Rule out Testing

Another great post from the Happy Hospitalist on rule out testing  here.. 
The post really needs to be read in its entirety at the link.

(As an aside one of the frustrating things about the insurance "game" is that the doctor will not be given approval to do a test for a diagnosis according to current CMS rules if the diagnosis is "rule out..."so in the middle ofspending time and effort with regard to the patient's diagnosis one has to creatively pursue a diagnosis for which the insurance company will agree to pay)

A 17 year old female is seen in the emergency room with a chief complaint of shortness of breath. Thus begins the rule out testing.

(..) 

This is where rule out testing feels so good.

Do you send the patient home with a diagnosis of panic attack and follow up with her doctor? Or do you pursue further testing for pulmonary embolism? That is the million dollar question. And let me answer it for you. Our current system is set up to pursue the diagnosis of exclusion without regards to cost. And here's why. Doctors act out of fear. Patients respond out of the comfort of knowing. And in both situations, neither is personally held responsible for for the cost of their desires. We pay for it through higher premiums. We will pay for it through higher taxes. The patient is immune from the immediate cost of feel good medicine. The doctor is immune from the fear of not knowing. A fear that is driven to spend other peoples money to prevent a bad outcome.

Look at my four box theory on Testing vs Outcomes. The physician will always want to stay on the top line. Because that's where the lawyers work for food. (Bold lettering mine...check out the "Testing vs Outcomes link for further elaboration from the Happy Hospitalist). That's where they feel good. And that's where the patients feel good. That's why rule out testing feels so good.