Has defensive medicine diminished the role telephone medicine?

The most recent story in the defensive medicine series led to the following comment:

Why would a physician even consider prescribing anything other than say, birth control, over the phone? That doesn’t sound like defensive medicine, it sounds like common sense.

This begs the question: Are there any diseases that can be treated over the phone?

The answer is yes. Go to your local drug store, and you will find many OTC medications that patients can simply pick up without even talking to a physician. Prilosec OTC for GERD or Claritin for allergic rhinitis. Both of these medications used to be prescription-only.

In the UK, antibacterial eyedrops for conjunctivitis and statins for hypercholesterolemia are now being sold OTC, further examples where patients can self-diagnose without a physician visit.

How about a UTI? Studies have shown that a history alone (without physical exam or laboratory testing) can diagnose some 90 percent of cases.

Do you call a physician every time you have a headache? Most would simply take a Tylenol and call it a day. Today, if you call a doctor about a headache, there is a good chance you’ll be told to come in for an office visit and walk out with an order for a head CT.

So no, not every complaint needs to be seen. Back when defensive medicine was less prevalent, many of these minor complaints could be treated over the phone. Patients were happy at the convenience. Physicians were happy because they did not drive up the cost of health care with unnecessary office visits. Emergency rooms were happy because they were not deluged with minor, non-emergent issues.

This scenario no longer exists today. Defensive medicine has diminished the role telephone medicine. Every patient needs to be seen without exception. After-hours, patients are directed to the emergency room for every complaint, further promoting ER overcrowding. Any refusal is documented in the chart. The consequences of not doing so are too great.

By the way, the comment above eluded to the “safety” of prescribing birth control over the phone. Try prescribing an oral contraceptive to a women with an unbeknownst elevated level of antiphospholipid antibodies over the phone. Note the pulmonary embolus that she received from her 2.3 times increased risk of venous thromboembolism. See the physician who prescribed the oral contraceptive over the phone get sued.

Comments

Curious JD
Aren’t similar risks (similar not being a good word, but you get my drift) present in any situation where you prescribe over the phone?
Again, if you have a long standing patient who you’ve treated often and have examined thoroughly previously, and can trust them to follow your instructions, then I can certainly see why an over the phone prescription might be fine. And of course, that’s the last patient who will sue you. As has been mentioned on this blog and others many times, the most important component in whether you will or won’t be sued is your relationship with the patient.
But with or without tort reform, it’s just surprising you would prescribe over the phone without that history.
If the answer is that you wouldn’t, then the liability climate, whatever it is, hasn’t changed how you act.
drdarcy
Thank you, Kevin, for hosting such an interesting discussion on defensive medicine … fascinating to hear what people are doing, and to see the various definitions of “defensive” in play. An interesting story illustrating 3 potential viewpoints: I was trapped next to a distant acquaintance while traveling a while back, and got to hear all about this person’s motivation to become a minor medmal plaintiff. Basically, the PCP did screw up, by Plaintiff’s report, and missed something he shouldn’t have missed. But, as C-JD points out, Plaintiff’s major issue with PCP was that “he didn’t care about my problem and was an arrogant jerk.” Plaintiff’s second issue, and the major driver behind the decision to sue, was P’s erroneous belief that as P was a member of our local Crappy-Ass HMO at the time, PCP was not treating P because he was getting financial kick-backs for not making referrals to specialists, as well as the huge sum of $20/month for having P in his practice. P believed this because when P switched to Relatively Decent PPO, after PCP had screwed up in the disputed incident and P had gone off on him a few times, PCP started referring P out of his practice for everything.
P was relatively open to some education around the truthfulness of this belief, but remained seriously pissed off.
BTW, Plaintiff is rather wealthy, knows that if there is a settlement, it will be financially negligible, and is contemplating doing this “for the Principle of the Thing.”
So, clearly, Plaintiff is a jerk.
And, clearly, difficulties with the health care system in this country contribute to the anger that leads to this lawsuit.
And, likely, PCP wanted P out of his practice after the screw-up and yelling, but was too polite, intimidated, whatever, to deal with it more effectively.
And, unfortunately, some medmal atty out there might take this case, since P can pay out-of-pocket, and doesn’t really care that the settlement would be quite small.
And, if it goes forward, PCP may well give up on CA-HMO, leaving a whole lot of patients in the lurch.
Will tort reform help here? Probably not.
Will defensive medicine help here? Probably not.
Would being able to actually spend time with patients, educate them about their conditions, their treatment options, and access to health care, in an environment where we’re not exhausted, frightened, broke, and therefore prone to make avoidable mistakes (as opposed to the many unavoidable ones)? Yep. Gonna happen? Probably not.
I could see this situation from the patient’s viewpoint, given my own issues with CA-HMO, and also from the PCP’s. Would C-JD care to comment on this type of situation from the medmal atty’s viewpoint?
Also, C-JD, unless you are actually a neurologist with an absolutely delightful sense of humor masquerading as a medmal atty to stir everyone up, you should know that CJD is the acronym for Creutzfelt-Jakob disease, also known as Mad Cow Disease. I’d keep the abbreviation, with that awareness. And, I’ll say that I, for one, appreciate your posts and your relative calm in the face of some unpleasant flaming.
Curious JD
I only post to keep Kevin’s hits high. He’s my cousin, it’s the least I can do.
On that situation, as an attorney, that’s the worst kind of client to take. Likely outlandish expectations and as a result, never satisfied. Since I rarely (maybe 3 total, all clear liability and small amounts) handle med mal, I probably would pass, especially if the client presents as you describe.
An experienced med mal attorney who does a lot of it would probably pass too, because it wasn’t enough injury to justify the expense and for the reasons I mention above.
Aggravated DocSurg
Thanks, Kevin, for keeping up this great series. Curious JD, I generally don’t have patients that I follow “long term,” as a primary care physician would. Even so, there is very littly that I can offer my postoperative patients other than a recommendation to come to the office or ER when they call with a problem. While it may seem to be a trivial matter to the patient, sometimes they simply are not aware of the potential complications of surgery to know whether or not something can be “treated on the phone” — which can put me into legal jeopardy. And, yes, when they refuse to come in to be seen, I dictate a nice long note about our conversation.
Curious JD
“While it may seem to be a trivial matter to the patient, sometimes they simply are not aware of the potential complications of surgery to know whether or not something can be “treated on the phone” — which can put me into legal jeopardy.”
Aggravated, in your situation, wouldn’t it also put you in a bit of a standard of care jeopardy regardless of the legal consequences? It appears you’re saying it simply wouldn’t be good practice for a surgeon to prescribe, post-op, drugs over the phone.
If that’s correct, then tort reform of any kind wouldn’t change how you act, would it?
Anonymous
You can treat URI’s, recurrent cystitis in a woman, vaginal yeast infection, diabetes (just follow-up sugar in uncomplicated cases), weight loss, hypothyroidism and even BP monitoring in a stable patient. Many things can be done quite safely on the phone or e-mail. The problem is that you don’t get payed and if a complication happens (which would happen anyway) a lawyer will try to crucify you.
Contrary to what somebody said, I would never prescribe birth control without a PAP every 12 mo and I usually give 12 mo refills.
To do phone medicine it is best to have a patient that you know and that has a decent IQ, plus strong communication with him. Communication is very time consuming and difficult to achieve in a managed care system. You can not communicate efficiently in 10 minutes (including the charting and exam).
Anonymous
The UK doesn’t allow these drugs OTC because they’re particularly enlightened compared to us. They do it because it puts the drugs and the doctor visit outside of their socialized system.
One less drug to pay for (paid out-of-pocket), one less physician visit to pay for (not done), and the waiting list is shortened accordingly. Anything that makes waiting lists shorter, for better or worse, makes them look good politically and is therefore OK. See Patel in Australia as an example.
I’d say, take advantage of the natural experiment and see if they get in trouble with it.
If, in real life, they DON’T see trouble with it, let’s see if their experience can translate to the USA, with some lowering of the cost of medicine as a result.
Presuming the trial bar doesn’t litigate it out of existence.
Anonymous
You know the number one way to practice defensive medicien is to not come off as an arrogant, know-it-all, dismissive, greedy jerk. Study after study proves that even in the face of clear liability. Doctors ignore this at their peril and whine about tort reform.
flydoc
Well, I’ve treated an anaphylactoid reaction over the phone… The patient was unknown to me, the history (what there was of it) and the symptoms were classical (wheezing, tongue swelling), and the emergency medical response would have taken more than 2 hours to get to the patient. They had access to adrenaline, I prescribed 0.3 mg i.m. and they survived.

Has defensive medicine diminished the role telephone medicine?

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