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This article came to mind this morning when I made my second visit to the orthopaedics department at a local hospital. The department schedules all patients for

This article came to mind this morning when I made my second visit to the orthopaedics department at a local hospital. The department schedules all patients for pre-appointment x-rays. That is, before the patient is even seen, before the doctor can determine if an x-ray would even be useful. On my first visit, I missed my x-ray appointment. The doctor I saw that day later said that was no problem. According to him, an x-ray wasn't necessary given my symptoms. I was scheduled for an expensive, unnecessary x-ray for no reason, basically. On today's visit I simply declined the x-ray, and the doctor I saw today was fine with that because he also did not recommend that any imaging be done.

rbanffy 9y ago
You were scheduled for an expensive, unnecessary dose of radiation that would be billed to your insurer and that's how the provider makes a ton of money out of you. The only priority of any sane health system should be to make people's health better.
- troycarlson 9y ago
  Bundled payments are slowly gaining traction and help align incentives a little better. https://en.wikipedia.org/wiki/Bundled_payment https://en.wikipedia.org/wiki/Bundled_payment
astura 9y ago
Same thing with me when I was referred to orthopedic surgeon for a lump in the soft tissue. Before even seeing me they called me in for a pre-appointment x-ray. It was never explained to be why a lump in the soft tissue would need an x-ray. I kinda went with it because it was such a surprise but I really wish I questioned it, seems like such a waste. Especially since the doctor ordered an MRI after seeing me.
- riahi 9y ago
  Because the Radiograph is a relatively cheap screening test to rule out an underlying bony abnormality as a possible explanation for the soft tissue lump. Further, radiographs and MRI provide complementary information. Taken together, they provide much more definitive characterization than either alone.
joshgel 9y ago
But you are underestimating the degree of variability between providers. Some providers may have felt the XRay was necessary and others may have not. In general, I find that patients have a sense that there is always a 'right' answer for what tests to order in order to diagnose their conditions. Some expect expensive tests to confirm a diagnosis that can be easily made at the bedside (like an MRI for sciatica for example). Others aren't interested in going through the difficulty of obtaining a somewhat difficult test like an MRI for a condition that is harder to diagnose at the bedside and would require further imaging to make a diagnosis. The truth is that diagnoses are rarely 100% certain. How certain you need to be to make the diagnosis depends a lot on the risks of being wrong or missing a diagnosis and the risks of the potential treatment. For example, we want to be as close to 100% that someone has cancer before we give them chemotherapy. But, are willing to be less sure about diagnosing a cold. Sure, it could be the flu, but the risks and outcomes aren't that different. The problem is that these probabilities aren't clear and doctors are humans and humans are bad at estimating with unclear probabilities. So there will be some doctors who estimate that the pain you were having that caused you to seek that doctor's opinion WAS enough to justify ruling out a fracture, because the risk of missing a fracture was worth the expense and very minor risk of radiation. Whereas the second doctor, may have seen things differently. AND this doctor has the added insight of the time that has past since your first appointment, ie you didn't get worse during that time (or maybe you did). That additional information of time, may have played into his estimation of the risks and benefit analysis for deciding on testing. This is a good article to really understand the much wider than expected variability in professionals, including physicians. https://hbr.org/2016/10/noise https://hbr.org/2016/10/noise
- cmiles74 9y ago
  I don't understand this argument at all. The poster claimed that his provider automatically scheduled an x-ray before any patient was seen. My understanding while reading was that this was regardless of the reason for the appointment. How can this be reasonable? It's impossible to know if imaging is required before seeing the patient, so it seems to me that a large number of these x-rays were unnecessary. In fact, the poster mentioned that on his last two visits he skipped the imaging and the doctor wouldn't have needed it anyway, bolstering my suspicion. I could be totally misunderstanding, but it sounds like you are arguing that requiring imaging before each visit is reasonable. That just sounds way off base to me and like an easy way to ratchet up the cost for each and every patient.
chefkoch 9y ago
An X-ray is really a cheap procedere compared to other imaging techniques. In germany a doctor gets around 20$-30$ for an X-ray. http://www.e-bis.de/goae/Goae00000137.html#O1 http://www.e-bis.de/goae/Goae00000137.html#O1
gascan 9y ago
Presumably it's a throughput & latency optimization. Doc only has to see you once if they already have the x-ray, instead of ordering an x-ray and then seeing you again. We speculatively do things in computers all the time in the name of speed & efficiency. If it cost nothing and the radiation carried no risk, nobody would have any problem with it. As it is, the cost is modest and the risk is low, so presumably healthcare waved their hands and said "close enough". (That said I still decline pre-appointment x-rays when I do not believe they are appropriate)

rbanffy 9y ago

You were scheduled for an expensive, unnecessary dose of radiation that would be billed to your insurer and that's how the provider makes a ton of money out of you. The only priority of any sane health system should be to make people's health better.

troycarlson 9y ago
Bundled payments are slowly gaining traction and help align incentives a little better. https://en.wikipedia.org/wiki/Bundled_payment https://en.wikipedia.org/wiki/Bundled_payment

astura 9y ago

Same thing with me when I was referred to orthopedic surgeon for a lump in the soft tissue. Before even seeing me they called me in for a pre-appointment x-ray. It was never explained to be why a lump in the soft tissue would need an x-ray. I kinda went with it because it was such a surprise but I really wish I questioned it, seems like such a waste. Especially since the doctor ordered an MRI after seeing me.

riahi 9y ago
Because the Radiograph is a relatively cheap screening test to rule out an underlying bony abnormality as a possible explanation for the soft tissue lump. Further, radiographs and MRI provide complementary information. Taken together, they provide much more definitive characterization than either alone.

joshgel 9y ago

But you are underestimating the degree of variability between providers. Some providers may have felt the XRay was necessary and others may have not. In general, I find that patients have a sense that there is always a 'right' answer for what tests to order in order to diagnose their conditions. Some expect expensive tests to confirm a diagnosis that can be easily made at the bedside (like an MRI for sciatica for example). Others aren't interested in going through the difficulty of obtaining a somewhat difficult test like an MRI for a condition that is harder to diagnose at the bedside and would require further imaging to make a diagnosis. The truth is that diagnoses are rarely 100% certain. How certain you need to be to make the diagnosis depends a lot on the risks of being wrong or missing a diagnosis and the risks of the potential treatment. For example, we want to be as close to 100% that someone has cancer before we give them chemotherapy. But, are willing to be less sure about diagnosing a cold. Sure, it could be the flu, but the risks and outcomes aren't that different. The problem is that these probabilities aren't clear and doctors are humans and humans are bad at estimating with unclear probabilities. So there will be some doctors who estimate that the pain you were having that caused you to seek that doctor's opinion WAS enough to justify ruling out a fracture, because the risk of missing a fracture was worth the expense and very minor risk of radiation. Whereas the second doctor, may have seen things differently. AND this doctor has the added insight of the time that has past since your first appointment, ie you didn't get worse during that time (or maybe you did). That additional information of time, may have played into his estimation of the risks and benefit analysis for deciding on testing. This is a good article to really understand the much wider than expected variability in professionals, including physicians. https://hbr.org/2016/10/noise https://hbr.org/2016/10/noise

cmiles74 9y ago
I don't understand this argument at all. The poster claimed that his provider automatically scheduled an x-ray before any patient was seen. My understanding while reading was that this was regardless of the reason for the appointment. How can this be reasonable? It's impossible to know if imaging is required before seeing the patient, so it seems to me that a large number of these x-rays were unnecessary. In fact, the poster mentioned that on his last two visits he skipped the imaging and the doctor wouldn't have needed it anyway, bolstering my suspicion. I could be totally misunderstanding, but it sounds like you are arguing that requiring imaging before each visit is reasonable. That just sounds way off base to me and like an easy way to ratchet up the cost for each and every patient.

chefkoch 9y ago

An X-ray is really a cheap procedere compared to other imaging techniques. In germany a doctor gets around 20$-30$ for an X-ray. http://www.e-bis.de/goae/Goae00000137.html#O1 http://www.e-bis.de/goae/Goae00000137.html#O1

gascan 9y ago

Presumably it's a throughput & latency optimization. Doc only has to see you once if they already have the x-ray, instead of ordering an x-ray and then seeing you again. We speculatively do things in computers all the time in the name of speed & efficiency. If it cost nothing and the radiation carried no risk, nobody would have any problem with it. As it is, the cost is modest and the risk is low, so presumably healthcare waved their hands and said "close enough". (That said I still decline pre-appointment x-rays when I do not believe they are appropriate)