Too many medical scans?

Originally posted 6-22-2010:
I came across a few interesting articles in the last week about overtesting in healthcare.  The Wisconsin State Journal published a national and local story about growing concerns that ER doctors are running too many tests on patients due to concerns about malpractice lawsuits.  Lawsuits are one of the major concerns in the healthcare culture, and is one of the reasons many care givers are wary of reporting medical errors and near misses. The low levels of reporting errors and near misses makes it harder to learn from the mistakes and fix the system to prevent a future occurrence.  The articles also hint at a few other issues including patient demands, overworked ER personnel, and the lack of familiarity between the ER staff and the patient. 

This quote: “We just want to make sure someone doesn’t have something that is serious or life-threatening,” does summarize why there is a lot of caution and extra testing.  The fact that missed heart attacks in the ER have dropped from 5% to under 1% in the last couple decades does show that the overtesting is producing positive results.

But what if all this testing is causing long term harm to the patient?  I read this article on that suggests we are getting exposed to too much radiation via medical imaging tests.  The article says the amount of CT scans given in the US have increased significantly over the years.  The first article gave an example of a patient that had a CT scan just to make sure she did not have appendicitis.  It is a very interesting thought that showing extra caution could potentially cause long term harm to a patient.  The MSNBC article does a very good job of highlighting a few of the healthcare cultural issues that have led to this overtesting.  Patient pressure, malpractice fear, and healthcare chaos are repeated as causes.

So what's to be done?  Which way should we be leaning on this?  I think the FDA is off to the right start trying to set standards on the radiation doses for imaging tests.  The idea of a "radiation medical record" is also another great idea and points to the continuing need to digitize medical records.  I would also think setting standards or guidelines for treatment can help reduce the number of unnecessary scans.  I got a sense from the articles that this is being explored as well. Not only should this thinking apply to medical scans, but I think there is benefit to looking at standardizing other treatments.  The success of the Keystone Project in standardizing central line insertions to reduce infections is an example of this.

One final thought.  I really liked the fact the articles provided questions for patients to ask while being treated.  Patients need to be part of the feedback loop with their care givers to help the safety and quality of their care.  Questions like "Do I need this?" and "Why are we doing this?" will ensure some double checking on testing. John Nance touches on the importance of including patient feedback on their care in his book "Why Hospitals Should Fly".

Are there other areas of healthcare where you have seen overtreatment?  What do you think is causing it to happen?