“The ER Is Where Overtesting Feels Inevitable”: Dr. Andrew Rudin, MD, on the High-Stakes Pressure Behind Emergency Diagnostics

Emergency departments are built for speed. When lives are on the line, decisions must be made in minutes—not hours. But what happens when the speed of modern medicine collides with the slow truths of diagnostic reasoning?

For this installment of our interview series, we asked Dr. Andrew Rudin, MD, a Tennessee-based cardiologist with years of experience consulting on acute cases, to talk about one of the most difficult places to practice careful medicine: the emergency room.

Q: Dr. Rudin, in your view, why is diagnostic overtesting so common in emergency departments?

Dr. Andrew Rudin:

Because the ER is where you’re expected to miss nothing. That’s the unspoken rule. If someone comes in with chest pain, no matter how low-risk, you get a full workup—EKG, troponins, chest X-ray, maybe even a CT angiogram. And I get it. No one wants to miss the one-in-a-thousand case.

But when we start testing everyone “just in case,” we’re no longer protecting patients—we’re protecting ourselves. That’s where harm creeps in.

Q: So it’s not just about patient care—it’s about legal and systemic pressure?

Dr. Rudin:

Absolutely. Emergency physicians operate under enormous medicolegal pressure. If something goes wrong after discharge, you can bet that every test you didn’t order will be questioned.

But we also have to recognize that this isn’t sustainable. We’re exposing patients to radiation, spending thousands on imaging, and often finding things that don’t need to be found. That’s not precision—it’s panic wrapped in protocol.

Q: Can you give an example of this overtesting in action?

Dr. Rudin:

Sure. A middle-aged man comes in with minor chest tightness. No risk factors, normal vitals, normal EKG. But the triage protocol demands a CT scan to rule out aortic dissection. That scan reveals a benign lung nodule. Now he’s getting pulmonary consults, repeat scans, and he's terrified he has cancer.

Was the dissection ever likely? No. Did the scan help? Arguably not. But now he's on a diagnostic treadmill that might last months—all because of a protocol that didn’t account for clinical judgment.

Q: Are these protocols the problem? Or is it the culture of emergency medicine itself?

Dr. Rudin:

It’s both. Protocols are useful—they standardize care. But they can also override intuition. A good doctor knows when to follow the flowchart and when to step off it. In the ED, though, stepping off can feel risky. That’s the culture we need to change.

We need to train doctors to think critically within protocols—not blindly follow them. And administrators need to support physicians who practice thoughtful, evidence-based restraint.

Q: What about patient expectations? Do they play a role in driving overtesting in the ER?

Dr. Rudin:

Definitely. Patients arrive scared. They want certainty. They want to leave with answers. And doctors want to provide that. But sometimes, the honest answer is: “I don’t think this is serious, and doing more tests might actually hurt you.”

The problem is, that doesn’t sound very reassuring. So instead of having that tough conversation, we scan. We test. We overdo it. It feels safer—for everyone—until it isn’t.

Q: What are the downstream consequences of this overtesting?

Dr. Rudin:

There are several. First, incidental findings—like tiny aneurysms, cysts, or nodules—that lead to expensive and unnecessary follow-ups. Second, the financial burden on patients. Even one CT scan can cost thousands, especially if it’s not fully covered.

Then there’s the emotional toll. Being told, “We found something, we don’t know what it is,” is profoundly destabilizing. People lose sleep over these findings. They change their lives over them. That’s not trivial.

Q: Is there any evidence that emergency physicians themselves recognize this pattern?

Dr. Rudin:

Yes—and many of them are incredibly thoughtful about it. There are some great studies showing that doctors often feel pressured to order tests they know aren’t necessary. It’s not about ignorance; it’s about fear and system design.

Many emergency docs want to scale back, but the policies, payment structures, and risk environment make that really hard to do.

Q: So what’s the path forward? How do we fix overtesting in the ER?

Dr. Rudin:

Start by building a system that supports thoughtful care. That means:

• Giving doctors room for clinical judgment.
• Reforming malpractice laws to protect evidence-based restraint.
• Paying for quality, not quantity.
• Teaching residents that courage sometimes means saying, “Let’s hold off.”

And we need public education, too. People need to know that sometimes not testing is the best form of care.

Q: What would you say to a young doctor working their first shift in the ER?

Dr. Rudin:

Don’t lose your clinical instincts. It’s tempting to lean on tests when you’re unsure. But the best medicine comes from listening, reasoning, and communicating.

And when you can, take the time to explain to patients why you’re not ordering a test. Most of them will thank you for it.

Conclusion

Emergency medicine saves lives—but it also exists in a high-pressure, high-liability bubble that often encourages more diagnostics than needed. Through voices like Dr. Andrew Rudin, MD, we’re reminded that careful thinking and compassionate communication are still the most powerful tools in medicine.