Ever tried to get a surgeon to operate on a patient without a CT? Often, the answer is “Call me back when you have the CT.”

Ever tried to admit a patient to the medicine service with a clinical diagnosis? Many will say, “Call me back when you have the lab values.”

There are those physicians who insist that every patient over the age of 60 have their cardiac enzymes checked, regardless of whether there is an indication. “What are the enzymes?” / “I did not–” / “Please pull a first set of enzymes, then call me back.”

The ER may order too many studies, but one must consider that these studies are often ordered due to pressure from consultants and admitting physicians, often from those who have not yet met the patient in person.

The last time I spoke to a medical malpractice lawyer about the misdiagnosis of appendicitis as a possible cause of action, his response was that there’s not enough money in it. “Tort reform” measures make it so costly to bring a malpractice case that, even with obvious malpractice resulting in a ruptured appendix, it’s not economically viable to bring a lawsuit. The patient usually ends up with pretty much the same scar and, even assuming a day or two in the hospital to recover from a more serious surgery or infection, that doesn’t translate into appreciable damages.

Are malpractice lawsuits truly more common in clinics or hospitals with limited access to CT scans, as opposed to those which have a surfeit of available machines? It has always been my impression that those hospitals most apt to order the type of CT scan or MRI you would deem “unnecessary” is significantly more interested in maximizing the return on its capital investment than in avoiding malpractice litigation.

“This study suggests that we need not perform CT scans in the obvious group.” The classic appendicitis presentation is not actually that common (some studies say only 10-20%)

Finally, I do not have access to medscape, so I cannot comment on this article which comments on a journal publication that is not listed. Is Dr. Chen an EM doc, a surgeon, a radiologist or a hospitalist, because of course all of these groups have their own biases.

I must take issue with your contention that emergency department use of technology and imaging is “not a really big piece of the pie” of healthcare cost increases — the underlying sentiment is that focused intervention on utilization reduction should be directed elsewhere (i.e., end-of-life care).

Healthcare costs are so out of control that we will never begin to solve the problem by only attacking the largest contributing factor — any reasonably sizable contributing factor is worthy of attention and intervention. My own home institution has witnessed an explosion in abdominal CT imaging volume and thoracic CT angiography volume since these technologies became available, and the vast majority of these studies are negative (internal QI data).

Save the CT’s for the odd presentation where you’re not sure what’s going on.

Yes, technology is over-used and it drives up healthcare costs in many ways but I don’t thin the ED use of technology is really a big piece of the pie. It is what happens to the patients after they are admitted that account for the largest portion. (i.e. end of life care)

There are risks other than the cost to the system with unnecessary ABD CT’s, such as rads for the patient. A confused & emergent environment, such as an ED, is notthe place to start refusing simple diagnostic tests because we are afraid of driving up the bill. There are many places in medicine costs can be improved but the ED is one of the last places we need to start cutting back.