Walk in My Shoes

Defensive medicine as the cost of an aggressive tort industry | RangelMD.com | 10.19.04

Another example is the high rate of cranial CAT-scans of children in the emergency department following head injuries. Every year thousands of children receive minor head injuries as a result of typical play and sports but every year thousands of these children receive CAT scans despite the fact that they have normal neurologic exams and normal mental status (i.e. no indication of serious intracranial injury).

As a result, thousands of children are exposed to very high levels of radiation despite the fact that there is no data that aggressive scanning changes head injury outcomes and very few of these scans show any intracranial pathology. One of the reasons many of these physicians give for ordering one of these scans is because of “pressure from worried parents”. The real reason for these excess scans is that ER physicians don’t want to sit in a court room and try to explain why they didn’t order a CAT scan for a child who is now dead or severely disabled. A single CAT scan can cost over a thousand dollars. This certainly adds to the costs of medical care.

Great article (as always)—but then I got to these paragraphs (supra) and I just had to comment. In my practice of Emergency Medicine (now into my 15^th year post-residency), my threshold for getting a head CT with isolated pediatric head trauma has gotten lower. I trained in a Level I trauma center and certainly saw the entire spectrum of head trauma (both isolated and in association with multi-system trauma) in adult and pediatric populations. Most of my practice has become more conservative—is it defensive, sure to a point. But it is also the natural course of training tempered by experience. It is also practice and experience tempered by practice realities. One of the most significant drivers for the need for head CT (along the lines of parent expectations) is the scripted responses from the advice nurse, which many health plans offer—planting the seed of need for a head CT. Or the call to the primary care provider (PCP)—who says go to ED immediately, the child needs a head CT… I’m placed in a no win situation, my hands are tied, and I order the test. Defensive? Yes, but not of my own doing. I’m sure many of my fellow emergency physicians can echo how our hands are tied by the seeds of expectation that are planted by those calls or those “front-desk” office visits with their PCPs (“you’re too sick to be seen here, go to the ER;” “we don’t take that insurance anymore go to the ER because you need a CT;” “you don’t have insurance, the ER can see you and do the tests,” or the barely legible scrawl on a presciption pad that says “patient is sick, please evaluate”). A reasonable history and physical would have disspelled any notion of a need for any testing.

With regards to the “cost” of the head CT, that is an artificial argument—because it really isn’t a cost argument, it is a “charge” argument—what is this particular patient going to be charged based upon their particular health plan. The marginal cost of that singular scan is quite small.

With regards to the “radiation” exposure, well that seems to be a much more significant argument, and certainly must be placed in the balance.

Finally, I practice on the tip of the emergent healthcare spear, some aspects of my practice are defensive in terms of thwarting future litigations; but also defensive because of the need to block the offenses of my fellow healthcare colleagues. My clinical agenda is many times set by the defensive agenda of my clinical colleague, and many times completely beyond any backfield maneuverings.