WhiteCoat

Defensive Medicine at Work

martial-arts-black-belt-defense

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.

73 Responses to “Defensive Medicine at Work”

  1. Tex says:

    So why do some of these patients need you for?
    They seem to know what tests they need/want.
    Oh, yeah…
    So they have someone to blame if they don’t.

  2. [...] medicine in the course of a day in his emergency room, and concludes that, no, the whole phenomenon isn’t just a figment of his imagination the way so many lawyers say it [...]

  3. Ron Miller says:

    Well, Tex, I certainly think you are in a good position to judge – from where you are sitting – the quality of the character of the patients this doctors saw that day. I suspect patient #3 was only looking for $1 million but the rest I think clearly were all looking to apply blame and collect at last $7.24 million.

  4. D. B. says:

    As a consumer of ER services in the past, I feel better knowing that the Dr. has exhausted all possibilities and that I really am fine. I’ve been on the other side, where I was in the hospital for a leg blood clot. I told the nurse that I was having a sharp pain in my back. She wanted to give me tylenol. I insisted she tell the dr. He ordered a “defensive” MRI and turns out I have a pulmonary embolism. So, in short, way to go. You have a clear conscious and your patients can sleep at night. Yeah!

    • D.B. just points out that not all good medicine is defensive medicine. Your Dr ordered a (most likely CT not MRI)to diagnose the PE because it was indicated. That is pure risk benefit. Maybe WC should have ordered the CT on the little old lady on Coumadin with the head bonk. But xray a leg that is clearly not fractured? That’s pure and simple DM with no real up side.

    • FWM says:

      D.B.

      [Partially readacted - please no ad hominem attacks]

      My point is that there is a whole layer that you do not understand, and shouldn’t be expected to. My point is a recurrent one: Just because you have a story, doesn’t mean it is relevant or that people will care.

      I reiterate, all you did here is demonstrate for the 5 million quadrillionth time what we already know: Patients/politicians/scum lawyers and everyone who should not be directly controlling medicine (if they know what is good for themselves) always proffer, but the net result is to worsen the situation.

  5. paul says:

    i agree with all of your cases except for the lady on coumadin.

    i recently saw a 60yr old man on coumadin for afib with “exacerbation of chronic headache.” there was nothing unusual about this headache, he periodically gets them and in fact is followed by a neurologist and had a negative mri brain 1 month prior to presentation. he had no focal findings on exam, and his inr was 2.3. ct was backed up and by the time they were ready for him, the toradol he got had kicked in and he felt “okay.”

    you can guess where this is going… the ct showed a giant subdural with 5cm shift.

    fear coumadin.

    but yeah, getting unnecessary xrays, or worse, giving unnecessary antibiotics for the sake of appeasing the press-ganey gods truly sickens me.

    • Phil says:

      Fear coumadin, no reason to fear coumadin if followed correctly, in the prior month the protime could have fluctuated. also I would not have given Toradol to a pt that I was treating for possible bleeding problems

  6. igloodoc says:

    40 yr old indigent street guppy shows up to the ER with altered level of consciousness. Blood alcohol was .3 (almost 4 times the normal intoxication limit 0.08). ER Doc runs CBC, metabolic panel that shows only elevated liver enzymes, no surprise for chronic alcoholism. ER Doc decides to wait it out, and discharges patient after almost a full shift, alert and oriented. (No discharge blood alcohol done)

    Said patient returns 1 hr later, again altered LOC. Being a bounce back, this time he gets the full work-up. Blood alcohol 0.12, CT shows subdural hematoma.

    Lawsuit with newly appearing relatives now “taking care” of said patient is settled, undisclosed sum. Malpractice allegations included sent home with subdural, sent home drunk and fell, sent home with elevated PT (actually only 2 sec over normal).

    Now, in that ER, all drunks are scanned, period. You have to irrefutably prove a negative. The “standard of care” in the ED is “prove to me you are well, and I’ll let you go home, else you stay and get poked and probed”.

    And the lawyers tell us defensive medicine doesn’t exist.

    What utter crap. Before we get universal health care, maybe we need universal legal care so the lawyers get paid a pittance by the government no matter how little they do.

    • That would actually happen with a government sponsored health system. There might be a no-fault system where patients got paid a standard amount for a particular kind of medical injury. That would be good. The problem is all the other problems of a gov’t system that would come along with that benefit. It’s not worth it. We can solve this without the gov’t being in control. Why not just publish standards of care that are proven by best evidence. For instance, elderly people with minor head injuries don’t get CT unless they are on anti-coagulants. Back pain doesn’t get CT, unless the patient has x number of risk factors such as co-existing thrombophlebitis. It’s not that hard.

      • Jon Hager says:

        Sounds good to me. If X number of ER docs agreed to the standards and signed agreement statement, then this could be used in defense of many lawsuits.

        Where are these statements…and how/where do I sign!?

  7. Peter says:

    This can be stated differently:

    Why is my skin always swabbed with alcohol before I get stuck? My skin is “usually” clean, and even if it weren’t I “probably” won’t get sick, and even if I get sick I “probably” won’t die.

    But they always do the alcohol wipe. Why?

    Answer: it’s cheap, and although it normally doesn’t much help, the times it does help it helps a lot.

    Same way with defensive medicine. If you track all of the patients in multiple emergency rooms, you’ll find the occasional person who really isn’t suicidal and really does have a chemical imbalance.

    Would you like to be the person with a simple imbalance who’s locked away for weeks to “cure” your “impulses”? Loosing your job, your reputation, your house? Or would you rather that some simple tests be done to reduce that chance?

  8. scalpel says:

    Zero Defect by Panda Bear MD is one of my favorite blog posts of all time.

    If we’re ever going to reduce our national healthcare expenses, we are going to have to reduce our expectations as a society.

  9. Dan says:

    I disagree, D.B.. I, too, am the infrequent consumer of ER services (for myself and family), and it annoys the hell out of me when they practice medicine. If I went in to the ER with *just* a backache, I’d be pretty ticked if they wanted to do an MRI ($1200 or so, right?). However, for you it sounds was appropriate given the leg clot (and, more saliently, a doc should be making the call, not a nurse).

    Every defensive x-ray, MRI, and study takes important resources away from where they could be better used. Exhausting “all possibilities”, however remote, is wasteful.

    And no, I’m not a doc, or remotely connected to the industry. I’m a computer programmer for a consulting company, and have no dog in this fight.

  10. Strong One says:

    So.. the best offense IS a good defense.

  11. Glyph says:

    DB is either confused or lying, in addition to having no idea what the typical presentation and treatment of PE is. Ignoring that there is no way that she was diagnosed with a PE via a “defensive MRI”, she fails to realize that nothing changed after her “MRI” and diagnosis of PE.

    (Some assumption on my part coming up)
    She was in the hospital for leg clots, likely already getting anticoag therapy. So with new symptoms of only mild sharp chest pain, it would have been safe to just assume mild PE and continue current anticoag. They don’t ramp up or change your therapy (thrombolytics, IVC filters, mechanical thrombolysis) for people with mild stable PEs. You would have had to get short of breath or otherwise “sicker” to warrant these new treatments, at which time serious radiologic investigating for PE (CT scan with contrast bolus) would be warranted and employed by any decent clinician.

    But no, its likely your situation was not improved or changed after spending the money to check for PE (even when you did have a PE).
    Its things like this that the laypublic just don’t get. These decisions should be left up to your doctors, not your grandma or your lawyer.

  12. damned if you do damned if you don’t…the old catch 22…to err is human to diagnose divine…good luck guys i feel for ya

  13. Max Kennerly says:

    “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 …”

    Last I heard, that was called a “differential diagnosis” and was one of the foundations of clinical practice.

    Are you suggesting patients on Coumadin who fall and have a “headache” (was it severe? prolonged?) should be sent home without a scan?

  14. Steve McGuinness says:

    So they want X-Rays and CAT Scans and all other manner of tests.

    Fine. Charge them through the nose for it. If years at Med School isnt enough training for them to accept the word of a trained doctor, maybe the words of a trained accountant telling them “Youre broke because you asked for scans you didnt need and refused to take the Doctors word for it” will provide a more telling lesson.

  15. Med Student says:

    Excellent post. I find it interesting that a huge portion of defensive medicine is unindicated imaging. What are your thoughts on malpractice reform, WC? I’d be interested to read a follow-up post on that subject.

  16. Doc C says:

    As a practicing ER doc, if I have a child in the ER who clearly is fine but have panicky parents, the line that I love that is nearly 100% effective in assuring that I get my way is, “we could do a CT scan but I’m concerned about subjecting Little Johnny to the radiation. Why don’t we …” It is one of the few instances where you can show someone the consequences of being overly aggressive. Plus I get to write in the chart: “discussed CT with parents – refused exam.”

    • Emily says:

      How clever. Manipulate the patient to get your way then, most important, cover your ass in case you’re wrong. What great ethics.

  17. Monty says:

    Well, ideally you would discuss with a patient the low likelyhood a diagnostic procedure would discover anything, and they would then decline the procedure. But in reality, if its the insurer’s money, how many people are going to make that decision.

  18. hawkdoc says:

    I believe we physicians are experiencing a shift in the expectation and therefore the delivery of medical care that I like to refer to as the “ER/Gray’s Anatomy/House Effect”. The way I was trained was to take a good history, develop differential diagnoses based on the history, and then perform labs, imaging studies, etc. to confirm or exclude the diagnosis based on these results. Instead, now I find I am having to perform tests to disprove diagnoses the patients have upon arrival to the department. Not only is the “E/GA/H Effect” powerful and pervasive, it is causing delay in treatment and costing a fortune.

    • WhiteCoat says:

      Well put. I agree.

      • It’s true that TV shows oversimplify disease, the same way they trivialize the lives of celebrities. Just because a woman on Grey’s Anatomy has an unusual set of symptoms, it does not mean that all women with the same set of symptoms are suffering the same condition.

        And yes, physicians have to deal with an exasperating new reality: the patient who thinks she’s a textbook example of House’s last patient. This often requires having to convince her otherwise, resulting in time and effort taken away from actual healing.

        We patients hear a lot of doctors sing this tune.

        But hey, doctors, get over it. That’s the world we live in now. I don’t want to go back to a world where the patient was COMPLETELY clueless and left to the absolute authority of the doctor. Better a misinformed patient who has to be re-educated than an uninformed patient who feels totally powerless over his own health.

        It is America’s litigious climate, not showbiz, that is the cause of defensive medicine.

  19. paul says:

    riiight… you discuss the risks, they decline the scan, you document as such and…

    if something is “missed,” they still sue anyway.
    little johnny with the missed brain tumor gets trotted out in front of the jury, and suddenly all the documentation in the world means jack squat.

  20. Dan says:

    Same way with defensive medicine. If you track all of the patients in multiple emergency rooms, you’ll find the occasional person who really isn’t suicidal and really does have a chemical imbalance.

    The alcohol swab is cheap. The MRI is not cheap.

    The X-ray could show a shadow that they do exploratory surgery to diagnose.

    Diagnostics are the monster of modern medicine.

    • Peter says:

      So, shall we run the numbers?
      The scenario is: patient walks in to the ER. They either have disease A (99%) or B (1%). If they have B, but you diagnose A, the cost to the country (lost wages, death etc) is $100,000. How expensive can the test b, and still be worth it to the country?

      Answer: about $1000.

      This is less than the cost of an MRI, and less than an XRay (at least according to Google)

      I’m in the software business. Most of my time is spent in “defensive” practices (“do we ship with any bitmaps that include text”, “do we include a EULA”, “have all the developers taken a course in software engineering”, “do you do this”, “do you do that”…. just endless) Why? Because getting one wrong is more expensive than the work to make sure that it’s right.

    • Family Doc says:

      The thing is, even if the tests are positive a lot of the time it doesn’t change the treatment. Say, for instance, the 93 year old had a new stroke. We’re not going to anticoagulate her. She’s probably already on aspirin. It doesn’t change anything. Lots of times people like this get an MRI too, just in case she had a stroke that wasn’t seen on CT. It doesn’t change anything, yet again. So even if the tests are positive, a lot of the time it wouldn’t change management anyway.

  21. Steve says:

    Paul- You gave a 60 year old on Coumadin Toradol???

  22. trinlayk says:

    Years ago, I showed up at the ER at 2am Saturday morning with my young child in tow…

    I was dehydrated from both ends, and had abdominal pain. I had driven myself there, (no choice) and wasn’t convulsed in pain… so they said “something viral” and sent me home. no tests, just something for the nausea, rehydration.

    I had a ruptured appendix, and a few days later was in a different hospital (having collapsed at work) for over a week.

    Apparently, my pain threshold is not “normal” PERHAPS in part because I’ve had chronic rather intense pain most of my life… and had to function anyway.

    so yeah, run the extra test, _I_ can’t tell you it might be my appendix, I’m not a doctor.

    • WhiteCoat says:

      So you wouldn’t have any problem with your young child getting CT scans every time he or she has abdominal pain, vomiting and diarrhea so that the radiation dose builds to the point that he or she will likely develop cancer from the “extra tests” later in life?
      Or what if the “extra tests” are abnormal for another reason and your child goes through an unnecessary surgery to find that his or her appendix was fine?
      Then what if your child had a bad reaction to the anesthesia and dies from the unnecessary surgery?
      Still OK to do the “extra test”?

      • jc says:

        Yes, still okay to do the extra test. My appendix blew out also, after repeated trips over a three week period to a gastroenterologist who told me I didn’t “look sick enough” to have appendicitis.

        Why are you all so huffy about listening to the patient? You see us for 10 minutes; we live with out bodies 24/7. Every doctor I’ve told my medical history to says, “Oh, so you didn’t go to the doctor soon enough” — but no, that gastro had multiple bites at the apple.

        Instead of owning up to your own shortcomings as highly educated humans, why do you look down on the patients as a bunch of stupid whiners? If you’re burned out on working with patients, maybe research would be a better field. I admire and appreciate my doctors — I wish they felt same about me.

      • trinlayk says:

        It was NOT my child that was sick, it was ME…

        I knew I was more than ordinarily ill and got sent home having been treated like a cry-baby/frequent flier.

        THEY DIDN’T even do a white cell count, so never mind whether a CT would have been excessive, they didn’t test to see if I DID have a serious infection going on.

  23. TONI says:

    Med-Surg nurse to MD. How about defensive calling from RN. To make sure we notified the MD about every little thing even though I know it’s not life threatening and a burping sensation doesn’t mean your having a MI!

  24. WC:
    Do you know, or does anyone know, a medical economist who has put a reasonable dollar amount of the cost of defensive medicine? I propose that if we had true, published standards of care, including but not limited to workups for suspected problems, under which if a physician operated he could not be sued, even if there was a bad response. That is not to say that the physician couldn’t do an extra test if he felt is necessary. But if we had SOC rules for workups, how much could we reasonably expect to save? Any ideas?

  25. Rogue Medic says:

    Peter, in 2 different comments, makes some suggestions that demonstrate a lack of understanding of medicine.

    1. Why is my skin always swabbed with alcohol before I get stuck? My skin is “usually” clean, and even if it weren’t I “probably” won’t get sick, and even if I get sick I “probably” won’t die.

    There are bacteria all over your clean arm. You have an excellent barrier to infection – intact skin. Once a hole is placed in that skin, by sticking a needle through to a vein, the risk of infection increases, not a little bit, but a lot.

    When it comes to infections, dying has nothing to do with it. Hospital acquired infections prevent the hospital from billing for your care. Then there is the legal cost of defending the harm done by introducing infections into all of these patients.

    You may have read about MRSA infections. Not a small cost, but MRSA is killed by poison. That is why we rub poison on your arm – to kill the bacteria. Yes, alcohol is a poison.

    2. So, shall we run the numbers?
    The scenario is: patient walks in to the ER. They either have disease A (99%) or B (1%). If they have B, but you diagnose A, the cost to the country (lost wages, death etc) is $100,000. How expensive can the test b, and still be worth it to the country?

    Answer: about $1000.

    Medicine is not binary. It isn’t a choice between disease A and disease B, between alive and dead.

    You presume that the test answers the question definitively. To that the answer is a big Maybe.

    For example, PE (pulmonary embolus). As Glyph wrote, there can be a PE, but what does that mean? How does that change treatment? Even having the diagnosis may do nothing to change treatment.

    To run the numbers:

    A. You have a pain in your back, that could be a PE. Your treatment already includes anti-coagulation. Your symptoms do not warrant any change in that treatment.

    B. You had an expensive test that did not change any of the stuff written in A, but now you have documentation.

    Are you any safer? No.

    Will it change treatment? No.

    C. The expensive test is inconclusive, but now that you have started to do these expensive tests, why stop? Let’s keep going until we run out of tests. Then, maybe we should repeat the tests, just because you can’t be too careful.

    You also forgot to include perhaps a dozen other factors in your cost analysis.

    • Peter says:

      Certainly, analysis is what’s needed. My analysis shows that it’s plausible for a doctor to grumble constantly at “defensive medicine” and yet be totally wrong.

      Your analysis says that the doctor might be right.

      Where do we go from here? Answer: a giant, carefully designed, chock-full-o-data analysis. Got a couple dozen million dollars lying around?

      • Dan says:

        The answer is evidence-based medicine. Mayo Clinic and the VHA both do giant amounts of data analysis (and share them with the public) to figure out what tests and procedures will actually benefit their patients.

        If I sound like I’m fans of those two institutions, it’s because I am. Patients there don’t get more care, they get better care.

  26. [...] Defensive Medicine at Work (WhiteCoat’s Call Room) [...]

  27. Matt says:

    “Many physicians are afraid to practice rational medicine based upon clinical judgment and physical examination skills. No one wants to face the liability.”

    Here’s the rub though – you don’t know if anything you did actually reduced your liability exposure. So it’s not really

    The other thing is that it doesn’t appear that any of the tests were actually truly unnecessary.

    And perhaps most telling, and indicative of why medicine’s economics are so troubling – you don’t appear to have ever given the patient the option to decide. Why? Because you know they aren’t actually paying out of pocket for them. The disconnect has given you no downside for ordering the test – you get paid for it and it costs the consumer of the test no more money to get it.

    That’s not “defensive”, it’s a flaw in the system that doesn’t reward you for your skills. “Defensive” medicine – ie medicine done to avoid the risk of liability, remains undefinable, because you don’t know if your liability is actually reduced by each “unnecessary” test you order.

    • WhiteCoat says:

      You are absolutely mistaken, Matt.
      Actually, you’re partially right about “downside.” Physicians have little “downside” to obtaining a test. Perhaps they get labeled as an “overutilizer,” but that’s about it.
      However, patients may have significant “downside” including expense (not all patients have insurance), inherent risks of the testing (radiation, dye load, operative risks, etc), and the added morbidity of chasing “false positive” tests “just to make sure” that something doesn’t exist.
      It also significantly affects the “consumer” in that the money spent on low yield testing is then not available for things like immunizations, basic medical care, and basic dental care – all of which are lacking throughout the country. Medicaid cuts will restrict the access to these basic medical needs even further.
      I’m glad that retrospectively you can say that the tests weren’t “truly necessary”. Since you appear to be well versed in the necessity of diagnostic testing, why don’t you give everyone a *prospective* rule on when it is and is not necessary to obtain x-rays in trauma, when it is and is not “necessary” to obtain cardiac testing in elderly patients who pass out, and when it is and is not “necessary” to obtain CT scans on patients who sustain minor head trauma. Assure me that I won’t incur liability for “missed diagnoses” if I follow your rules.
      If you can’t do that, and I’m sure that you won’t, your opinions about what tests are and are not “necessary” are nothing more “Monday morning quarterbacking” that you use to advance your own agenda at the expense of others who no longer have access to medical care because of defensive medical testing.
      So I’ve laid down a challenge that I know you won’t accept. Instead, you’ll raise issues not germane to the challenge and weasel around the issue without answering the questions.
      Then everyone who reads this blog and who reads “Overlawyered.com” will know that you are just blowing smoke.

  28. Matt says:

    “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.”

    By the way, how is this “defensive medicine”? It’s a patient asking for something they’re willing to pay for (you gave no details about that part so I’m assuming she or her insurer did pay for it). You advised that you didn’t think it was necessary, you presumably advised her of the risks, but she wanted it anyway and would pay for it. What’s the problem?

    How exactly will any of the proposed “solutions” to the “defensive medicine problem” change that example?

    Again, “defensive medicine” remains undefinable.

  29. Family Doc says:

    Matt, the problem with a patient demanding an unnecessary test is that he or she does NOT pay for it. If the patient pays in cash, that’s fine with me to do an unnecessary test. However, the insurance pays for it. Every test paid for by insurance leads to a premium increase for everyone else who has insurance. So the truth is that we are all paying for the unnecessary tests. I imagine that if we started demanding people pay cash for unnecessary tests, the number performed would decrease markedly.

  30. vinal says:

    And these are probably the same people that complain when their health insurance premiums are raised each year.

  31. Matt says:

    “However, the insurance pays for it. Every test paid for by insurance leads to a premium increase for everyone else who has insurance.”

    Actually, that’s not really true at all. Insurance premiums are determined by a variety of factors, including regulatory environment, investment profile, and the real estate and stock market.

    We’re not all paying for “unnecessary tests”. Number one, if you’re billing someone for it and it’s truly unnecessary you’re committing fraud. And the insurer is going to be watching for this anyway and will start rejecting payment, and you can make them cash.

    But if you want to go to a cash basis, that’s on you providers. Do it and the people will follow. Most other professions do.

  32. Matt says:

    All that said, I still don’t understand how that episode is “defensive medicine”, under any definition you want to try and apply to the concept.

  33. Family Doc says:

    Matt, every year my insurance premium rises. And every year the company sends out a letter stating that they must increase the price due to increased costs due to increased costs of and use of services. So I really don’t buy into your idea that insurance premiums have to do with the stock market. And honestly, do you really think that everyone demanding CT scans and MRIs wouldn’t affect your insurance rates?

    Also, the thing about unnecessary tests is that one can always make an argument that they are necessary. As others have mentioned, people have a different tolerance for missing uncommon diagnoses. Most people don’t do tests that are entirely unjustifiable. But some people say if there’s a 1 in 1000 chance of missing something, they’re comfortable with that. Others are not. We as a society need to come up with a way to decide when it’s acceptable to miss that rare diagnosis, and what amount we’re willing to pay for it.

  34. WhiteCoat says:

    Those who don’t believe that “defensive medicine” exists still have failed to answer my initial question:

    Tell me which “bad outcomes” are OK to miss in the absence of exhaustive diagnostic testing.

    It seems that you would advocate exhaustive workups on every patient complaint. If that is that case, explain why medicine is full of studies that determine “risk stratification” – i.e. whether a patient is “low risk” or “high risk” for a given complication based on given clinical or laboratory findings. Using your definition, everyone needs exhaustive testing for everything, so why bother risk stratifying patients?

    If you don’t believe that exhaustive workups are necessary, then explain how to different “necessary” from “unnecessary.”

    I look forward to an explanation so that we can put this issue to rest.

    • Matt says:

      You misunderstand the basis for the “defensive medicine” argument. The whole thing is a lobbying phrase used to push tort reform, nothing more. But how can you say it exists until you accurately define it. So far you have yet to do that.

      I do not in the least advocate exhaustive workups on every patient complaint.

      • WhiteCoat says:

        You have such a wealth of information about all these aspects of medical testing, but you can’t “Google” the term “defensive medicine”? Or is it just that you don’t *want* to do so?
        Here’s one definition:
        “Medical practices designed to avert the future possibility of malpractice suits. In defensive medicine, responses are undertaken primarily to avoid liability rather than to benefit the patient. Doctors may order tests, procedures, or visits, or avoid high-risk patients or procedures primarily (but not necessarily solely) to reduce their exposure to malpractice liability. Defensive medicine is one of the least desirable effects of the rise in medical litigation. Defensive medicine increases the cost of health care and may expose patients to unnecessary risks.”
        So your argument is that low-yield and CYA testing doesn’t exist?

        You say that you don’t “advocate exhaustive workups on every patient complaint.” So give some examples of complaints that don’t require exhaustive workups.

        Just like I predicted above – you tapdance around the issue without answering substantive questions. You just pose more irrelevant questions and unsubstantiated factual assertions.

        Your credibility is crumbling along with your “arguments.”

  35. Matt says:

    “And every year the company sends out a letter stating that they must increase the price due to increased costs due to increased costs of and use of services.”

    That’s simply incorrect. For many physicians, during the boom market of the 90s, insurance rates declined as the market got flooded with new companies looking to grab share and profit on the float. You can easily verify that.

    “We as a society need to come up with a way to decide when it’s acceptable to miss that rare diagnosis, and what amount we’re willing to pay for it.”

    Identifying problems in health care is easy and everyone does it. What’s your solution?

  36. [...] an emergency physician, is nearing convinced by those who baptize defensive medicament a figment of the medical talent’s [...]

  37. Matt says:

    ““Medical practices designed to avert the future possibility of malpractice suits. In defensive medicine, responses are undertaken primarily to avoid liability rather than to benefit the patient. Doctors may order tests, procedures, or visits, or avoid high-risk patients or procedures primarily (but not necessarily solely) to reduce their exposure to malpractice liability. Defensive medicine is one of the least desirable effects of the rise in medical litigation. Defensive medicine increases the cost of health care and may expose patients to unnecessary risks.””

    That’s not a definition, that’s a supposition. Why? Because of the examples you cite above. Again, how does the old lady who wants and pays for an additional test constitute “defensive medicine”? You didn’t even order it for her!

    You gave me several examples of complaints that don’t require exhaustive workups, including her. You went ahead and did them in some cases, but here’s the thing about that: You don’t know if it actually did reduce your exposure, and if it did, to what degree? What’s more, you can’t actually say they were truly unnecessary – at least you can’t and still get reimbursed by the party paying.

    You don’t need to be rude, I’m not tapdancing around anything. I’m quite clearly saying that you are using a phrase that you have applied to literally everything you disagree with, rendering it so broad that it is meaningless. The term literally only means whatever this or that physicians says it means. So its usefulness to a policy discussion is quite limited. It’s a term most likely invented by insurance lobbyists, so is there really any surprise that it’s not one with a firm definition?

    • Dan says:

      Do you at least see the perverse incentives in giving 200 x-rays to the population in order to find one ailment? Because those 200 x-rays will stochastically cause cancer in some number of the patients, but a lawyer can’t point to the specific x-ray that caused cancer and so we all end up sicker.

  38. Matt says:

    Dan, here’s where we disagree. You can’t show me that giving those 200 xrays actually did reduce anyone’s liability. Nor can you give me the statistics that everyone getting one more xray increases our chance of cancer X percent. Perhaps if the public knew that getting that Xray increased their chance by .0001 percent of getting cancer they’d say its worth it to find out what’s wrong with me. And perhaps giving those xrays in this or that situation didn’t reduce your liability exposure at all.

    That’s the real question – why are physicians making treatment decisions based on fear of liability when there is no statistical analysis as to whether their liability is actually reduced? Are barely understood and factually minimal anecdotes really the best basis upon which to make medical decisions?

  39. jc says:

    I pay for a lot of my medical care out of pocket and do so happily. I don’t like it at all that doctors are making diagnostic and treatment decisions based on not running up my insurance premiums.

    Let me worry about the cost; you worry about not killing me.

  40. [...] stability of our health care system and the treatment we receive as patients. In a few articles on Emergency Physicians Monthly(EPmonthly) and at KevinMD.com , both physicians discuss the resulting “Defensive [...]

  41. [...] even worse, a loved one is in pain, we’re far less rational consumers.  I’ve mentioned before White Coats’ post on his own daily prompts to practice defensive medicine and provide care that he, as a doctor, thinks is likely unwarranted.  The most obvious of these [...]

  42. David says:

    WOW it looks like you single-handedly wasted just a ton of taxpayer/insurance company (consumer) money. Doesn’t your department have any protocols on cardiac complaints at all? Is this confession admissible at your utilization review hearings? But I bet the folks in radiology aren’t complaining.

    Lest we scientists begin to forget, this post proves nothing, other than fearfulness of one physician.

  43. [...] Health care reform is a cultural and political problem more than a medical or economic one. In Canada and Europe, they are getting no frills Beetle that gets you from A to B 90% of the time. That’s why their systems are cheaper, but that wouldn’t fly here. The American culture expects (or has been conditioned to demand) the best possible care (decreasing benefit) as soon as possible (increasing cost) paid by someone else (employer or government) and sues if the outcome isn’t acceptable (defensive medicine). [...]

  44. Richard says:

    I just watched a British documentary on the effects of low level radiation. Apparently, radiation in low doses over a prolonged period of time does NOT increase the risk of cancer, but actually may be beneficial to dna based organisms in preventing cancer!
    I believe it was titled “the nuclear nightmare”
    Animals trapped in the area around the former nuclear plant almost twenty years after Chernobyl show no adverse effects even though their preserved skins are still radioactive.
    Sure, all of the first responders in the accident died of radiation poisoning, but in total less than 60 people who were living near the reactor at the time of the accident have died as a proven result of exposure to radiation.
    There is no evidence to demonstrate that airline or military pilots (who are exposed to a crapload of radiation during their service lives) have any higher cancer incidence than the average person.
    Other examples were given but you get the drift…go figure!

  45. Our ER docs tell me that 70% of their CT scans are defensive. C section rates used to be 14% and now are 30% plus. End of life care can’t be refused because of fear of a suit from a family member. We biopsy people and follow them closely because we fear missing something . I think this adds up to 20-25% of all medical costs and could be mostly saved by changing lawsuits to arbitration, health courts, panels, or a workers’ comp like system or a combo of these. The injured pts would be compensated more quickly and the lawyers wouldn’t have to get 30-40% of an award.
    Food for thought and reform

  46. Jan says:

    “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.”

    Actually what has changed is the expectation that you do the most cost-effective approach rather than the best approach for the patient.

    In most of your examples the additional work-up did benefit the patient by ruling out a possible complicating factor. It may have only been a one in ten or one in a hundred chance that you ruled out, but it was not zero (except in one or two cases).

    It used to be that dr’s would want to rule out these possibilities. Now the insurance co’s have so fouled up our ideas of what medicine ought to be that we can’t even see that point of view any more.

    As your potential patient, it is certainly my opinion that most of those tests would have been in my best interests.

  47. Hunter says:

    I’m a first year medical student, and the reason I’ve read this article and all these comments is because I am worried that I will allow Defensive Medicine to interfere with my future practice.

    I’m afraid that if I allow the fear of litigation to run my practice, I will cause unnecessary harm and discomfort to my patients (radiation, invasive diagnostics, over medicating, etc). I’m also afraid that if I don’t exhaust my differential, I might miss something and allow harm to come which I was in a possition to prevent. And yes, I’m afraid for myself and my family if I were to be sued.

    In reading these comments, both physicians and patients are on both sides of the issue. Some physicians are on the “unnecessary harm” side, and some are on the “don’t miss it” side. Others, I’m sure, are mostly concerned with protecting themselves which is completely understandable.

    Some patients want the (perceived) absolute certainty of such and such being ruled out. Others probably avoid getting checked up for as long as possible because they don’t want $1200 scans that everyone knows will likely be normal. And, perhaps, a few patients are looking for a buck.

    So what should I do? My default instinct is to cover my own butt and worry about myself before I worry about the patient. But I AM worried about the patient. After some thought, it seems to me that the best option is to present the patient with your knowledge and clinical assessment, then discuss the tests that will rule out the less likely diagnoses and allow the patient to decide.

    I’m only 6 months into my medical training, and perhaps I’m missing something, but this seems like a fairly simple solution. Wouldn’t it free the practicioner from liability? Wouldn’t it allow the patient to decide if they want to pay that enormous bill, or if they want to take the chance that something improbable will be overlooked? Shouldn’t they decide if they want to risk the adverse effects of additional diagnostics? Doctors are employed by patients, so it shouldn’t really be my decision at all.

  48. cory says:

    Maybe I’m missing something.
    I’ll assume that in every example the test you did that was negative was unnecessary -though I’m not sure and there is no way for us to tell (i.e. we didn’t see the patient, perhaps one of those X-rays or CTs might have clearly had an indication).
    But here’s my point -suppose one test was positive and had launched a lawsuit – wouldn’t the costs be far higher than what was expended? IF you missed a subdural in the anticoagulated patient with head trauma the answer almost certainly would be yes.
    IF you “know” something is normal then you should have no problem in not doing it- with the full knowledge you are taking the consequences (missing a small fracture may have far fewer consequences than missing a subdural) and offering that as your defense if you turn out to be wrong.
    Yes, that means taking some risk – and potentially the costs in a the first phases of a lawsuit.
    But what exactly is the alternative- you can put in legislation to deter some suits but if you make that too onerous, patients will be hurt – and medicine will suffer.

  49. MultipleFactors says:

    Cory,

    The costs of a lawsuit would be higher than the cost of the test for that one patient, yes. But not necessarily higher than the sum total cost of that test in the 1000 other similar patients that it takes to find that one patient with a positive result. And possibly one(or more) of those other 1000 patients are harmed in someway(renal failure through IV contrast, future cancer from radiation exposure, actual contrast allergy, some ditzel is seen on the CT that leads to future CTs and/or procedures to further characterize the ditzel which 2 years and countless dollars and lots of worry and maybe a cool new scar later is nothing, etc. All of these f/u procedures have their own risk as well. Where does one draw the risk/benefit line? Does money play a role? Sure. But absolutely also playing a role is the how many people do I cause harm to by doing this test to find the one positive result?

  50. Ben says:

    Hunter,

    Your solution is impractical, as you will learn when you start your clinical rotations in 2 years.

    Sometimes your patient will be able to understand your explanations and the choices you’re offering. Sometimes you will have the extra time to explain all the ramifications of the choices. But not all the time, not even most of the time, not even very often.

    On top of that, most patients don’t want to make the choice. They want the doctor to decide. Hopefully, within a few years you’ll be experienced enough that your abilities will justify their trust in you.

  51. medical news, medical students, medical forums, medicine, clinical trials…

    [...]Defensive Medicine at Work | WhiteCoat's Call Room[...]…

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