A little light reading about defensive medicine

A personal example: appendicitis. I was nearly alone among surgeons in my community, in wanting to see the patient before deciding if a CT was needed. Virtually every other would hardly take a call from the ER if the study hadn’t already been done. I felt that in the vast majority of cases, the diagnosis could be made on clinical grounds. And yet, in seeing a patient and diagnosing appendicitis, and recommending surgery absent a CT scan, I always felt a bit “out there,” and always felt the need to let a patient know it could be ordered and that in fact most would order it. It was, I’m happy to say, a rarity that a patient requested it after my full explanation. What’s the point? You tell me. I can’t figure it all out.

Steve,

I’m sorry you are having a bad time of things. My undergrad degree is in economics. One of the central tenets of economics is you can predict the behavior or groups of people (not always individuals) by the financial incentives they are exposed to.

You might be interested to know that when a doctor orders a test like blood work, radiologic tests, or a referral to a specialists, they do not get extra money for that. There is a law called Stark or the anti-kickback law that prevents that.

The reason that doctors over-order tests is to reduce the small, but non-neglible risk that they will be sued for an unexpected outcome. You could make the argument that this is financial in that if the lawsuit is big enough it may exceed their insurance limits. My personal view is that it is very painful for most doctors to be told that they did a bad job and used poor judgement by a group of their peers. In economic speak, there is a greater disutility in missing a rare disease than by ordering many extra tests.

The cost/benefit analysis gets a little muddy when the tests aren’t benign. It is very rare to have a dangerous reaction to a blood draw. It is not rare to have a stroke from a cardiac catheterization, which is sometimes ordered for a positive stress test, which can sometimes be a false positive. This is often cited as the classic example. If someone presents to your office asking for a screening stress test the answer is no (for non-diabetics) because by ordering the test, there is a real chance you could harm them.

Until the current culture of perfect success is revised, this incentive will always exert influence on decision makers. I’m sorry you have had problems with this. I think the short length of time you spend with your physician is really a separate issue. Another separate issue you bring up is diagnostic acumen related to the history and physical. I can promise no physician is 100% accurate in their assessment of pneumonia from their physical exam. (their is clear data to support that claim). The issue is really how best to avoid a lawsuit without exposing your patients to physical harm. (convenience to the patient is obviously not considered here.)
b

It seems to me that we are in an unfortunate position where the actions of physicians are being dictated by the insanity of the tort system (Canada, by the way, isn’t that far behind the US). The economic assessment above has been demonstrated to be true, and it is (most likely) providing a disservice to patients.

In an ideal world, testing would be governed by Bayes theorem – using pre- and post-test likelihoods. If the test doesn’t substantially change the likelihood of disease, or won’t substantially change your course of action, then you shouldn’t do it. If the answer to either of the above is affirmative, then it becomes a risk/benefit assessment.

Of course, this would also presume that we as physicians (mainly specialists, of which I am one, so I will take responsibility for this too) will stop crapping on those who stand at the front lines (ER, primary care, etc) and don’t have the same luxuries of time, and information such as past history. For each “missed” diagnosis by an ER doc, there are probably 50-60 emergencies that were handled brillliantly and concurrently on the same night by the same doc (not to mention all the other nights and docs that go by un-noticed).

Defensive medicine doesn’t make for happy or effective physicians.

So if you’re all doing all this extra defensive medicine as you claim, is it working? According to physicians, more of them get sued than ever, so clearly it’s not.

Have you done the actual risk/benefit assessment?

And what policies do you believe would reduce defensive medicine? Given that according to the Studdert study, juries get it right the vast majority of the time and in fact favor the physician mightily, what percentage of correct findings from an alternate system would reduce defensive medicine? Do you agree with the findings of your medical review boards 100% of the time? Those are committees made up of experts, are they not?

Dear CFM,

I think you just called all doctors prostitutes. I take great offense to that. I would never order a test that had no value to the patient just for “further office visits for further evaluation”. Additionally, you insult the patient themselves by assuming they are so naive they would fall for that. In my limited (5 years) experience, if you spend time explaining why you are doing something the patients understand 99% of the time.

Additionally, if you make patients come back 4 times a year to check their TSH for their hypothyroidism they will leave you. There is no reason to do this. This may work for supersubspecialists who treat rare diseases, but when a patient hears their friend only has to see the doctor once a year for their well controlled hypertension and they have to see you 4 times a year, the wheels of logic start rolling.

I am not an economist. I am an internist.

The specialists very rarely send primary care doctors patients because the people that see the specialists were usually sent there by someone else. I’ve found that the “I’ll wash your back if you wash mine” mentality is not as prevalent as you might think.

It is clear you are speaking outside of the profession and don’t have the benefit of day to day exposure to understand these points. I would encourage you then not to flame the fire of suspicion when you have no data on the subject. Conspiracy theories are fun to talk about, but you shouldn’t use them in an argument, as it makes you look silly.
b

As a vascular ultrasound tech I can say that defensive medicine definitely exists (the ER docs have even told me so, after my 3rd callback of the night to do another BS LE venous duplex)

The funny thing is that we passed tort reform in this state 2 years ago (or was it 4?) and I haven’t noticed a difference at all. Yet the ACEP rates us as one of the best states to practice in with respect to torts. -shrug-

I still love medicine (see previous posts on med school aspirations), but sometimes the “business of medicine” can really piss you off (whether you’re a patient or healthcare provider).

-Dan

One last point,

Steve,

I think you have illustrated a point that is uncomfortable. most patients do not understand how their doctor is paid. In the past, the doctor would give you a bill and you would take that to your insurance company and depending on the kind of contract you signed, they would pay a certain percentage of that. This was called indemnity insurance. You knew what you were charged from the bill.

Now, in most cases, there is a third party payor. This is someone that the patient contracts with and the physicians bill directly. Medicare works the same way. The problem is that it isn’t always obvious with EOB (explanation of benefits) what the charge was for and who charged it.

When people are charged alot of money and it isn’t clear where it came from the natural tendency is to be mistrustful of everyone involved including the doctor, the insurance company and the hospital.

I don’t know any physicians who get paid for taking phone calls or for signing off on charts without examining and managing patients. In my group, call is 1/4 nights and weekends and we get paid only according to how many patients we admit to the hospital. The fee we collect is related to how sick and complex the patient is. If the ER calls me and says they saw Mrs. Jones and discharged her and that I should see her the next morning in my office, there is no one for me to bill for that. Insurance companies and medicare do not allow that billing. When I had a patient wake me up one morning at 7AM on Sunday when I was on call complaining that she was tired, I had no one to bill. (and was unsuccessful in explaining to her that what she was doing was misusing my time and good nature by calling the emergency number with a non-emergency issue)

I suppose there might be some physicians who work directly for an insurance company who might have some productive formula that includes phone calls, but I’ve never met them. There are nurse prationers and nurses who get paid by their doctors to take call as a way to screen people, but the doctor digs out of his own pocket to pay them. Call is not a revenue generating activity.

Hospitals and emergency rooms sometimes have to pay specialists to take call. Perhaps that is what you have heard. Most of the general surgeons I’ve spoken to explain that the patients who come in unassigned (and without insurance) far exceed the patients who have good insurance and can reimburse the surgeons for the 3AM acute abdomen. (general surgeons, you are my heroes).

In business you always want to know how your advisors or investment managers are paid. That will affect their decisions with regard to your money. The same is true for any other endeavor. In general, if you are working with honest physicians (and CFM is right, I can’t telll you what percent of doctors are honest), they charge you according to direct contact, for a procedure performed, or for a study interpreted. To do otherwise would be stealing. You may not realize this, but your insurance company has certain checks and balances against overcharging you. They don’t do this to help you of course, but to increase their profit.

Sorry this was so disorganized, but the more transparent the pricing is, the more people trust each other. I think that the doctor patient relationship has sufferred recently from a lack of trust.
b

That is an interesting point that there is a specific teaching that one should CYA. There is a fine line between CYA and looking for a rare disease, no? If you find a rare disease, you are a great doctor. If you test without finding a rare disease you are a waster. If you don’t test and miss the rare disease, you are a goat. Don’t we all want to be winners? That is the problem, it isn’t just about covering your ass. To some extent it is about providing thoughtful care. It is just hard to know where to draw the line.
b

Why would health courts be any more sensible with regard to correctly determining fault? When every nonpartisan study of the current system concludes, as Mr. Studdert did, that:

““Some critics have suggested that the malpractice system is inundated with groundless lawsuits, and that whether a plaintiff recovers money is like a random ‘lottery,’ virtually unrelated to whether the claim has merit,” said lead author David Studdert, associate professor of law and public health at HSPH. “These findings cast doubt on that view by showing that most malpractice claims involve medical error and serious injury, and that claims with merit are far more likely to be paid than claims without merit.”

Health courts are backdoor damage caps. Nothing more.

CJD,

I’m late to this party but you’ve pulled so much pro-malpractice crap straight out of your ass that that you alone have stunk up the room enough to push everyone else out. If only malpractice lawsuits were correlated with actual wrongdoing.

Here, I’ll give you a very basic example. Neurosurgeous and ob-gyns are sued at about 100 times the rate of other docs in low-risk specialties like psychiatry. So does this mean that neurosurgeons and baby-deliverers are 100X as incompetent as shrinks?

No– it means that they’re in higher-risk specialities that inevitably expose them to higher liability, even though their level of training and ability is much higher. Yet our med mal system and the self-fellating idiots who call themselves “medical malpractice lawyers” have no concept of this.

Any sensible malpractice system would basically be no-fault and provide for the financial needs of patients with adverse outcomes– the way e.g. Sweden and the Netherlands do it– rather than indulging in this bullshit system that pits patient against doctor as adversaries, which benefits nobody but the malpractice trial lawyers. Until states like New York and Pennsylvania feel real pain for their stupidity, this won’t change.