I heard recently about a case of over-testing that seems so typical nowadays that it makes me wonder not just how we got here, but how we go back. A 9-year-old child comes to the ED with abdominal pain and vomiting, RLQ tenderness and guarding, and a CT that is read as ‘equivocal, appendix not well visualized’. White count was up a bit. No surgical consult in the ED. Child sent home. Goes to a different ED a day later, same story, exam more pronounced with rebound tenderness and a 19,000 WBC with temp of 38.9. Surgeon called, insists on repeat CT before seeing patient. Repeat CT shows acute appy. Appendix found to be ruptured in the OR with early multiple abscess formation. How did we get here?
In 1976, when I first started practicing emergency medicine, the diagnosis of acute appendicitis was made clinically, and confirmed (or not) in the OR, or with the tincture of time and reexamination. The only value of an elevated WBC was that it helped us get the surgeon out of bed. A classic set of signs and symptoms would do the same, if you were confident enough and the surgeon trusted your judgment, though admission and surgical consult in the AM was a reasonable approach if the patient did not look toxic. No CT, no ultrasound, just plain old clinical judgment. Sure, there were a few negative explorations, but the operative risks, even in ‘them old days’, was low, and I suspect perforations were no more frequently encountered (though socio-medical reasons for these ruptures are complicated, then and now). Certainly that initial and subsequent additional dose of radiation might have been avoided in this case by use of ultrasound. The increasing skills of EPs behind the U/S probe have reduced the stress on the ultrasound techs, who are often in limited supply, especially after hours. Still, our reliance on diagnostic testing when the clinically obvious is clinically obvious seems like economic, legal, and medical overkill.
There are so many reasons why this is happening to medicine and to patients in the U.S. that returning to the era of decision-making based on sound clinical judgment as the standard, rather than the exception, seems all but impossible. Patient expectation, fear of malpractice suits, lack of access to close follow-up post ED discharge, de-linking of care and primary care provider relationships, reluctance to pay for revisits to the ED, high copays for ED visits, physician life-style issues, poor reimbursement for the care of most children, job insecurity, pressure by hospitals to over-test, contractions in time spent with patients: the list goes on. Not even capitation can overcome these incentives to over-test and over-treat. Choosing Wisely? Yea, that’s certainly caught on like wildfire. I fear that even if we could reverse or eliminate some of these factors that predispose physicians to over-test, physicians may have lost too many of their clinical skills, and/or lost the ability to pass them on to clinicians in training. Even as testing gets more ‘accurate’, it seems to get more overly sensitive, causing physicians to chase down every borderline abnormality, and ‘over-diagnose’ these findings to justify the over-testing. A slightly elevated creatinine due to dehydration becomes renal insufficiency and then acute renal injury resulting in renal ultrasounds and who knows what else.
If I had a way to return to the days before CTs and Ultrasounds, MRIs, sensitive troponins, and the rest, would I do it? Of course not: the problem isn’t with these miraculous instruments and tests, it is with those who use them, the incentives to rely so excessively on them, and the system that incorporates their overuse into standards of care. We can’t afford to go forward in the same vein: it could bankrupt the country. We can’t afford to go back: we will lose the real advantage of advances in care. All physicians can do at this point is, like the addict, acknowledge their dependence, strive to do better, and hope for forgiveness.