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Risky Business

Ballard, Dustin MD

Emergency Medicine News: May 2010 - Volume 32 - Issue 5 - p
doi: 10.1097/01.EEM.0000372579.62749.57
Articles

Dr. Ballard is an emergency physician in northern California. He is the author of The Bullet's Yaw, serialized by EMN athttp://bit.ly/BulletsYaw, and of the award-winning travel narrative A Blistered Kind of Love: One Couple's Trial by Trail (with Angela Ballard, Mountaineers Books, 2003), both available through his web site, http://incisionanddrainage.blogspot.com.

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In the midst of the national discussion about health care reform, much has been made of dynamics that encourage overutilization of medical resources. If the term “overutilization” doesn't outrage you, think of it as medicalese for unnecessary care, such as the excess use of diagnostic tests and overly aggressive treatments. Some of the commonly cited instigators of overutilization are the litigious nature of our society, the millions of uninsured patients who defer primary care and seek (more expensive and usually last-minute) treatment in the emergency department, and fee-for-service reimbursement structures that reward doctors who provide more care (whether it's needed or not) rather than less.

If you haven't read it, Dr. Atul Gawande's recent article, “The Cost Conundrum,” in the New Yorker is an excellent examination of this topic. (http://bit.ly/Gawande; follow-up article at http://bit.ly/Gawande2.) But there is one variable Dr. Gawande, a journalist and surgeon at Brigham and Women's Hospital in Boston, fails to discuss, and it is an important one: personality. Specifically, I am talking about the risk tolerance of individual doctors. Risk tolerance? This phrase is commonly associated with the diversification of 401(k) portfolios and jumping out of airplanes, but it actually plays a bigger role in medical decision-making than you might realize.

Consider a study from the University of Pennsylvania published last month in the American Journal of Emergency Medicine. Jesse Pines, MD, and his colleagues examined the use of abdominal CT scans in the ED, and correlated the ordering trends of individual physicians with their responses to a standard risk-taking survey. (Am J Emerg Med 2009;27[5]:552.) The study catalogued 838 adult patients with new-onset belly pain (excluding those who were pregnant or had suffered an injury), and reviewed their records to see if they received an abdominal CT or other imaging studies.

The abdominal CT was by far the most commonly used imaging test, and in this respect the University of Pennsylvania study captured a microcosm of the national debate on overutilization. The abdominal CT is an expensive test (costs vary, but a typical bill is at least several thousand dollars), and involves some risk to the patient (in radiation exposure and potential harm to the kidneys). Belly pain can, however, be caused by a lot of different things, and CTs are a reliable way to rule out most of the concerning diagnoses, such as appendicitis or metastatic cancer. The University of Pennsylvania team hypothesized that physicians who are more willing to take risks would order fewer abdominal CTs, foregoing them in low-risk situations, than risk-averse ones.

To distinguish between the two types of doctors, the researchers used a subscale of the Jackson Personality Index that asked respondents to indicate how much they agree with statements such as “I try to avoid situations that have uncertain outcomes,” and “Taking risks doesn't bother me if the gains involved are high.” When they crunched the numbers and adjusted for other variables (such as gender, age, and the specific location of the patient's belly pain), they found that their hunch was correct.

The most risk-tolerant physicians were 15 percent less likely to order an abdominal CT. Interestingly, when they searched for two other predictors of increased use of CT — fear of malpractice and stress scores in uncertain situations — there were no associations. Based on this study, the risk-taking nature of physicians, rather than their fear of being sued or their reaction to stressful situations, is a key determinant of how they practice medicine. Other studies involving chest pain patients and those with strep throat symptoms also demonstrate that risk-taking doctors have different practice patterns than risk-averse ones.

Before we start testing all prospective medical students for risk-taking preferences (see where you fall on the spectrum at http://testyourself.psychtests.com/testid/2122), let's take a step back, and ask what these findings mean.

Do doctors who order fewer abdominal CTs provide less-than-optimal patient care? The University of Pennsylvania study didn't address this question, but I'd venture to say that more CTs do not necessarily mean better care. In fact, physicians who order more CTs may expose their patients to unnecessary risks. As Johann von Goethe once wrote, “The dangers of life are infinite, and among them is safety.”

Do the results of this study mean that physicians who agitate about the high costs of runaway medical malpractice claims are blowing smoke because it may be that their personalities are more to blame than the lawyers? Once again, not necessarily. There are a number of other studies that have found an association between fear of being sued and overtreatment, and it may be that this connection only applies in certain clinical situations. I know plenty of physicians (and would include myself in this group) who sometimes make decisions in the treatment room that are aimed at avoiding a date in the courtroom.

Finally, this is a single study, involving a relatively small group of physicians and performed in a setting (a university medical center) that functions differently than most “normal” community EDs. Nonetheless, this study is further proof that from one physician to the next, there can be significant differences in how medicine is practiced. At the risk of being called a socialist, I contend that individual variations in care, while inevitable and necessary, should be constrained within reasonable limits. Risk-taking physicians should be encouraged to consider the worst-case scenario when they decide to minimize care, and risk-averse physicians should remember that overtesting not only costs money, but can lead to further unnecessary testing and procedures. Many physicians have grumbled that practice guidelines and comparative effectiveness research unduly limit their autonomy, but I see these as tools to help modulate the inherent human attributes that contribute to doctoring, whether they be experience, empathy, or tolerance of risk.

Medical care consumers may want to consider not only the risk tolerance of their physicians (perhaps risk-averse patients are well served by having a risk-tolerant physician), but also the risks associated with their own lifestyle habits. This is a topic for another day; I am off for an afternoon of bungee jumping and drag car racing.

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