I read the article “Overtesting and Overdiagnosis: A Problem Masquerading as a Solution” with great interest. (EMN 2013;35:15; http://bit.ly/ScvylS.) As a practicing physician in Philadelphia, there is a lot to be concerned about with respect to testing, overtesting, risk and benefit, patient expectations, and patient wants.
In such a high-litigation location like Philadelphia, a missed disease (from an insignificant fracture to a lung nodule) can lead to litigation against the emergency physician (which has its own negative connotations and effects on the doctor) for a finding that does not or would not change any outcome except the patient “knowing.”
An example would be the missed fracture, which does not affect function but can lead to chronic pain and preventing a young athlete from going to his top-choice school because of the inability to compete for the scholarship, and hence a lawsuit.
I am not saying that my fear is the lawsuit (though it is in many cases). I think defensive medicine is dangerous, fraught with risk and increased morbidity, but in this day and age, and location, it is the standard of care.
What leg do you have to stand on when you don't get the CT (when the risk is close to zero for PE) and the patient then goes to another ED and they find a subsegmental PE (which would have probably resolved on its own)? Or the patient with a swollen leg, who is told to get an outpatient ultrasound because there is no respiratory complaint, etc., and a DVT is found. Did the delay of two days really make a difference? Probably not.
I'd be interested in what your readers have to say.
Scott Goldstein, DO Philadelphia