Dr. Mirvis
is the Editor-in-Chief of this journal and Professor of
Radiology, Diagnostic Imaging Department, University of Maryland
Medical Center, Baltiimore, MD.
During a casual conversation with an emergency department fellow
who was doing an elective in our radiology section, I commented on
the rather large number of negative imaging studies we were seeing
every day from his department. The cryptic response was "We never
let the history and physical stand in the way of ordering lots of
tests." As he saw it, this was the unofficial dogma of the
emergency physician, a "do studies now, ask questions later"
philosophy. All of us have experienced, perhaps numerous times
daily, a clinical physician who wants to obtain or review imaging
studies of patients they have not yet actually seen. Many
"consultants" will not consult officially until certain diagnostic
studies are ordered and reviewed, whether or not they may actually
be indicated, something the consultant might help decide by seeing
the patient first.
As far as radiologists are concerned, all these studies are good
for the bottom line and job security (do you know any out-of-work
radiologists?), but perhaps this situation is less than desirable,
considering the man-hours devoted to covering the steadily
increasing workload when many departments are also understaffed.
When it comes to academia, the increasing demand for study
performance and interpretation is effectively killing off any time
for serious research; that has become a fact of life in many
academic departments.
So why are we doing all these "indicated" studies (and the issue
involves all medical specialties, not just the emergency room)?
Have clinicians completely lost faith in their clinical skills and
judgment? Is the fear of lawsuits so great that we all must
obsessively do everything possible to protect ourselves from
litigation? Has diagnostic imaging technology become so impressive
and accurate that without it there is no secure diagnosis? I do not
know which, if not all, of these questions should be answered in
the affirmative. The reason does not seem to matter. Government and
nongovernment insurers just pressure reimbursements downward as
study counts go up. Radiologists work faster and faster, with less
time available to concentrate on interpretation, as the number of
studies rammed through per unit time increases. Medical malpractice
insurance providers just raise rates (especially in down stock
markets) to keep shareholders happy. Lawyers continue to fight to
maintain open-ended punitive malpractice awards to protect their
"injured patient's interests" and Congress continues to favor the
trial lawyers' lobbyists over the physicians'. Patients get more
tests, and they usually like that, especially painless ones,
because the tests make them feel cared for. Who is concerned about
the effects of invisible radiation? DNA feels no pain.
Well, we have a real mess on our hands, folks. Our goal as
diagnostic imaging physicians should always be to promote the
appropriate and medically necessary use of diagnostic imaging
studies. This philosophy was perhaps mentioned in medical school,
but barely gets lip service on the clinical wards. If physicians
could really practice medicine in a nonthreatening medical legal
environment, the nation's medical bill for covering all these
"cover your butt" studies would drop significantly, although it
might take some time to break such well-established habits. In
turn, the recovered revenue could help finance health care for the
more than 40 million medically uninsured citizens of this country.
Isn't that an appropriate goal to attain in the world's greatest
and richest nation? Malpractice insurance premiums could be
maintained at a level at which physicians could actually consider
practicing medicine.
Despite the urging of the current President, Congress is again
in the business of failing to address the needs of the people they
serve in favor of a powerful special interest. At the time of this
writing, the medical tort reform bill is a prisoner in House
committees, waiting to die a quiet death as the Congressional
session runs out.
1
The failure of the Federal government, once again, to pass tort
reform for medical malpractice is beyond shameful. It is a total
sell-out to the lawyers with whom many in Congress identify so
closely. Select panels of professionals with expertise in medical
disability should adjudicate compensation for clear medical
negligence injuries and not juries whose emotions, rather than
knowledge, decide awards and punitive damages. Those assessed
damages should be realistic and not boundless. Sorry, but there is
a huge greed factor in operation here that goes well beyond the
plaintiffs' just compensation. Physicians across this nation should
be furious and should not hide their feelings. Otherwise, next time
around, we really will have ourselves to blame.
Without the ever-looming malpractice axe over their heads,
clinical physicians could perhaps once again walk into the
radiology reading area and discuss the patient's signs and symptoms
and ask a question about what imaging study, if any, is needed,
rather than shoot the "diagnostic works" and see what useful
information might fall out the bottom. The great art of medicine
could begin to revive from a long hibernation.
Perhaps it's too much to hope for, and some physicians probably
prefer the status quo. The current system clearly does not provide
the greatest benefit to the greatest number. The nation's medical
system is a morass of limited or no coverage for many, overwhelming
bureaucratic complexity, lopsided distribution of physicians and
technologic resources, and fear-motivated, over- utilization of
diagnostic testing--among many other problems. It is still,
amazingly enough, a good system for many, but it could be so much
better for more.
Hopefully, people with common sense and authority will recognize
the sad situation that exists and unite with much greater vigor to
deal with it at the national level.
Many states are working hard on medical tort reform. Perhaps,
after the next election, there will be more members of Congress
whose vision extends beyond the next fundraiser or lobbyist's check
to seek ways to provide for the real health needs of many millions
of our fellow citizens. It is possible. Real national medical tort
reform is a key step to improve efficiency in our health care
system, allow physicians to exercise their art and skills without
fear, and extend medical care to those in need throughout our
nation.