As a residency trained, board certified emergency medicine physician who practiced for over 20 years, I was not surprised entirely by a recent Health Leaders’ article stating that ED physicians order unnecessary imaging tests, based on a research article published in Academic Emergency Medicine in April of 2015.
There is no question that as a practicing physician in the emergency department, you try to make decisions based on sound evidence-based medicine. The reality is that other factors are constantly influencing decisions, such as patient demands, other physicians involved in a case, liability issues, and just not wanting to miss something that could harm the patient. On multiple occasions during my career as a medical director and practicing emergency department physician, I have seen patients with a history and physical exam that did not justify ordering an additional imaging test, however, medicine is an art and often instinct plays into decisions. If emergency department physicians ordered tests based exclusively on what evidence based medicine supports, many emergent diagnoses would be missed causing a poor outcome for the patient. The assumption is that not ordering a test because the evidence does not support it will protect you in a malpractice lawsuit. However, those who have practiced medicine for years know this is not always the case.
The best approach for now is to continue to look at innovative ways to engage patients and physicians. For physicians, this will include having real-time prompts and reminders tied into the electronic medical record ordering system, based on evidence based guidelines that are easy to use and access. Today, patient education and engagement tools are mostly used outside an acute emergency department, but perhaps these tools with their easy-to-use clinical information, statistics, and images could also provide real-time education for the patient to help explain why certain imaging tests are not required. Tort reform may be one way to influence excessive ordering of diagnostics test but I believe the clinical instinct and art of medicine, as well as evidence based guidelines and patient education, are important to achieving the best outcomes.
Byron C. Scott, MD, MBA, FACEP, FACPE
Medical Director, National Clinical Medical Leader