annually on unnecessary tests, procedures and treatments, the researchers contended.
Physicians said they ordered too many imaging tests because they are worried about missing an unlikely—but possible—illness, and fear being sued if they don't cover all their bases, the survey revealed.
The ER docs surveyed also suspect they aren't the only staff doing this. More than 85 percent believe too many diagnostic tests are ordered in their own emergency departments, by themselves and others.
"We don't like uncertainty, and so we're driven by this culture that says if there's any doubt, we should do the test, and we don't acknowledge the potential harms of this approach," said the study's lead author Dr. Hemal Kanzaria, an emergency physician at the University of California, Los Angeles.
Beyond increasing the cost of medicine, unnecessary imaging tests also expose patients to a real risk of harm, said Kanzaria, who is also a Robert Wood Johnson Foundation Clinical Scholar with support from the U.S. Department of Veterans Affairs.
An unneeded scan might find a "false positive"—a test result that suggests a person might have a medical problem that they don't really have. The patient could end up getting biopsies, tests, and even potentially harmful treatments, for a disease they don't have, he said.
There's also the risk that an imaging scan will uncover a medical problem that isn't causing any symptoms or illness. Doctors will feel pressure to treat the condition, even if the treatment harms the patient's quality of life even more than the undetected disease did, Kanzaria added.
"I would encourage patients to ask their physicians what the chance of them having the disease that's getting worked up is," Kanzaria said. "Ask if the tests are needed. I would also encourage patients to think about both the potential benefits and the potential harms."
Findings from the survey were released March 24 in the journal Academic Emergency Medicine.
Dr. Jay Kaplan, president-elect of the American College of Emergency Physicians, said ordering advanced imaging scans is the second-most costly decision that an ER doctor makes, only behind whether a patient should be admitted to the hospital.
Despite that, Kaplan was not surprised by what his colleagues revealed in the survey.
"I think it is a widespread concern," said Kaplan, who works in the trauma center and emergency department of Marin General Hospital in Greenbrae, Calif. "It's one reason why physicians in general and emergency physicians specifically have lobbied for medical liability reform."
Kaplan gave a couple of examples of times when an unnecessary imaging test might be ordered:
- A patient comes in with chest pain and shortness of breath, indicating a possible heart attack. An ER doc might order an MRI or CT scan to rule out "a tear in the major blood vessel coming out of the heart, which can be catastrophic if not diagnosed," he said.
- A patient has a terrible headache that is likely a tension headache or a migraine, but an MRI scan might be ordered to rule out the possibility of a small aneurysm.
"Those would be relatively uncommon diagnoses, and yet a physician might feel concerned enough to order the advanced imaging study just to be on the safe side," Kaplan said.
This problem could be solved with "safe harbor" legislation, which would protect physicians from lawsuits if they are following evidence-based medical guidelines in caring for patients, Kaplan said.
"That could help reduce defensive medicine," he said. "If a doctor could follow those guidelines and have some protection, we think it would lead to fewer unnecessary test and procedures."
Kanzaria also called for more patient education and shared decision-making—laying out the risks and benefits of imaging scans, and allowing patients to help decide whether they need these tests.
In addition, hospitals can help their doctors by providing feedback on the number of imaging scans and other diagnostic tests they order, compared with their colleagues. Doctors in the survey specifically cited this sort of feedback as something they'd find valuable.
"It won't necessarily say what's appropriate, but it certainly deepens the discussion about overuse and underuse, and it allows physicians to compare what they're doing to what their colleagues are doing," Kanzaria said.
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