Hemorrhagic Ovarian Cyst
Here are the facts as CBS presented them last night-
A young college student presents to the ER with abdominal pain. She gets a CT scan. The CT scan shows an ovarian cyst. Dad, who is an MD, gets the bill for over $8,000, most of which is for the CT. Dad goes on CBS says his daughter should have had an ultrasound because it was cheaper. He says it is because the ER docs were practicing defensive medicine.
What we do not know is anything else. What was the history of pain? Sudden onset or gradual onset? Lower or upper abdominal? Associated nausea and vomiting? Fever? New sexual partner? Urinary symptoms?
We also are not told what the young woman’s exam showed. Did she fever? Was the pain right or left sided? Rebound and guarding? Absent or hyperactive bowel sounds? CVA tenderness? What did her pelvic exam show? Cervical motion tenderness? Cervical discharge?
What about her lab findings – UA, Hemoccult, CBC, Pregnancy test?
So many little details that would have informed the discussion. But we were not told any of them. The poor ER doc barely got a word in edgewise.
There are three possibilities as I see them –
1. The ER docs did everything right. Based on the history, physical and lab studies, they were worried about an appendix, and decided she needed a CT. An ultrasound could show an ovarian cyst, but ovarian cysts are incredibly common and not necessarily painful. They can certainly co-exist with an inflamed appendix.
In this case, if the patient had had an appy, and a delay to diagnosis had led to rupture because she had a sono and then the CT, CBS’s story would be about how Dad is accusing the ER for failing to diagnose daughter’s appendicitis in a timely fashion.
2. The patient presented with signs and symptoms typical for an ovarian cyst (sudden onset of pain mid cycle, no fever or elevation in white count, negative pregnancy test, pain improving as she waited in the ER), and the doctors either didn’t get a full history or misinterpreted the clinical scenario. In that case, Dad is right, not because the ER docs were practicing defensive medicine but because they did not use clinical judgement.
3. The ER docs order a CT on every patient with abdominal pain because they are practicing defensive medicine. That’s what the news story implied.
Unfortunately, we’ll never know what really happened, and so we cannot have an informed debate about the topic. And that’s a shame, because it is an important topic. Maybe Kevin, MD knows what really happened, since he was interviewed for the spot. (Congrats, Kevin!)
Of course, in the days before CT, this young woman would more than likely have ended up in the OR with an appendectomy and removal of her ovarian cyst. Now that would have been a big bill….
UPDATE
The Dad-Doc in the story has weighed in on the discussion in the comments section below (Thanks, Dr Bob!). Here’s what he said –
I am the Dad-Doctor in the CBS piece. Here is more clarification:
1. No fever
2. Cursory hx and exam by PA
3. No pelvic examIn my experience, today’s ER’s have become CT Triage Centers
Nicely said!
My brother, my husband, myself, and my son were all diagnosed with appendicitis (in 1965, 1973, 1976, and 1987 respectively). In none of our cases did the diagnosis require a CT scan. Or do you suppose none of us had appendicitis, just unnecessary appendectomies?
rl – thanks!
mss-
CT has become fairly standard for the diagnosis of an appy, and has led to less unnecessary appendectomies. In the days before CT, the mantra was that if you weren’t taking out at least a few normal appendices, you were probably mnissing more than that. Sort of like accepting a certain rate of false postivies in return for a low false negative rate.
Now with CT, surgeries are more targeted, and actually if an appendeceal abscess is seen, often delayed so the abscess has time to “cool down”.
That said, if a patient presents with the classic history, signs and symptoms of an appy, then probably CT is not necessary, as was shown in a recent study. And I might add, with my daughter, who basically prsented as if she had read and memorized the textbook. She even said to the ER doc “When I raise my right leg while I’m lying down, that pain gets really really bad…”
I’m actually shocked, not living in the USA, that a ultra-sound in a hospital costs 1400$. Even given the US machine you can get for 100K, and assuming you use it on one patient a day (surely I’ve given us at least an 100x factor here), surely you’re paying the doctor or her boss at least 500$ too much for these 15 minutes. Am I missing something?
If the ER doc’s radiologists are anything like the ones who read my patients’ films, the young woman would have had the ultrasound, and they would have then recommended the CT scan in their report, so she would likely have had both!
Your post is excellent; it sounds like a witch hunt, and I’d like to know if Doctor Dad was present with her to provide input on the work-up in real-time.
dI am the Dad-Doctor in the CBS piece. Her is more clarification:
1. No fever
2. Cursory hx and examby PA
3. No pelvic exam
In my experience, today’s ER’s have become CT Triage Centers
Dr Bob –
Wow- thanks for your comments. It provides the clarity that the news story did not.
Peace.
TBTAM
Well the dad-doc’s comments certainly do make the case. No excuse for doing a lousy history and a partial exam and calling it CT time. On the other hand I can be pushed to do a CT under a couple of circumstances. One is that it is “after hours” for the US tech in my community hospital, the pain isn’t clear-cut, and the white count is up. Another is the patient or family member who pushes for it because the story looks like appendicitis and the white count is borderline and the patient and/or family is uncomfortable with the “go home and wait and see approach.” Had one of those recently where even the CT was iffy. The patient got IV antibiotics and stayed the night; AM WBC was better and the pain had resolved. Will he be back? Probably.
Laurie
I practice in a medium sized ED in South Carolina. I’ve been thinking a lot about the CT scan issue these days. And I’ve come to the conclusion that we probably do order too many CT scans.
However, I think this is driven by more than defensive medicine. First, in cases of abdominal pain that might require surgical intervention, the surgeons simply insist on CT scans. They won’t do anything without them. I’ve seen penetrating abdominal trauma that was sent to the CT scanner. Seems to me (and I’m just a hillbilly hick from WV) they have to be opened up or have laparoscopy anyway to use that most amazing scanner of all, the human eye.
But even with fever, elevated WBC, anorexia, nausea and migrating RLQ pain, surgeons these days insist on CT. Are they practicing defensive medicine? Possibly. Are they concerned with false negative laparotomies and adverse peer review? Possibly. Is it a delaying tactic so that they can sleep or finish clinic? Possibly. Lots of reasons may be at work. I don’t know the surgical literature, so maybe there are compelling reasons from recent research. I can’t speak to that.
Now, let’s look at another issue: the unfortunate drive to customer service-based medicine. If patients aren’t satisfied with the answer ‘I don’t know what it is, but I don’t believe it’s dangerous’ then they complain. When they complain, satisfaction scores fall. When they fall, doctors often get scolded along with nurses and nurse managers. When this happens, salaries sometimes fall, bonuses evaporate or jobs are lost.
What’s easier: to discuss the sensitivity and specificity of CT with a patient, or to do what the ‘client’ wants, or what the client’s family will ultimately insist upon, and keep looking until everything is ruled out?
Finally, please read my latest blog post on why that CT cost $8000, or something ridiculous like that, and what we should do with that bill.
Anyway, I sympathize with all parties. As a dad, I want reasonable, cost-efficient care for my children. As a doc, seeing lots of people very fast, sometimes the test that rules out the worst things fastest is the way to go. And though I’m not a surgeon, I understand that in a litigation-prone world, more information is always better than less.
It seems we want everything done, nothing missed, and all of it at a discount. Welcome to reality!
Edwin Leap, MD, FACEP
I’m glad the Dad gave us more info, but I am wondering if the young woman needed to be seen in the ER in the first place?
Contemporary ERs are extremely difficult places to practice medicine, and it’s all about triage there–sorting out the life-threatening emergencies, from the urgencies, and I am sympathetic to ER staff feeling like a CT scan is the fastest way to get a definitive answer (yes or no to appendicitis).
Dr. Leap is right about surgeons–getting a thoughtful consult these days (before a CT scan) is more difficult all the time.
If someone performed a pelvic CT on my kid with raised WCC , positive rebound and fever I would consider it malpractice – acute appendicitis requires surgery , not radiology!
PS anybody read the recent AAP concerns about concerns surrounding pelvic CT in children and CA risk?
Hi TBTAM, This post was an eye-opener. Sometime ago a blog friend told me in her chat box that a CT scan would cost ‘an arm, a leg & more’ in the US. I understand now. I thought of commenting here two days ago when I first saw this, but decided to post the response in my blog. It’s a different look at the issue. Your comments would be welcome.
PS. I assumed Blogger would automatically link/trackback to this post. That had not happened, hence the comment & link here.
As a person in the field of radiology, CT scans pose a much higher dose of radiation and I often feel they are overused when not completely necessary. Understandably, too, ER doctors are very busy and I think it is safe to say that pelvic exams are not in their protocol for lower abdominal pain. That being said, if the daughter was not displaying any fever or other significant symptoms, why did they not call in ultrasound? Yes, it is much less expensive and essentially safer than CT. (Mind you, I am not saying CT is unsafe, just not necessary in this case)
Very interesting post – I have a response posted on my own blog at http://idiopathicmedicine.wordpress.com/2010/07/04/to-scan-or-not-to-scan/ for your perusal. Excellent site!
Guys,
We can debate this point about medically necessary vs unnecessary until we are blue in the face. However, the more important issue is having to pay the extremely steep price these CTs.
Profit margins in medicine in US are criminally high.
Regards,
—
RK