Part of a series. Click here to read Pro/Con ‘Unnecessary’ Testing.
One of the most memorable scenes in the iconic movie Jerry Maguire is when Tom Cruise comes to Cuba Gooding Jr. in the locker room and gives his imploring, desperate “Help me help you” speech. When Gooding finally erupts in laughter and Cruise starts to walk away, the camera pans back to the now-naked Gooding, who says, “Oh come on Jerry, you think we’re fighting and I think we’re finally talking!.” I’ve tried to reference this scene with my wife when we have been locked in an argument before, but for some reason it doesn’t seem to land. Maybe she’d listen if I had Cuba’s abs. But let’s be honest: she sees me more as the Cuba Gooding Jr. from Daddy Day Camp.
Be that as it may, it is true that sometimes we have to really get into an argument to start talking about the important topics. Drs. Hemal Kanzaria, Jerry Hoffman and Marc Probst et al touched a nerve with their study confirming what we all have had queasy feelings about for a long time. Don’t tell anybody, but it’s possible that doctors sometimes order tests where they already know the result, feel that the test result is irrelevant to the treatment of the case, or are only ordering the test in case someone sues for some unknown reason. That is what many of us would call an “unnecessary” test. But as Bill Sullivan points out on page 24, maybe the test isn’t really “unnecessary” after all, even if we kinda sorta feel it could be. After all, every now and then the test results surprise us. If I had a hundred dollars for every surprise test result I’ve ordered, I’d have, well, at least a few hundred dollars. But he is right that we need to count the cost of blabbing to the whole world that emergency physicians are knowingly ordering countless expensive tests that they themselves don’t think are necessary.
This argument is, however, worth having – behind closed doors – because it involves several great principles of our practice. First, American medicine costs too much. Or at least it seems that way compared to what other countries seem to be getting for significantly less money. We need to address this issue and it has many sources and potential solutions. To think that medicine cannot contract without putting patients at risk and reducing quality is tough to defend. We can and must look for all the potential answers.
Second, we physicians are part of the problem or at least we could be. I once had a marriage counselor tell me a very important phrase to use when arguing with my wife. “You could be right.” (As an aside, I know it sounds like Rebecca and I fight all the time, but we don’t. If you’ve been married 40 years like me and haven’t talked to a counselor a time or two, you are either a tyrant, a wimp, or just stupid). The phrase simply creates space to consider other possibilities. As we consider solutions to expensive medicine, we need to expand the solution set, not put on blinders of pride. Is it possible that we order too many tests? Yes. Is it possible that we admit too much culpability in the problem? Yes. I know that I’ve been pressured to admit guilt in arguments before when I really wasn’t at fault (Honey, if you are reading this, I really don’t feel this way. I’m just saying it to make a point in the magazine). And yes, it is true, the media wants to blame us for the problem. Jerry is right that we must challenge the public’s intolerance to uncertainty and the notion that every bad outcome has a medical error attached to it, along with a big check. But in the end, we can only change our own behavior (I seem to remember hearing the counselor tell me that, too). I would add that this is one area that might be best addressed through legislation, which is one of the reasons I’ve entered the political arena. We might simply need to change how we do blame assessment through litigation. It will take a long time to change how Americans think about personal risk and responsibility, but I think it is appropriate to try.
It is frustrating night after night explaining the same thing to patient after patient. “No we really don’t need to get that CT scan. I know a negative test would make you sleep better knowing that Johnny didn’t sustain a life threatening head injury when he fell and hit his head on the carpeted floor. But there would actually be greater risk to him that he might develop brain cancer from the radiation. Are you OK with us just watching him for a while and then letting him go home?” It would actually be easier to order the dang test and let everyone go home happy. Then I’ll sleep better knowing that I have good patient satisfaction scores and the hospital is happy with me for making them gobs of money. But we have a responsibility that is larger than just you, me and the patient when payment for this system goes beyond ourselves to the community, even to the the next generation. Like it or not, we have become the stewards of the system.
Was the Kanzaria et al study imprecise? Of course, it was. A convenience sample? That too. It dealt with the “perceptions” of the EPs that were questioned. And perceptions will always be imprecise. But to battle over the precise terms of the study misses the point of it all. This is where I learned Bill’s “void for vagueness” argument may win a court case on a legal technicality, but it doesn’t fly in normal life. I’ve tried it many times. “Honey, if you can’t remember the exact words I said, you can’t prove that I was being a jerk.” Yeah, that goes over like a lead balloon. I might win the argument, but I definitely did not win the case.
In the end this study was about the pressures we face as emergency physicians, both internally and externally, to do things that we might not always feel so comfortable about. That is a truism that I find hard to dispute. Anyone who has worked in an ER-in-the-round knows the stress of working 12 hours with a room full of people watching you, evaluating every move you make, every chuckle at a joke, every time you stop racing about to gulp a cup of coffee. But that’s our life.
And now that emergency medicine is center stage in the debate over health care costs and how to reduce them, we find that we now have not only a group of angry patients, but a nation of insurers, pundits, and politicians watching our every move. Does it hurt us when we admit to the world that everyone one of us – OK 97% of us – admit to sometimes feeling that we have compromised perfection in some way? To some it does. Will certain people use that honesty and transparency to throw stones at us? It pains me to say it, but my brief experience in politics so far has shown me that yes, that is true as well. But we do, nevertheless, live in a glass house. Let’s just not be guilty of breaking the windows while throwing rocks at each other.
Photo by Tiberiu Ana.
I agree that often certain medical treatments/tests/etc. are unnecessary. I would appreciate if patients were given more autonomy and choice. If I am a patient, I would prefer the option to refuse treatment, examinations, and evaluations, along with the responsibility for the decision. Patients may feel more empowered if their autonomy to make decisions to reduce cost and waste were more well-received.