I think you are in agreement with most of the comments and DB’s original rant. The “resource utilization” that Stalwart Hospitalist mentioned works in the opposite way that you’re thinking. Doctors are rewarded (or at least not reprimanded) for having LOWER costs/admission, not higher.

You are absolutely right that “no harm done” isn’t a good defense and I think DB would agree with you (correct me if I’m wrong). I think he was just saying that in this one case, nothing bad happened but we shouldn’t risk it.

In short, I agree with you and think most other doctors do too.

If I am a patient, I may 1) have high deductible 2) I may have % co-insurance rather than a fixed co-payment 3) be really struggling to pay my bills and to feed my kids. How is taking my money for a test that is not indicated because Stalwart Hospitalist above wants to achieve better “resource utilization” is different from him stealing my money? If my insurance pays for it, how is it different from insurance fraud?

Additionally, I take exception to “no harm done” statement. All these tests have false positives. A false positive may lead to a more invasive test like, I don’t know, catherization that has 1/1000 chance of stroke. Sure this risk may be small, but if I don’t need the test, you have no right to subject me to it at least without my consent. A patient in an ER for, I don’t know, broken ribs is hardly in a position to object; nor is usually any time given to him to do so.

Really, pray explain me how a doctor ordering an unnecessary test for financial gain is different from a common thief.

If one of my clinical evaluation metrics is the average cost per case on the patient’s I admit, then I need to be the one making the final decision on whether additional consults need to be called or whether more tests need to be ordered.

Fun anecdote — I was once asked to consult for hypertension and diabetes on an orthopedic surgery patient. Two days later, I see in the chart that Ortho (the PRIMARY team) has decided to “sign off.”

When there is no one driving the boat, so to speak, there is so much more opportunity for error. I’ve been the hospitalist on cases in which there is a general surgeon, a nephrologist, an intensivist, and a cardiologist involved, and all the docs start writing orders that contradict each other. Potentially disastrous.

(1) capitate specialist procedure payments (does that 90-year-old really NEED another echo, even though one was done when they were admitted 3 months ago?)

(2) mandate that certain procedures (eg. echo, nuclear stress) cannot be ordered by a physician with a financial stake in performing the test (hello? where is pete stark on this one?). I don’t know how one would do this, perhaps have a limited number of medicare-certified facilities & a central databank with results?

But specialists “consulting” other specialists is just ripping off the system, and very short-sighted, ruining healthcare in the long run.

What drives me a little crazy is when some patient comes into the E.R. needing admission for some purely specialist oriented problem and the E.R. doc is told by the specialist “Admit it to drsam and consult me.”

That way, they can just buzz in and do less paperwork and get paid more as the consultant and for doing their procedures. Meanwhile, I get to do all the lower paying scut work on some patient where I really have nothing of substance to contribute to the case.

If I were a hospitalist, I don’t think I’d mind it so much, but I’m not a hospitalist. I have an outpatient clinic that is 12 miles away from the hospital. I don’t usually have many patients in the hospital, and most frequently have none. When I do, it means a lot of extra driving and time taken away from my clinic patients, personal life, etc.

When it is one of my established patients that gets admitted, or when there is a genuine need for my involvement, I don’t mind being the admitting physician. When this is not the case however, and I’m only being involved so the specialist can have less busy work, I do mind that. I didn’t become a family medicine physician simply to be a scut-monkey for the specialists.

Unfortunately, our hospital is too small to support a hospitalist program since Hurricane Katrina. It is slowly growing back as the community slowly returns and some day will be busy enough for a hospitalist program to be an option. I look forward to that day!