$9000 Bill for Shingles

docB · Feb 7, 2010

The February 2010 Annals has an article (not a study) about a retired physician who ran up a $9000 bill in an ED to get diagnosed with shingles.

See the article here.

It's an interesting article. To summarize, the patient, a retired doc, thought it was shingles but was worried it might be something more serious so he went to the ED. The EP agreed that shingles was the most likely cause but asked the patient if he would agree to be seen by neuro and optho. He was and one of the consults ordered an MRI which had a soft read of possible venous cavernous thrombosis. 12 hours, a contrast CT, a repeat MRI, 9 grand and he was back to the original diagnosis of shingles.

Several people sound off about how this is an illustrative incident about the failings of healthcare in general and EM in particular.

I think Dr. Angela Gardner, ACEP president said it best:

Liability would have entered into my thought process, said Angela Gardner, MD, president of ACEP, who reviewed Dr. Coulehan's account. If he had come to the emergency department with those symptoms, and he really did have an obscure, life-threatening neurological illness, and the ED had just let him go, I can guarantee you there would have been a lawsuit.

Dr. Gardner said Dr. Coulehan's experiences are partly explained by the difference between emergency medicine and other specialties. In other practices, physicians approach a diagnosis by looking for the most common cause. In emergency medicine, Dr. Gardner said, physicians look at things from the standpoint of what could kill you, rather than what is most likely causing a patient's illness.

Our patients self select, she said. When they choose to come to an ED, they're declaring it to be an emergency. Emergency physicians are held to the standard of Why didn't you treat this life-threatening illness. We're not held to the standard of What is the most likely illness. Even among our medical colleagues there's not the knowledge that we do think differently than primary care providers. We assume your emergency is our emergency.

Stitch · Feb 9, 2010

Wow, that's crazy. And it's partly why I tell people not to look for things you don't want the answer to. More testing isn't always good, but often we're forced into it.

Of course, the lawyers like to insist that defensive medicine doesn't exist. 🙄

Doctor Bob · Feb 22, 2010

docB said:
In other practices, physicians approach a diagnosis by looking for the most common cause. In emergency medicine, Dr. Gardner said, physicians look at things from the standpoint of what could kill you, rather than what is most likely causing a patient's illness.

Emergency medicine is a field of sensitivity
All other specialties are fields of specificity

NinerNiner999 · Feb 25, 2010

Truthfully, this physician had no business presenting to an emergency department with a dermatologic question unless he thought it was life-threatening. A dermatologist would have charged him a premium for their service, but he would have been done with it.

docB · Mar 4, 2010

NinerNiner999 said:
Truthfully, this physician had no business presenting to an emergency department with a dermatologic question unless he thought it was life-threatening. A dermatologist would have charged him a premium for their service, but he would have been done with it.

I agree with you in principle. He went to the ED because it was after hours and he didn't want to wait for his private doc to open. If you're using the ED as an after hours clinic then to some degree you get what you get.

On the other hand shingles is a pretty bread and butter clinical entity that we're very familiar with. We should be able to manage it without consultants. In my mind if someone is calling consultants on this it's because of the liability issues.

specepic · Mar 19, 2010

Lets face it-I would bet most of us have pt bias...physician or lawyer or bigtime CEO, they get consults and tests out the whazzo.

I also think its silly this guy complained about it. He was offered the consults/tests more than 99% of people had the knowledge base to rightly refuse and could have said no. It's called informed consent.

psychotrope · Mar 19, 2010

docB said:
The February 2010 Annals has an article (not a study) about a retired physician who ran up a $9000 bill in an ED to get diagnosed with shingles.

See the article here.

It's an interesting article. To summarize, the patient, a retired doc, thought it was shingles but was worried it might be something more serious so he went to the ED. The EP agreed that shingles was the most likely cause but asked the patient if he would agree to be seen by neuro and optho. He was and one of the consults ordered an MRI which had a soft read of possible venous cavernous thrombosis. 12 hours, a contrast CT, a repeat MRI, 9 grand and he was back to the original diagnosis of shingles.

Several people sound off about how this is an illustrative incident about the failings of healthcare in general and EM in particular.

I think Dr. Angela Gardner, ACEP president said it best:

am actually surprised it was only 9k.....two MRI's and a contrast CT and lots of other stuff to....I would have guessed 15k or so

docB · Mar 20, 2010

psychotrope said:
am actually surprised it was only 9k.....two MRI's and a contrast CT and lots of other stuff to....I would have guessed 15k or so

Good point. In my house it probably would have been that much.

EM2BE · Mar 27, 2010

An MRI as an outpatient in the midwest is around $2200. Don't know how much a CT with contrast of the head costs, but I do know a CT of the abd without contrast is around $1300. That's pretty much around $3000 at a minimum for those 2 tests alone. I remember reading the article thinking why did the doc let them do all this if he were only going to gripe about it later. The only answer I could come up with was that he thought it was legitimate at the time and didn't want one of those potentially bad things to happen to them. He basically had a medical student moment (thinking oh what happens if I am the one in a million this could happen to. Physicians are well known to be on one end of the spectrum, either thinking they always have something wrong or will deny something until it's too late (or later than most would allow). If you were faced with this situation, would you have let all this happen or would you have refused it all and said you would follow up later?

$9000 Bill for Shingles

docB

Chronically painful

Stitch

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Doctor Bob

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NinerNiner999

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docB

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specepic

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psychotrope

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docB

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EM2BE

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