There it was, glowing on the computer screen next to each patient's name, and repeated again, up on the emergency-department tracking board: "Abd Pn," the abbreviation for abdominal pain. It appeared again and again, 12 times.
As other ER staff around me examined the board, the groans began. Anyone who works in an emergency department knows why: treating patients with belly pain is the ER doctor's booby prize. Invariably, care involves dealing with bodily fluids, internal exams and choosing between a dizzying array of diagnostic tests and therapies. Diagnosis is not easy.
It would have been one thing if the dozen patients with belly pain that morning had all gotten sick at the same Philly-cheesesteak joint, but nope. It turned out that each case was completely different from the next. Some patients were old and some were young. A few had potentially life-threatening causes for their pain, others had nothing but gas. One ended up in the operating room, three were admitted overnight and the other eight went home. A quarter of them received a CT scan. And, perhaps most alarmingly, nearly half of the belly-pain patients that day including those who got what we call the million-dollar workup (blood tests and multiple imaging tests) left the ER without a definitive diagnosis.
According to the Centers for Disease Control and Prevention (CDC), abdominal pain is the single most common reason that American patients visit the ER, accounting for 7 million visits per year. It is a widespread and frustrating complaint. And the difficulty of treating belly pain perfectly illuminates the major challenges and issues that currently face the health care system at large: the risks and benefits of diagnostic tests, the cost of care, variations in practice, medical malpractice and patient expectations.
Why is belly pain such a health care bear? First, it's a bit of a black box. Conditions that cause it can be immediately life-threatening (such as a leaking aortic aneurysm or a ruptured ectopic pregnancy) or painful but not all that serious (intestinal cramps or ruptured ovarian cysts) or somewhere in between. The CDC estimates that about 17% of all ER visits for abdominal pain are due to what it classifies as "serious diagnoses."
Second, the tools we use to look in that black box are far from perfect. Take the CT scan the two-dimensional X-ray is one of the most commonly ordered ER tests for patients with belly pain. The pros: CT scans are readily available, able to look at every organ in the abdomen and pelvis, and very good for ruling out many of the immediately life-threatening causes of belly pain. CT scans can also reduce the need for exploratory surgery. The cons: Often, CTs can't diagnose the actual cause of ER patients' abdominal pain. Worse, CTs deliver significant doses of radiation to a patient's abdomen and pelvis (equivalent to between 100 and 250 chest X-rays). Over a lifetime, patients who receive two or three abdominal CT scans are exposed to more radiation than many Hiroshima survivors.
Third, we don't have great evidence for deciding exactly who should get what test for abdominal pain. Based on the evidence, doctors know, for instance, how to identify low-risk neck-injury patients who don't need to be subjected to spine X-rays; we also know which head-injury patients need brain imaging and which don't. But no such clinical prediction rules exist currently, or in the foreseeable future, for abdominal-pain patients because the condition is both so common and its symptoms so varied.
Fourth, there are major misconceptions and variable expectations, among both patients and doctors, when it comes to diagnosis and testing of abdominal pain. A recent survey of patients who went to the ER with belly complaints found that those who received extensive testing including CT scans and blood work were more likely to feel confident with their care than those who didn't. More worrisome, over 70% of the same sample vastly underestimated the risk of the cumulative radiation exposure for the CT scans, and many of them did not recall accurately if they had ever received this test before.
Patients also expect a diagnosis from a doctor, but when it comes to belly pain, you don't always get one. An ER doctor may be able to control your pain and give reassurance that you don't have an immediately life-threatening condition but you may still feel frustrated because we can't tell you exactly what's wrong.
But on the ER physician's side, there's a lot of pressure to make a correct diagnosis the first time around: missed diagnoses for abdominal pain are a major source of malpractice suits against emergency docs. But, again, it's a morass. When surveyed, emergency physicians could agree on only 12 of 50 acute abdominal-pain conditions that were "acceptable not to diagnose" during an ER visit.
So is there a possible solution to the multitude of problems that attend belly pain in the ER? Policymakers are making serious efforts to reduce the overuse of tests that emit radiation, to standardize care and to curb runaway costs of health care in the U.S. But that won't stop people from flooding the ER with abdominal pain, nor will it stop doctors from doing tests because of the threat of a long-term risk: for many doctors and patients, the immediate worry of potentially missing appendicitis is going to trump the more distant concerns of cancer and cost.
Doctors know we are probably ordering too many abdominal CT scans in the ER, but we are doing it more and more. In the past decade, the use of CT scans has more than doubled nearly 25% of all patients with belly pain in the ER get one but it hasn't improved detection of disease: diagnoses of abdominal conditions such as appendicitis, diverticulitis and gall-bladder disease have held steady. It isn't even clear that all this CT use has reduced hospitalization rates.
So, how are we going to work our way out of this belly-pain boondoggle? Both blunt and nuanced solutions have been proposed including penalties for physicians who order excess tests, and computer programs that make it easier to grasp, and explain to patients, the risks and benefits of diagnostic tests.
There are certainly other, more creative answers. In the coming week the Medical Insider will moderate a discussion among medical experts who will add their perspectives and talk about possible solutions to these dilemmas. Check back next Wednesday for the best of that back-and-forth.
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Dr. Meisel is a Robert Wood Johnson Foundation clinical scholar and an emergency physician at the University of Pennsylvania.