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What Defines an Unnecessary Test?

December 9, 2012
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Answer me this: If you went to any healthcare facility – family medicine clinic, urgent care center, an ologist’s office, an ER, whatever – with a knee you just injured playing sports, and they ordered a CAT scan of your chest and expected you and your insurance company to pay the multi-thousand dollar bill for the test, would you feel like this was thorough and excellent care, or would you feel ripped off? Hold your answer for a few minutes.

A story of a lawsuit was published in my local newspaper recently. Here is the link to the full story:

www.star-telegram.com/2012/12/03/4457356/wrongful-death-suit-seeks-16-million.html#storylink=misearch

I don’t know anything else about this case other than what was printed in the paper, but I thought it was a great case to illustrate some ideas about testing, healthcare system waste, and public expectations for the outcomes a healthcare system should promise in the first place.

If you didn’t open the link to the story, the gist of it is that a 21-year-old college student went to the student health center after injuring his knee, which was swollen. He went back later for a follow up visit, where apparently they told him to stick to the treatment plan. He died the next day of a pulmonary embolism, which is a blood clot that probably broke off from a clot in his leg that traveled through the heart to the lungs, thereby blocking the flow of blood to his lungs, so he died.

The parents are suing the school for $16 million. I assume they’re suing the doctor for medical malpractice too. However with tort reform in Texas, the university now has the deepest pockets.

I don’t care what the further details are; this is one of those one-in-a-gazillion rare cases. Why in the world would a 21-year-old young man die of a pulmonary embolism? There was apparently no bizarre family history of blood clotting diseases, because both of his parents are alive.

When did this embolism develop? Was the painful leg really a sign of a blood clot in his leg that had nothing to do with a sports injury? Did a blood clot develop later in his leg after the injury? Was the embolism a one-time catastrophic event, or had he been experiencing a shower of smaller blood clots whose effect built up over time?

None of these questions are answerable to any degree of certainty. The newspaper article said he had abnormal vital signs, but provides no further detail. If he was breathing 40 times a minute, then maybe the doctors should have thought beyond the knee injury. If his blood pressure was 142/78, then they would have absolutely no reason to think of other diseases beyond an injured knee. An increased blood pressure (abnormal vital sign) is a normal response to any kind of stress, and a painful knee is stressful enough to cause this. Also, I don’t know if he reported other embolism symptoms such as chest pain or shortness of breath.

This case brings to light the difficult issues that our country refuses to face as it continues to ineffectively struggle with rising healthcare costs. This case highlights the two deeper issues that must be addressed to bring healthcare costs under control: risk and cost.

First let’s look at the risk issue. Even a person who feels the doctors committed malpractice would have to agree that this was an extremely rare event. But unfortunately in the American tort system, all the relevant risks are not taken into account.

To achieve a more complete risk assessment, we have to look at all outcomes, not just the plaintiff of the lawsuit. This is extremely difficult for juries and politicians to think about. The truth is, we have to ask, what is the balance of risks and benefits for a million people who present to the healthcare system with a similar story for the following medical decision-making fork in the road: do the CAT scan or don’t do the CAT scan, which is the currently favored test to look for a pulmonary embolism (PE)? (And I realize this analysis could get even more complex if we consider other options such as d-dimers and leg Dopplers. For the sake of relative simplicity, I won’t discuss these options further.)

On the beneficial side, the CAT scan will find PEs in a significant number of people. Treatment can be started early, which in theory will prevent deaths, but not all deaths. No treatment works 100% of the time.

Here are the harms of CAT-scanning a million people who injured their knee. First, the CAT scan will generate several thousand false positives test results, which means people are told they have a blood clot when they really don’t. They will all be treated, which means a little less than 1% of them will develop life-threatening bleeding episodes such as bleeding in the brain and stomach. All who experience these adverse events will be hospitalized and a few of them will die from the bleeds.

Second, the CAT scan will ever so slightly increase the risk that some of these million people will develop cancer in their chest caused by radiation from the test, especially if they have more CAT scans in the future. All who develop cancer will undergo expensive treatments, and some of these people will die from the cancer.

Of course, neither of these reasons not to do the CAT scan would be heard by a jury. They really aren’t allowed to consider these facts in large part because lawyers believe they are not capable of understanding the information (“It’s too technical”). Also, judges tend to not allow evidence that does not directly pertain to the victim, so considering societal harms of the policy implications of the outcome of an individual malpractice case is also verboten.

If we were going to be completely numerical geeks about this case and do some sort of probabilistic analysis of this situation to determine which approach – CAT scan or no CAT scan – is the mostly likely to create the best outcome for a population of 1,000,000 young men who hurt their knee playing sports, what would be the result?

No one knows.

There are no studies of the prevalence of PEs in young men with acute knee injuries, so there are no valid numbers on which to create the mathematical prediction model.

The second important societal issue is cost. Even if we assume the harms of testing are zero, how much should the healthcare industry spend to find a rare event? Even if we assume the total cost of the clinic visits and testing were $1,000 and that treatment would completely eliminate the risk of the PE killing him, this still means ONE BILLION DOLLARS would be spent to find this one-in-a-million disease. To put this in contrast, the newspaper article mentioned that the lawsuit claimed his future engineering career would have generated $4 million in future income.

Writers such as Shannon Brownlee (Overtreated) and Rosemary Gibson (The Treatment Trap) have told stories of the harms of over-testing and over-treating. Of course, these stories also will not be considered in this lawsuit.

Yet it is this story that strikes fear in the hearts of physicians all across the U.S. We are the only country in the world whose general population believes dying is an option, and that technology will save them from all pain and suffering. It is tragic that this man died so young, but this lawsuit will only help to entrench our healthcare system into further waste and inefficiency, and will not bring him back.

The irony of this case and thousands like it is that it drives up the cost of healthcare for everyone, which in the U.S. means more people become uninsured, which has a measurable negative effect on their health. The further irony is that many college seniors will not find good jobs this spring, because of the burden of exorbitantly-priced U.S. healthcare on businesses and governments.

I have noticed over my career that the only people who give a rat’s ass about the emotional well-being of physicians are physicians. This is a huge mistake on the part of the non-physician society, because doctor’s decisions cause trillions of dollars to change hands each year. Even in a state with effective tort reform like Texas, I have heard of doctors ordering tests and treatments to cover their butts. National data show that the difference in the rate of testing for rare situations (CYA tests) is not much different between high lawsuit and tort reform states.

The suits (business types) in the healthcare industry tend to call these CYA tests unnecessary. A more accurate label is that these tests are extremely rarely useful, but in a culture that assumes more technology is always better, the expected benefits of the test will always trump the harms of over-testing in the eyes of physicians, politicians, and juries.

The solution for this problem is for future knee injuries to occur in a society that tells its doctors: We want you to exercise reasonable judgment, look for rare causes of symptoms only after you’ve ruled out the common causes and the test of time shows the symptoms aren’t getting better, and we will not professionally crucify you when the rare bad outcome happens to one of your patients. These very rare injuries and deaths are not your fault or the patient’s fault, they just happen. We, the greater society, have got your back on this.

This is not what doctors hear now.

Risk and cost. How rare can a condition be that it is just too unlikely to look for?  How costly can a testing or treatment approach be for a society to conclude it’s just not worth it?

The healthcare systems of most other developed countries have learned to incorporate these concepts into their policies (NICE in the UK for example). Until we directly address these issues in the U.S., we will perpetually pay too much for healthcare.

2 Responses to What Defines an Unnecessary Test?

  1. Tracie Updike MD on December 9, 2012 at 8:24 pm

    This is indeed a tragic case, but even if this young man had went to the ER I don’t think they would have thought about a PE. It is true that almost all of my patients over 50 who went to ER no manner what the reason would get a cat scan of the chest–pretty much a given in my area.
    It is a sad state of affairs when I am afraid to go to work because of the threat of missing a zebra.

  2. T. Grant Phillips, MD on December 20, 2012 at 2:25 pm

    It is too bad that politicians, many of whom are lawyers, choose not to think of the big picture, and instead continue to support a system that benefits so few but harms so many. It is arguable that the current tort system causes more misery that legitimate malpractice.

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