[NPInfo] Defensive medicine

Thu Sep 27 15:10:31 PDT 2007

Well, not sure if this fits,
  but I used Flomax .4 on an elder with incontinence, and then the incont NP evaluated her 3 wkes later. she went from a residual of 400 cc to 50 cc!!!  remarkable.  Nothing in the literature, just anecdotal statements from some urologist who use flomax in women. It is not efective in all though. The doc I work with is now convinced, so I am sure we will use more of it.
  paula

Carla Anderson <carla_rayne at yahoo.com> wrote:
  Along these lines, as an adjunct or instead of ordering tests that are possibly unnecessary, or to "rule out"... I document very well that I spoke with the patient about differential diagnosis, and if an initial work up does not include a certain test or consult, than I document that the patient was strongly informed to go to the ED or to keep the consult with the specialist, etc, if they do not wish to get this test at this time... I feel that patients need to be partners, and not just bystanders that can pursue litigation if something goes awry, when they agreed to do or not do something, or they were the very reason something was not done. However, that being said, does this protect us? Especially with the ehr, when the patient actually does not sign anything saying they agree, and it can turn into a he said/she said situation, and they may deny ever being told anything like what is documented. 

I too try to focus on clinical guidelines and standard of care when I am presenting treatment and testing options, such as when would any type of cardiac work up play in for the 20 something person with daily c/o "chest pain", with multiple stressors, medication issues, musculoskeletal issues, and one cousin who died at age 13 of heart disease.... this can bring up the worst case scenario that there is some underlying cardiac pathology, even when the exam is normal.. as we know many people that have "just had a complete physical" and dropped dead of an MI.. because a physical does not take pictures of the coronary arteries, or catch the heart in all rhythms , and certainly does not take the place of a stress test, or look at the valves. 

So I try to do my best, with documentation and education, and really try to get a good history... which can give so many clues.. but still, I have to agree it is in the back of my mind that we live in a litiginious society. I also am still amazed by the number of patients that want to be told how to think, and told what medications they take as it is "in the chart" and what to do over and over again, and do not want to take responsibility to make any decisions at all no matter how how much information I relay to them to help them make these decisions. Carla 

Jeffrey Hazzard wrote:
Sue,
Thank you for your thoughtful reply. To quote myself, "It is killing us." I wrote that very deliberately. I meant it literally and figuratively. I am aware of all the things you mention. I don't have answers. We need some liability to keep us honest. We need some protection to keep us cost effective.
I challenge you that you are conducting more needless tests than you are aware. Defensive medicine is so ingrained in us that we are not aware that we are doing it.

Jeff (St. Petersburg tonight)

Sue Wiers wrote:
Wow. What is the malpractice suit rate in Florida compared to other states?

I am not naive enough to believe that I will never be sued. However, I 
honestly do not find myself constantly considering lawsuit potential of my 
clinical decision making. I am sure that I will not be so cavalier when I 
do get sued.

I do have a rather elaborate system for following up on concerning or high 
risk situations so that people do not fall through the cracks. I do not use 
medications off-label and do not prescribe antibiotics over the phone (I 
once heard it said, that the phone is not a diagnostic tool). So, I do take 
measures to protect myself and provide appropriate care. However, I don't 
believe that potential lawsuits greatly influence my daily clinical decision 
making. I try to follow what the standard of care dictates, clinical 
guidelines, etc.

Another factor in this is insurance reimbursement. I cannot imagine many 
insurance companies paying for annual stress tests in otherwise healthy 
adults, with few risk factors for CAD, just because they have reached a 
certain age. Our office is heavily based on managed care. We treat all 
patients equally regardless of insurance, but cost-containment, quality of 
care, yield, etc. are all always considerations for us. If we didn't, we 
would be out of business.

There is also the potential negative impact of unnecessary testing to be 
considered. Incidental findings requiring further follow-up that often 
yields nothing. Additional procedures that could actually result in harm. 
So, I can understand your approach, but it also isn't without risk.

Sue Wiers

>From: Jeffrey Hazzard 
>Reply-To: NP Info 
>To: ACC Listserv , npinfo npinfo 
>, Tony L Moffitt 
>Subject: [NPInfo] Defensive medicine
>Date: Wed, 26 Sep 2007 10:31:06 -0700 (PDT)
>
> 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
> ----------------------------------------------------------------
>
> 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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Healing Presence Family Practice, PC 
carla_rayne at yahoo.com
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