When I was a resident, I was particularly lucky to have one of the best cost-control experts in the US as one of my teachers. He was amazing at keeping patient costs low by following a simple rule, “don’t order so many tests”.
For some reason, many of us in the medical field have been trained that if we order enough tests that we won’t “miss” something. In reality, this practice in more cases than not results in more problems and less answers. A good doctor takes the time to ask the right questions so that they will be able to order the right tests and nothing else. A confused doctor orders everything under the sun and ends up with more questions than answers.
Case in point. A few weeks ago I saw little Chastity who was brought in to the ER by her mother for a “fever that wasn’t going away”. When I entered the room, Chastity was busy playing and singing – a good sign that her fever was not much to be concerned about. Her mother though was sure that it was something serious because the fever was now in its third day. She actually came to the ER on the first day and was told that it was likely “a cold”, but this morning she was talking to a friend of hers who works in a “bigger hospital” and was told that Chastity “should have some blood tests” to make sure there was no “serious infection”.
(I’ll have to discuss the whole idea of people treating the ER like Burger King and ordering things the way they want it a bit later)
So, I was stuck in a corner. I was 100% sure that little Chastity was going to be fine but I didn’t want to deny the mother her “request” since I do put a lot of weight into mother’s intuition. If a mother really feels strongly about something for her child I really need to have a solid reason to say no. So I ordered the all-knowing blood test.
When I got the test back though, I was very surprised. Her infection profile (WBC count) was high (21k). Was the mother right after all? I explained to the mother, and the smug looking “bigger hospital” worker sitting with her, that her test was abnormally high. A high number like this in a child with fever has to have a source – ears, lungs, urine, brain, belly, etc. – or it could also mean nothing (since we don’t routinely do blood tests on happy playful children).
The next 3 hours witnessed several more tests, all of which were normal. Chastity was still playing, asking for food and in a generally good mood. I discussed the case with her pediatrician and he saw the corner I was backed into and agreed to observe her in the hospital overnight in case something was brewing. Chastity went home the next morning with no real reason as to why her WBC count was high except that she probably had “a cold”. All in all, about $10,000 in medical expenses for a cold.
And yes, I resisted the incredible urge to tell her smug hospital friend “I told you so!”
What is the moral of the story? Ordering more tests isn’t usually very helpful if you already have a good idea of what is happening based on getting a solid history and physical examination. On the other hand, ordering tests are a great way to drive people into the poor house.
Come back tomorrow to learn 5 simple things that can do to help keep costs down the next time you have to go to the hospital!