Quote :

"CHICAGO - Too much cancer screening, too many heart tests, too many cesarean sections. A spate of recent reports suggest that too many Americans — maybe even President Barack Obama — are being overtreated. Is it doctors practicing defensive medicine? Or are patients so accustomed to a culture of medical technology that they insist on extensive tests and treatments? A combination of both is at work, but now new evidence and guidelines are recommending a step back and more thorough doctor-patient conversations about risks and benefits. As a medical journal editorial said this week about Obama's recent checkup, Americans including the commander in chief need to realize that "more care is not necessarily better care.""

full article: http://health.yahoo.com/news/ap/us_med_unnecessary_tests.html


I remember in highschool going to an urgent care place because I had a bronchitis. The doctor and nurse seemed to be pushing for a bunch of other tests that were barely related to the symptoms I had. I remember feeling very pressured, but I did decline most of them. In hindsight the guy probably gets commission (call it "fee for service").

3/12/2010 5:08:53 PM

I asked my wife about this. She basically said that doctors do not want to get sued for malpractice, so they order a lot of tests to cover their asses.

3/12/2010 5:36:45 PM

^ Nailed it.

3/12/2010 7:03:44 PM

Quote :

"that were barely related to the symptoms I had"

are you sure they were 'barely related"?
i'm not trying to say you're wrong (hell i could be wrong, which is why i ask....)

youd be amazed at the connections one disease has with another



and with that being said, i 'm sure that doctors do overtest and overtreat for insurance/medicare/medicaid reimbursements. (assuming of course they cover the cost of the test)

[Edited on March 12, 2010 at 7:04 PM. Reason : i also agree with gonzo up there. there is a multitude of reasons. ]

3/12/2010 7:04:17 PM

It's because malpractice lawsuits are out of control in this country. Doctors have to send every patient that comes in with a headache to get a $3,000 MRI (and hospitals over billing is a whole separate issue, $1000 aspirin?) on the one in a million chance that one of those patients might develop a brain tumor down the road and decide to sue them for everything they're worth because they didn't send them for that MRI 2 years ago. If the government really wants to lower the price of healthcare they should start with tort reform.

3/12/2010 7:17:33 PM

my coworker's wife is originally from Mexico and her family is still there. They went back to Mexico to have their baby and paid less for the delivery there then they did for one prenatal visit here.

3/12/2010 7:37:00 PM

thats not surprising

3/12/2010 7:48:34 PM

^^^they order the tests because they have to pay off that million dollar MRI machine, not because they're afraid of getting sued. tort reform won't change the number of tests that get ordered.

3/12/2010 8:51:32 PM

Quote :

"I asked my wife about this. She basically said that doctors do not want to get sued for malpractice, so they order a lot of tests to cover their asses."

This is true, but the other half is it helps increase revenue per patient as reimbursements drop. So it helps raise revenue while CYA.

When in school our Dr gave us a question in neuro class. He asked what percentage of 18 yr old women complaining of HA would have a tumor. The answer was really low, like under .5%. Then says good. Ok, now say you play the odds and that patient HAS a tumor. Their lawyer will ask you 2 questions. 1. Would a MRI have shown this tumor? (yes) 2. Why didnt you run a MRI? And you are dead in the water...the answer is run the test. The jury wont give a shit about the odds.

^lowering the costs of medical equipment is a topic that is never discussed in reform discussions. The fact that a pair of forcepts (tweezers) costs over 100 dollars. We have people selling medical equipment making mroe than the docs actually doing the surgery. The flipside is, you dont want to lose research into better equipment, but relaxing the regulations on what we can use would help lower costs. Simply labeling the same thing sold OTC as Medical and charging 100X more for it, needs to stop.

[Edited on March 12, 2010 at 9:00 PM. Reason : .]

3/12/2010 8:56:14 PM

It's pretty much a business like every other service in this country. How can we make more $$$$$$?

3/12/2010 9:11:05 PM

^well yes and no.

3/12/2010 9:20:06 PM

physicians test to CYA. until there is real malpractice reform this will not change, nor should anyone expect it to change. but patients are just as responsible here though. everyone loves to promote evidence-based rationing, except when they themselves are the patient, that is.

3/12/2010 9:48:37 PM

Any opinions on what you feel should be the "maximum" amount that doctors can be sued for? I know people like to argue that you can't put a price on life.

I'd argue it should be 2 million or salary * (65-age), whatever is higher.

3/12/2010 10:13:24 PM

just saw a scare-mongering commercial about women in their 20s getting cervical cancer

3/13/2010 12:11:06 AM

Yeah, it's because of malpractice, even in states like texas that already have medical malpractice reform that every republican is demanding.

3/13/2010 2:56:50 AM

Quote :

"When in school our Dr gave us a question in neuro class. He asked what percentage of 18 yr old women complaining of HA would have a tumor. The answer was really low, like under .5%. Then says good. Ok, now say you play the odds and that patient HAS a tumor. Their lawyer will ask you 2 questions. 1. Would a MRI have shown this tumor? (yes) 2. Why didnt you run a MRI? And you are dead in the water...the answer is run the test. The jury wont give a shit about the odds. "

well, aneurysms can cause headaches too.........and 50% of folks with a ruptured aneurysm dont live long enough to get to the hospital. A large percentage of the folks that do make it to the hospital have significant morbidities. So not scanning someone with a history of severe headaches is an open door to a lawsuit

Yes, doctors are afraid of being sued because folks dont seem to realize that not everyone gets to live and not everyone gets to make a full recovery from whatever illness they have.

3/13/2010 5:28:01 AM

Quote :

"well, aneurysms can cause headaches too.........and 50% of folks with a ruptured aneurysm dont live long enough to get to the hospital. A large percentage of the folks that do make it to the hospital have significant morbidities. So not scanning someone with a history of severe headaches is an open door to a lawsuit "

Thats a retarded example. Ruptured aneurisms cause intense, rapid onset, "worst pain of my life" headaches and usually a lot of neurologic deficit as well, so they get a CT for about 1/4 of the cost and 15x the speed of an MRI. Brain tumors may not even cause a headache depending on where they are located, and its not going to be a 1 or 2 second onset.

Every patient coming in with symptoms of a ruptured aneurism is getting a scan, no questions asked, and you should be sued if you don't. If you scanned every patient that came in with a simple or even chronic headache, you would be wasting your money 99.9 percent of the time.

3/13/2010 5:38:23 AM

Quote :

"you would be wasting your money 99.9 percent of the time."

Incorrect. You would be wasting somebody else's money.

A question for those knowledgeable ... does this trend occur with other countries in the world? i.e. Canada or European countries with similar Western culture perform the same barrage of tests?

[Edited on March 13, 2010 at 6:24 AM. Reason : .]

3/13/2010 6:22:41 AM

got to get it all in before universal healthcare. After that, the opposite may happen.

3/13/2010 7:32:55 AM

Quote :

"everyone loves to promote evidence-based rationing, except when they themselves are the patient, that is. "

Exactly. Patients demand these tests and want to see a specialist, especially if it cost them little or nothing.

This remends me of the kid on here that got into a car wreck and cut his head and wanted transported to a level 1 trauma center.

3/13/2010 10:53:15 AM

^x8 - IMHO, I don't think maximum payouts are the answer to malpractice reform. Huge payouts are an issue, but only a small part of the problem. The entire process needs change. Caps are just the only step which to date has been politically feasible. The trial lawyer's lobby has very deep pockets.

- I don't have exact figures, and I'm too lazy to find a source, but I've repeatedly heard numbers to the effect of: 9/10 cases brought are thrown out, of that 10%, another 9/10 cases tried are judged in favor of the physician. Settlements, even when no malpractice has occurred, have become less expensive and less time consuming than fighting. However, for every case, the physician has to take time out of his/her day, time that could be spent making money, to meet with attorneys for themselves, the hospital, etc. This situation alone is enough to induce across the board CYA.

- Who wins in this situation? Ambulance chasers. Who loses in this situation? EVERYONE else. Physicians, all patients who pay higher overall costs, society at large and especially tax payers, and finally, ESPECIALLY patients who were truly wronged, who far to often fail to get appropriate justice.

- Something needs to be done to change this "jackpot justice" situation where there is no penalty for frivolous lawsuits, and in fact, sometimes a reward in the form of a settlement. I would like to see plaintiffs forced to pay court and lawyer fees for the defendant if the case is thrown out or found in favor of the physician.

3/13/2010 1:23:18 PM

Quote :

"doctors do not want to get sued for malpractice, so they order a lot of tests to cover their asses"

i was thinking this as well. it's unfortunate because i recently ended up paying a bunch of money for tests i ultimately didn't need oh well, good to know i'm not dying!

[Edited on March 13, 2010 at 1:31 PM. Reason : ]

3/13/2010 1:30:51 PM

Quote :

"hats a retarded example. Ruptured aneurisms cause intense, rapid onset, "worst pain of my life" headaches and usually a lot of neurologic deficit as well, so they get a CT for about 1/4 of the cost and 15x the speed of an MRI. Brain tumors may not even cause a headache depending on where they are located, and its not going to be a 1 or 2 second onset."

im not exactly talking about ruptured aneurysms


there are such things as "sentinel headaches" from a growing aneurysm or a leaking arteriovenous malformation.

your average healthy young adult with severe headaches that do not respond to OTC medications should probably go see a doctor for a workup.

Sometimes a migraine is a migraine or a cluster headache is a cluster headache.......but sometimes those migraines are a symptom of something worse. And sometimes these headaches ARE accompanied by very very subtle neuro deficits that the average person doesnt pick up on.

I mean who is gonna pick up on a homonymous quadranopsia when they are in the middle of a bad headache?

http://www.neurologyreviews.com/nov00/nr_nov00_headache.html

in a non emergent situation an MRI/MRA is much more sensitive test.

neuro...........its kind of what i do for a living

3/13/2010 4:07:05 PM

^ How about doing a visual field? Also very sensitive and much much much less $$

3/13/2010 5:24:28 PM

There is this cool doctor at student health that told it to me straight last time I was in there for a killer sore throat. She was like, you're throat is very red but out of every 100 students that come in here and get tested for strep only about 3 of them actually have it. If it isn't strep there are broad spectrum antibiotics that I can give you, but if its just some virus then chances are they won't do anything to help you. I thought it was nice of her to tell me that so I didn't wind up spending money on tests and drugs that I can't really afford.

3/13/2010 5:44:28 PM

i like how people in here are saying they were ordered to have tests they "didn't need." because clearly if the patient thinks he/she doesn't need a test, then it is unnecessary!

3/13/2010 6:38:09 PM

^ The problem is people judge physician decisions based on outcomes. A negative result means a test was unnecessary. A missed rare diagnosis means the same test was necessary. Until our society decides what level of risk it is willing to accept, the charade will continue.

3/13/2010 6:52:17 PM

Quote :

"im not exactly talking about ruptured aneurysms there are such things as "sentinel headaches" from a growing aneurysm or a leaking arteriovenous malformation. your average healthy young adult with severe headaches that do not respond to OTC medications should probably go see a doctor for a workup. Sometimes a migraine is a migraine or a cluster headache is a cluster headache.......but sometimes those migraines are a symptom of something worse. And sometimes these headaches ARE accompanied by very very subtle neuro deficits that the average person doesnt pick up on. I mean who is gonna pick up on a homonymous quadranopsia when they are in the middle of a bad headache? http://www.neurologyreviews.com/nov00/nr_nov00_headache.html in a non emergent situation an MRI/MRA is much more sensitive test. neuro...........its kind of what i do for a living"

This thread is about waste in medicine, not the most sensitive test for these disorders. My point was that a headache without any accompanying symptoms or a concerning pattern shouldn't get worked up for something more serious. Almost every point in that article you posted had accompanying neurologic symptoms or a history to indicate the need for imaging.

I mean sure, a SAH may be missed, but do they have the meningismus? history of polycystic kidney disease? Connective tissue disorder? In addition, you're not likely to order an MRI, which is much more expensive than a simple contrasted CT scan. If you're looking for AVM's or what not, you want to do CTA or plain film angiography anyway.

But I guess you know everything. Where did you do your residency in neurology again?



[Edited on March 13, 2010 at 8:21 PM. Reason : ]

3/13/2010 8:19:11 PM

^ haha i think she's a nurse on a neuro unit or something

Quote :

"^ The problem is people judge physician decisions based on outcomes. A negative result means a test was unnecessary. A missed rare diagnosis means the same test was necessary. Until our society decides what level of risk it is willing to accept, the charade will continue."

everyone has 20/20 hindsight, and no test is 100% sensitive AND specific. so until people understand the complex thought process behind medical decisions (i.e. go through medical school and residency), they cannot claim to know that a test was unnecessary.

3/13/2010 8:44:07 PM

That's pretty much what I was saying. A result confirming a diagnosis is often just as informative as a result refuting a diagnosis - hardly unnecessary. That doesn't stop people from forming those opinions though.

3/13/2010 8:58:12 PM

nope not a doctor, i am really glad i am not a doctor.....im not the first person to be sued.

Quote :

"How about doing a visual field? Also very sensitive and much much much less $$ "

ok sure.....thats gonna be done in the office visit and the ER before a scan is ordered, but not everyone has a visual field cut as their symptom.....


yes this is a medical wast thread, sometimes you have to order a bunch of tests and labs and figure out what a patient doesnt have in order to find out what IS wrong.

Doctors and Nurses have to do what is PRUDENT.

Quote :

"This thread is about waste in medicine, not the most sensitive test for these disorders. My point was that a headache without any accompanying symptoms or a concerning pattern shouldn't get worked up for something more serious. Almost every point in that article you posted had accompanying neurologic symptoms or a history to indicate the need for imaging. I mean sure, a SAH may be missed, but do they have the meningismus? history of polycystic kidney disease? Connective tissue disorder? In addition, you're not likely to order an MRI, which is much more expensive than a simple contrasted CT scan. If you're looking for AVM's or what not, you want to do CTA or plain film angiography anyway. "

I am not talking about the person that shows up in the ED with an SAH.

Most of the folks that show up in my ICU with an SAH had a history of prior headaches(but they didnt go to the doctor for them) and when we do their history and physical we ask about double vision and other visual changes etc......most of the time they say "now that you mention it.... yea i did..." The average joe isnt going to make that clinical correlation?

I see tons of SAH patients float in and out of this ICU and not many of them had polycystic kidneys, or connective tissue disorders.


A few lucky patients each year come in for an elective aneurysm clipping because they had persistent awful headaches, but not the "shotgun" "thunderclap" "worst headache of my life headaches that are typical for an SAH. I am talking about the folks that have a headache that didnt respond to OTC meds but is bad enough to keep in them in bed for the day and miserable bad enough to affect their quality of life. Those lucky folks that do go to the doctor's office for a thorough OUTPATIENT work up. So the prudent doctor might do an MRI to rule out a tumor... but what the hell, while they are getting an MRI in the first place they can add on MRI with angiography, just in case there is a vascular deformity. Maybe the studies show nothing at all, maybe it really is a migraine. Maybe I would feel like i wasted some money on these tests since they showed nothing.......but then again...... can you put a price tag on peace of mind. The peace of knowing I dont have a ticking time bomb in my head?


My point is for the vast majority of patients, there are few unnecessary tests. Sometimes it takes a lots of tests to figure out what exactly is going on. In the end the peace of mind and relief of symptoms is pretty priceless.


For those in this thread that had what they felt were unnessesary tests......you have the legal right to refuse the test if you dont want it. However, I AM glad that your test turned out negative. In the end i guess maybe you didnt need it.......but how would you feel if the test WAS positive and you received the appropriate treatment. What if the doc didnt order the test, and you died.....

Thankfully medicine is evolving....we learn something new everyday.

3/13/2010 11:50:11 PM

Quote :

"For those in this thread that had what they felt were unnessesary tests......you have the legal right to refuse the test if you dont want it. However, I AM glad that your test turned out negative. In the end i guess maybe you didnt need it.......but how would you feel if the test WAS positive and you received the appropriate treatment. What if the doc didnt order the test, and you died....."

And what if you walked out your door and were mauled by a bear, you'd be sorry you didn't carry a can of bear mace on you. There's a difference between preparedness, caution and paranoia, and I think as a country we're starting to move into paranoia.

I think the problem is the lack of knowledge of the patient vs the expected knowledge of a doctor, and this may also be a symptom of the ever decreasing interaction time between doctors and patients. But I know that I'm sick of going to doctors and feeling like I'm being asked to make my own medical decisions on incomplete knowledge. I realize that the doctor needs to and should present all options, but from a patient perspective, if you went to a doctor and he asked you if you wanted a test, you are already inclined to say yes merely because you feel if the test were not important the doctor wouldn't mention it.

Too often though, patients are confronted with a list of possible problems and a list of tests and treatments and asked to choose the one they prefer. I would much rather (and I think most people as well) that my doctor know me well, and present the problem and treatment course most likely based on their detailed analysis and questioning of my concerns and symptoms and provide me with things to watch for that may indicate a change in treatment is necessary. The chance of me having sudden brain death disease is extremely small, so the only time the doctor should be bringing up testing for sudden brain death disease is when either my symptoms have increased the likelihood of sudden brain death disease above normal, or treatment for other more likely problems is not responding as it should.

Now to be fair, this means that people need to accept that sometimes life just tosses curve balls and the absolute unlikely happens, and you can't blame your doctor for thinking your symptoms which are like 99.9% of the people with problem Q means that you have problem Q and not sudden brain death disease.

[Edited on March 14, 2010 at 12:06 AM. Reason : sdfg]

3/14/2010 12:05:41 AM

^ my unsolicited advice to you and others in your situation is that you are your own best advocate. There is a commercial on TV that talks about the importance of asking your doctor questions while you have his attention. If you dont know what questions to ask do a bit of reading about your concerns.

Im not chastising at all here, my advice really is to ask tons of questions and dont stop until you feel like you understand your options.

if the doc wants to do a test.........ask him what exactly is he looking to find with it etc

3/14/2010 12:15:37 AM

Like I said though, the problem is the expectation (and to be honest, what should happen) is that the doctor should be the expert here. Yes it never hurts to ask questions and to be informed, but ultimately, if a doctor is suggesting I get a test, it should damn well be for a reason other than I might get mauled by a bear today, and the doctor wants to cover his ass. I should be asking questions for my own information, not so that I can attempt to decipher whether my doctor is actually recommending a proper course of treatment; that is after all, what I pay him so much money to do.

3/14/2010 12:27:01 AM

my point is:

Quote :

"if the test were not important the doctor wouldn't mention it"

he has ordered the test because he feels it will tell him whats wrong with you or it will mark one of the differential diagnosis off of the list. The test isnt ordered because he is afraid of random bear attacks. You went to him with a problem, he thinks the test will help him solve it for you.

Quote :

"Removing diagnoses from the list is done by making observations and using tests that should have different results, depending on which diagnosis is correct. "

As for asking questions......if you were to have surgery you sign an informed consent paper saying that the procedure has been explained in detail and that the risks, benefits and complications were explained to your satisfaction. It is up to you to decide what that level of satisfaction is. So grill your doctor before you sign your life away. Death is always on that list of potential risks.


I personally am having a CT at the end of the month for sinusitis.....simple little sinusitis that never completely goes away. I cant wait to have it........because i am sick and tired of being miserable and i want to know what the hell is in there. I wish i had had it yesterday! i am sure that its gonna cost a pretty penny even with my insurance. I dont care......i want to know whats going on and i want it fixed. Thats probably the attitude for the majority of healthcare consumers.


I hate to see healtcare professionals attacked, because ultimately they want what is best for you. It sucks that sometimes they arent able to give their patients what they want or even need....a cure and a complete recovery.... sometimes thats just not in the realm of possibility. And it sucks big donkey dick that some healtcare consumers look for a reason to sue, or someone to blame.

Medical negligence is different.....it should never happen, but thats a whole different argument

[Edited on March 14, 2010 at 1:06 AM. Reason : .]

3/14/2010 1:03:57 AM

Quote :

"So the prudent doctor might do an MRI to rule out a tumor... but what the hell, while they are getting an MRI in the first place they can add on MRI with angiography, just in case there is a vascular deformity. Maybe the studies show nothing at all, maybe it really is a migraine. Maybe I would feel like i wasted some money on these tests since they showed nothing.......but then again...... can you put a price tag on peace of mind. The peace of knowing I dont have a ticking time bomb in my head? "

Ok so lets shoot everyone up with contrast and give them nephropathy, or lets just irradiate everyone to be sure we don't have a tumor. You're also forgetting that a large portion of patients don't pay dick for their services, so its coming out of John Q Taxpayer's pocket or results in larger premiums for everyone because some crazy wanted their head scanned even though it probably wasn't necessary. I don't know how much that happens but you get the point. Peace of mind is great....if YOU are paying for it. How much are YOU willing to pay for peace of mind is how it should be...instead its a group of fucks sitting around thinking about how much everyone else should be paying for your peace of mind in too many cases.

That said, if Doc thinks it should be ordered, order it. I'm just saying that you don't order a freakin test/scan for every headache, tooth itch, fibro flare, etc. unless theres good reason and its going to change your management. You're not thinking through this in context like a physician should...where its more than a headache that sends you to the scanner.

You're also looking at it from the perspective in a Neuro ICU, where you see only the worst cases of these things. From my perspective, there are thousands of patients who have headaches who come to the doctor, and very few (relatively speaking) of them end up seeing you in the ICU. For every one person you see with a SAH there are hundreds or thousands who present with the same symptoms he had or worse before the thing ruptured and didn't even have an aneurism/avm/etc.

I appreciate what you're trying to do I think, which is defend the health care profession, but I think its ok to order less tests especially in certian situations. If someone is paranoid and wants to pay out of pocket for their tests, by all means test away, but thats not the way our "someone else pay for it" mentality lets the health care system operate.

Quote :

"nope not a doctor, i am really glad i am not a doctor.....im not the first person to be sued. "

so you can armchair quarterback it. At least you admit it. And I don't claim to know everything. A lot of this is personal opinion. All I know is I have some attendings who would slap the shit out of me if I tried to order an MRA on some of these patients we're talking about without damn good reason. In addition to that, we have a family friend whose daughter is going through a rough stretch with migranes and they wouldn't scan her head until she was laid out of school for a week and unable to keep food down or get out of bed. Turns out, scans were negative as they predicted. I actually think she does have an MRI scheduled at the end of the month, which would put her around 6 weeks, but they will cancel if she gets better.

[Edited on March 14, 2010 at 1:38 AM. Reason : ]

3/14/2010 1:37:06 AM

wolfpAAcki get it you are what 2nd 3rd year student?

Quote :

"My point was that a headache without any accompanying symptoms or a concerning pattern shouldn't get worked up for something more serious."

MY point is that if someone has a headache BAD enough/often enough to send them to the doctor...there is a reason for the headache. Before the doctor can say oh! its just migraines, he has to rule out the worst case scenario be it tumor, AVM, aneurysm, ICH or whatever. Its that "what if" scenario, it will get you everytime.

In several years with some clinical experience you too will order that 3k CT with and without contrast and or CTA. When that shows nothing you will order that 5k MRI because even though its a longshot your patient might have a tumor, a small one that isnt quite large enough to cause a focal deficit. It still has to be ruled in or out.


edit: you and are probably arguing in circles, it would be interesting to discuss it face to face, but whatever....... lets get out of the hospital for a second and go to the primary care physician.


a few drug seekers here and there would probably go to the ER with a run of the mill tension headache or whatnot.

personal example, someone i know with no prior history of severe headaches suddenly starts having them on a regular basis. Her primary care doc tries meds to no avail. not sure if he CT'd her or if he referred her to a neurologist. CT neg, MRI neg great no tumor or aneurysm. awesome she could breathe that sigh of relief, but she still has a damn headache that leaves her in tears. I asked one of my attendings what he thought his first question..........was she scanned?

Turns out yes, they were migraines that only responded to outpatient mag sulfate injections. Then a few weeks later came the tremor........so she has to be worked up for parkinsons and MS, heavy metal toxicity specifically copper the mayo clinic is the only place that can do the test so you know its expensive. thankfully no MS, parkinsons or copper toxicity. she still has headaches and a terrible tremor, she is out on medical leave and has a pretty shit quality of life, stressed out because no one knows whats wrong with her. I cant remember what else they tested for, but in the end it was some wacky metabolic disorder that doesnt even have a name, but they eventually found a fix for the tremor. She still has the occaisional migraine, but is back at work and isnt confined to home, and isnt stuck using a walker to get around. So every bit of money spent on tests was worth it in the end, because no definitive test existed to diagnose her. The doctors had to do it by the numbers.

[Edited on March 14, 2010 at 3:32 AM. Reason : .]

3/14/2010 3:15:28 AM

Agreed that it would be a better convo face to face. I'm finishing up 3rd year right now which is why I qualified my statements in my last post. I know nothing, although certianly more than the non-healthcare workers posting here. A lot of this is based on opinion and you can find evidence to back up either side of the argument. I'm giving the "i've seen this in clinic before and gotten the shit pimped out of me over it" perspective, where its always conservative treatment first.


I do think that your friend was treated properly. Those aren't run of the mill migranes. They're refractory to treatment, and debilitating past just a day or 2 out of work. Thats the point where you start getting concerned. My whole thing is that you do the conservative management first (which was done), then move onto more tests/scans when the first options don't work. Your attending asked if she was scanned because thats what you do for atypical presentations /refractory headaches. I'm under the impression that you were arguing that more people with typical headaches should be scanned earlier in the thread.

I think you deleted a few sentences or words from your last post after the edit. I'm actually giving the perspective more from an office visit perspective, even maybe an ED...although in the ED you're a hell of a lot more likely to get an unnecessary scan than anywhere else. Primary care physicians see headaches every day and rarely send their patients to get scanned, because thats the standard of care unless there are concerning symptoms or an atypical course.



and just to add, someone correct me if I'm wrong, I think CT scans are on the order of $700-1500 and MRIs are around 4000 depending on what kind of scanner and what sequences are running.

[Edited on March 14, 2010 at 4:21 AM. Reason : ]

3/14/2010 4:18:59 AM

well no matter the necessity of these tests, at the end of the day if your problem isn't surgical - you're fucked

3/14/2010 7:46:29 AM

hell no i dont think a person with a typical headache should have a CT scan.

Then again typical headaches respond to medication.

the majority of headaches are dehydration and or tension related. Those i am well aware of. After picking someone elses patient off of the floor, ive got one hell of a tension headache.

However, i know my body and i know that even my worst headache complete with photophobia responded to ibuprofen. If i ever had a headache that didnt get better with a big glass of water, 800mg of ibuprofen, and a nap.........i would be calling my PCP or hitching a ride to the urgent care. I feel very fortunate to have never suffered from a migraine.


maybe my perspective is a bit skewed i do see the worst of the worst. Some of the most unfortunate shit ever. jane doe has a mild MVC a week later complains of headaches. A scan was prudent because she could have had a slow leaking subdural hematoma. That scan was a stroke of luck or maybe bad luck.......there was something "suspicious" in the region of the thalamus. It warranted an MRI.......it was a damn tumor, relatively small...it was followed up with periodic MRIs to measure its progress. A future scan showed growth, no intervention needed at that time. THEN her optho found papiledema......no bueno, she shortly thereafter developed gait/balance issues. was biopsied and thought to be low grade. a month later during the resection..........oh fuck its a damn GBM.......prognosis..........one year. In the end that headache probably had nothing to do with that car crash. But that headache has forever changed her life she had her whole life ahead of her, and those 2 shifts depressed the shit out of me.


2 years ago i had to have one of those not terribly cheap VQ scans.
I had an acute severe sinus infection and couldnt breathe through my nose..... at work while trying to eat, chew and breathe through my mouth i became very short of breath. I stopped eating obviously, but after the better part of an hour i still couldnt "catch my breath" developed chest pains, did a spot check with the pulse ox............my sats were fine but i was tachy into the mid 140s not quite SVT but still creates a really uncomfortable sensation in ones chest. My pulse was thready. I didnt want to go to the ED, but my coworkers convinced me to go. get there and get triaged.......12 lead doesnt show ischemic changes........yay im not having a heart attack! ok so now what? waited a couple of hours had some labs drawn and a chest xray..........standard chest pain protocol. few hours later a bed opens up in one of the pods.....so they start some fluids........heartrate is slowing down by now o2 sats are back to my baseline. The attending takes my history does his physical and says his first concern is for a PE due to the sudden onset of symptoms. my only risk factor was i was on the pill at the time. sent a d-dimer to the lab.

they were about to discharge me..........when it came back slightly elevated. So to confirm or disprove a PE they needed to scan me. He opted to not expose me to the higher radiation from a spiral CTA. So i had my VQ scan, i am so glad it was negative. in the end it was probably the solumedrol kicking my ass with some help from sudafed. So even tho the scan was negative, it wasnt a waste. Without it i would have unknowingly been throwing clots. and a person can throw many many clots in their lungs before the big one hits. And i was dreading the thought of being an in patient bored out of my mind for days on a heparin drip micromanaging my nurses cuz ive seen what happens when the heparin protocols arent followed correctly. And a massive PE is a painful scary way to die. These patients before they lose consciousness are gasping for air with looks of sheer terror on their faces. Its hard to reassure them.......especially if they are blue from the nipple line upwards, cuz its not going to be a good outcome for them.

[Edited on March 14, 2010 at 9:02 AM. Reason : more anecdotal evidence]

3/14/2010 8:40:21 AM

Once again, you're giving evidence for testing where there is sufficient evidence to do so...for the most part. I also assume that you're paying into the healthcare system being a young person with a job, so when you go to the doctor freaking out with a differential of a PE, Panic attack, drug reaction, heart attack you pay for the tests you get. That said, your insurance company is paying for a lot of it and to a certain extent they should pay without screwing other customers over....they just don't unfortunately.

Regarding the patient with the GBM, thats how a lot of them are discovered honestly. That person with some wierd symptoms a week after an MVA needs to be scanned because you're at a higher risk for a bleed after trauma. Your GBM was a death sentence for sure, and once discovered we're talking about a completely different situation.

3/14/2010 1:37:07 PM

I'm beginning to see doctors more as highly trained automotive dealership technicians.

3/14/2010 5:03:56 PM

except for the fact that they save lives

3/14/2010 5:28:31 PM

Say whatever you want about too many tests to prevent malpractice. I'll go along with that.

But what about cesarean sections? In some areas, close to 50% of births are c-sections. The national rate is about 30%. We're talking about a completely natural process that the body needs zero assistance to complete (in the large majority of cases). And 1 out of 3 women are having surgery (often scheduled) to deliver.

3/14/2010 5:51:05 PM

it's called an electrive C-section. And in a lot of cases (not always), it's a waste of healthcare resources--simply a matter of convenience.

3/14/2010 6:44:10 PM

Because when its your baby who may or may not be in danger from a delayed natural birth and it comes out fucked up when the OB could have delivered quicker/more safely with a c-section you will be pissed and sue them into the ground.


At least thats what they will have you believe. OB/GYNs pay the highest insurance of any specialty because they're on he hook basically for every birth for 18 years, even though some defect may no have been prevenable by managing the delivery differently. Its a totally fucked up system.

3/14/2010 6:48:03 PM

Everyone wants a perfect baby - and they will sue if they don't receive one. From the OB/GYN standpoint it is simple: avoid potential lawsuits, perform a service which earns more money, maybe go home earlier. Yes, child labor is natural. So is occassional death during labor, for both mother and baby.

3/14/2010 8:18:50 PM

Yeah OB/GYNs definitely have it the worst when it comes to this sort of stuff.

Who do you figure is 2nd for completely pointless lawsuits? Maybe oncologists?

3/14/2010 8:26:42 PM

Quote :

"avoid potential lawsuits, perform a service which earns more money, maybe go home earlier"

pretty much. got to make that bank. and get off on time


[Edited on March 14, 2010 at 8:30 PM. Reason : .]

3/14/2010 8:29:09 PM

set em up

3/14/2010 8:43:04 PM