During a recent ED shift, just for the heck of it, I started taking notes as I went from room to room treating patients. I wanted to try to show myself whether or not “defensive medicine” was a figment of my imagination. It isn’t.
Although an incomplete list, here are some of the patients that I saw:
- A patient came in after being hit on the wrist with a metal bar at work several days ago. The back of his wrist was swollen. From his clinical examination, it appeared that the swelling was a ganglion cyst, but there was also some pain beneath the cyst. He mentioned several times that his boss wanted him to get an x-ray. So I did a wrist x-ray to “make sure” that there was no fracture. There wasn’t. Then I used a modified “Bible technique” (i.e. I used both of my thumbs to apply sudden pressure) to rupture the cyst. Problem solved.
- A patient dropped a TV on his foot. There was only a little red mark on the back of his foot, but the patient stated that he could not bear weight on his foot. I was inclined to wrap him up and send him home with pain medication and crutches, but I did an x-ray of his foot to “make sure” that there was no fracture. There wasn’t. Treatment was the same.
- A patient in her 60s fell and hit her head 5 days ago. She was having a headache. I couldn’t find a mark on her and was inclined to send her home with pain medications. But she was on Coumadin which put her at risk of bleeding. So I did a CT scan of her head to “make sure” that she didn’t have a bleed. She didn’t.
- An out of town patient in her 40’s who had a long history of smoking and a history of COPD came in for coughing and shortness of breath. She was at a baby shower and had forgotten her albuterol inhaler. Her oxygen saturation was 92% on room air. Her heart rate was 105. She got a couple of treatments and steroids and was marginally improved. Even though her symptoms were most likely explained by her underlying COPD, and I was inclined to discharge her with a prescription for steroids and another inhaler. Instead, I did a CT scan of her chest to “make sure” that she didn’t have a pulmonary embolism. She didn’t. She went home on steroids and an inhaler. We made sure to recommend that she stop smoking so that we wouldn’t get dinged by CMS for failing to meet a “quality indicator.”
- A nice little old lady slipped on the stairs on her house and scraped her leg on the edge of the stair, causing a deep “V” shaped skin laceration. The wound was bleeding, but most of the skin was not able to be sewn back together because of the way the skin had been torn. I removed the nonviable skin, put a dressing on it, and was going to send the patient home. Her daughter, whom I had been forewarned was a nurse and who had complained about care in the ED before, asked me why I wasn’t going to do an x-ray. When I explained that she did not have any signs of a break. After I left, she asked the nurse to call the hospital administrator. That got her mother the x-ray that she so desperately didn’t need. And no, there wasn’t a fracture.
- A 94 year old demented lady was brought in because she was not “acting right.” Her daughter tried to wake her from sleep and had a more difficult time than usual waking the patient up. The daughter stated that the patient was “acting different,” even though nurses who had seen the patient before and the nursing home staff stated that the patient was not acting different. The patient got a bunch of labs and a head CT just to “make sure” that the allegedly incremental increase in her dementia wasn’t caused by a metabolic problem or a spontaneous bleed in her brain. It wasn’t. She was discharged back to the nursing home to finish her nap.
- A 74 year old little bitty was attending a party, had “a couple” drinks, and passed out. She took the first dose of a new blood pressure medication before she left for the party. Eight other little old bitties accompanied her to the ED, each one of them in turn telling the staff that the dizzy bitty had a “heart problem.” We did a breathalyzer on the patient and it was 92 – over the legal limit. She felt fine. She looked fine. Her symptoms were gone. Nevertheless, she got a complete set of cardiac labs, was kept on a cardiac monitor, and got an EKG just to “make sure” that her “heart problem” didn’t cause her to pass out. It probably didn’t. I bit the bullet and sent her home after everything came back normal.
- Then there was the suicidal patient. She was drinking, became upset with her boyfriend, and used a piece of broken glass to cut her wrists. Her alcohol level was in the mid-200s. She was drunk and she “was going to f***ing die.” But no psychiatric institution would accept her in transfer until she had a complete laboratory and toxicological workup, including an EKG and a urinalysis just to “make sure” that a whacked out chloride level or a raging UTI wasn’t really behind her suicidal tendencies.
By the end of the shift, I was getting annoyed with myself because I kept second-guessing my decisions to order tests that would most likely be normal. Why was I ordering all of these things when my clinical judgment led me to believe that they would “probably” not lead to any changes in the patient’s management?
The answer is because in our culture, “probably” doesn’t cut the mustard any more. Clinical medical judgment has been supplanted by the demand that physicians disprove the improbable. Society has made it so that physicians are more concerned with proving that unlikely diagnoses with the possibility of a “bad outcome” don’t exist and with maintaining good Press Ganey scores. Many physicians are afraid to practice rational medicine based upon clinical judgment and physical examination skills. No one wants to face the liability.
For those who would assert that I was practicing inappropriate medicine for ordering all of the “unnecessary tests” above, tell me which conditions that it would have been acceptable to “fail to diagnose” on the possibility that my clinical examination alone missed an unlikely disease process. The little old lady with the head injury? The “dizzy bitty”? The worker whose hand was injured by a piece of metal? Tell me which “bad outcomes” are OK to miss in the absence of exhaustive diagnostic testing.
You know and I know that had I missed anything, I would be either be explaining myself to hospital administration when the patient complained about paying the bill for the “dumb doctor” that didn’t diagnose the problem or that I would be spending the next several years listening to a plaintiff’s attorney telling everyone how the patient’s injury is an example of why I am a bad doctor and why clinical examination alone is simply not good enough.
That, my friends, is defensive medicine at work.