[NPInfo] Defensive medicine

[Jeffrey Hazzard]

    Hello again!
   
        Do we live and work in the same universe?  I am astounded that the culture of practicing defensive medicine is so ubiquitous here in Florida, and seemingly not part of the lexicon and practice model of providers in other states.  Wow!
   
        In the big picture, it is probably true that more money is spent on the insurance premiums of needless tests than on professional malpractice premiums, litigation, and judgment award payouts combined.  But who is willing to risk the odds?  Not me.  Not anyone I know.  The only acceptable defense is, "Yes, I thought of it and ruled it out."  Being wrong or making a mistake is not acceptable.  When you have such a high standard of professional practice, hanging over us like a gullotine every day, the decisions are based on fear, not science.  I admit it.  I am afraid that using my common sense is going to cost me.  It is not fraudulent to think of a legitimate diagnosis, though a somewhat less likely one, and then to rule it out.
   
         I don't think your notion of "doing only the tests that help make the medical decision in the differential diagnosis" is wrong.  I just think the differential diagnosis in Florida has a lot more striped horses (ZEBRAS) than it does in your state.  Here, it is pretty well accepted that there are no acts of God, nor grace from the wronged party for a mistake, nor an acceptable risk of missing a diagnosis, failing to arrange for proper follow up care, or delaying an appropriate timely referral.  We don't even do same-sex hernia checks without a witness.  I would estimate that a Florida ER of 50,000 census does $2,000 in low probability tests per hour.  And the average primary care provider does $150 in low probability tests per hour.  
   
        My guru, a very competent Florida family practice doc with 30 years experience (who has been sued twice) told me, "If you think of it, order it.  Be good to every one.  Remember their humanity.  AND DON'T EVER MISS ANYTHING."  So far, I have done all those things.
   
         Not to be disrespectful, but you and the author of the article below don't live in my (our Florida) reality.  The reality here is that needless tests are ordered every day by lawyers.
   
              Jeff, Tampa
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     The so-called 'CYA' testing(s)/Labs/etc. are not
 necessary, are not the
standard of care, and are wasteful.  Statistically
 testing/labs/etc. which
are done, particularly if done to cover one's a--, are
 in and of themselves
an even greater source of litigation than not doing
 uneccessary tests/etc. -
that is a fact.  With surprising frequency, all those
 extra CYA
tests/labs/etc. will actually serve as useful evidence
 against the
practitioner. Further, ordering uneccessary
 tests/labs/etc. could constitute
health insurance or medicare fraud!  Such practices
 could also stimulate
patient complaints against a doctor to the Medical
 Board (not that they
would care, they are all pretty much Teflon coated).

Picture a physician in a deposition, either as a
 witness or as a defendant:
Question(s) by Plaintiff's Counsel:  Well, Doctor, you
 ordered all of those
tests, all of those labs, spent all that extra money -
 Doesn't that show us
that you knew that there was a problem?
You would not have spent your patient's money like
 that, several thousand
dollars, if there wasn't a problem would you?
Next Q:  After ordering all of those tests/labs/etc.
  you did not carefully
review each of them did you?
Next Q: You did not call the patient back to review
 all of the results with
her did you?
Next Q: You spent how many $$$$ of my client's money,
 and you still missed
x, y, and z?  Isn't that the plain, simple,
 uncontrevertable truth Doctor?




Here's an interesting article:

January 10, 2006
On the defense? Not exactly.
Yesterday I wrote my first post on Tom Baker's book
 The Medical Malpratice
Myth. I talked about how the number of people injured
 every year is
drastically larger than those who bring suits, as well
 as the fact that all
malpractice spending (premiums, legal representation,
 awards, etc) amounts
to less than one half of one percent of all health
 care spending.

A commentor was keen to pick up on another malpractice
 talking point -- the
notion of "defensive medicine". So where does
 defensive medicine fit in the
malpractice spending puzzle?

As far as we can tell, "defensive medicine" is one of
 those tiny puzzle
pieces with the really strange shape (you know, the
 one that seems to have
2.5 sides?) -- you can't figure out where it goes
 until you've trudged your
way through the majority of the puzzle.

That's because defensive medicine is notoriously
 difficult to study. First,
researchers have to decide what constitutes defensive
 medicine. Then they
have to tease out whether the effects of those actions
 were harmful or
helpful. Given the fact that 100,000 people die per
 year because of medical
error, some instances of defensive medicine will be
 helpful because they'll
help reduce that number. Others will simply be
 unnecessary tests or more
invasive procedures to ensure "certainty", leading to
 increased spending and
even more risk.

The research that has been conducted indicates, for
 the most part, that
defensive medicine has little effect overall and that
 states with tort
reform have slightly lower rates of spending than
 those without. But one
thing is clear -- malpractice fears aren't sending
 shock waves through the
system.

. In a clinic scenario survey by the Office of
 Technology Assessment, where
doctors were given a situation and asked how they
 would proceed, researchers
calculated that 95% of doctors did nothing but order a
 test or diagnostic
procedure. The principle reason doctors gave for
 ordering the procedure
"almost all of the time" was medical indications.
 "Malpractice concerns"
were given as a reason in less than one half of one
 percent of the cases.
OTA researchers concluded defensive medicine is "not
 likely to explain very
much of the huge growth in health-care expenses over
 the last century".

. Researchers at Syracuse examined birth records and
 compared cesarean
delivery rates according to the number of malpractice
 cases per county. They
found that in places with a higher malpractice risk
 that there was actually
a slight decrease in c-sections.

. Harvard researchers compared cesarean rates to the
 actual hospital rates
of malpractice suits and found that, controlling for
 all other factors, a
woman who gave birth at a hospital with high
 malpractice rates was 30% more
likely to have a c-section. Except researchers also
 found that giving birth
at a hospital with a high c-section rate (and not
 necessarily malpractice
rate) increased the risk of having a c-section 10
 times.

. Mark McClellan (current secretary of CMS) found that
 heart disease
expenses for the elderly grew only 5-7% less in state
 with tort reform
(expenses grew 24% per year in non-reform states, and
 17% in reform states)
, and that the gains seemed to decrease after 5 years.

This research shows that, when researchers have been
 able to puzzle out ways
to measure it, they found very small rates of
 increased spending and
intervention due to "defensive medicine".

The bottom line is that while the evidence isn't
 crystal clear that
defensive medicine plays no part, there's nothing that
 shows defensive
medicine is dictating doctors' behavior. More
 contemporary research needs to
be done (the majority of these projects were in the
 late 1980's and early
1990's), but there's no indication of a rash of
 doctors performing
unnecessary procedures and tests because of their fear
 of frivolous
lawsuits.


       
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