Friday, June 24, 200513
"I practiced defensive medicine today" 5
The next part of this continuing series. I'm sure that many can relate to this story. A reader writes:
Please e-mail me your stories of "how you practiced defensive medicine today", and it will be posted anonymously as part of this continuing series.
(Disclaimer: Any pictures shown are not of the patient. All identifying features, including race, age, gender and ethnicity have been modified significantly or fictionalized.)
A 30-year old woman comes into her PCP's office with a complaint of chest pain for the past couple weeks. It is described as sharp and pricking along the left sternal border. It hurts when you press on it and does not radiate. It does not change with position, exertion or food. It lasts hours at a time.Defensive medicine is one of the leading factors in driving up health care costs today. The purpose of this series is to breathe some real-life examples into the numbers, and to provide some insight into how the threat of malpractice litigation pervades medical decision making.
She is otherwise healthy and does not take medications. There is no family history of heart disease. Vital signs are stable and the physical exam is only revealing for reproducible chest tenderness. The EKG and cholesterol panel are normal. We now pick up the conversation:Doctor
Based on your symptoms, the chest pain is unlikely to be heart-related in origin. Your EKG, blood pressure and cholesterol are normal, and you do not have a family history of heart disease. I believe that your chest pain is musculoskeletal in origin, since this is the most common cause of chest pain.
Patient
I want to be 100% sure this isn't my heart.
Doctor
Well, there are no absolutes in medicine. But from my experience and your history and physical, I can be reasonably sure that this isn't cardiac in origin.
Patient
I'm just really nervous. I've heard some stories of young adults dropping dead of a heart attack, and I really don't want that to happen to me. I heard you can run on a treadmill to see if your arteries are blocked.
Doctor
It's called an exercise stress test. In my opinion, this test will be of low yield in your case.
Patient
What percentage of heart disease does this test pick up?
Doctor
Well, the estimated sensitivity of the test is between 65-70% - meaning that a negative test result will miss about 30-35% of coronary heart disease.
Patient
That doesn't sound very accurate. Isn't there anything better?
Doctor
There are stress tests with imaging, like an echocardiogram or nuclear scan, that can push the sensitivity up to 85-90%.
Patient
That sounds good - it would be make me feel a lot better if we went that route. I understand that it's likely going to be negative, but I just don't want to be that 1 in a million case where someone like me can have heart disease.
Doctor
Ok, I'll go ahead and order that test for you - just to be on the safe side.
Cost of ordering an imaging stress test in this low-yield patient: several hundred dollars.
Cost of knowing that there will be zero chance of being sued for this visit: priceless.
Please e-mail me your stories of "how you practiced defensive medicine today", and it will be posted anonymously as part of this continuing series.
(Disclaimer: Any pictures shown are not of the patient. All identifying features, including race, age, gender and ethnicity have been modified significantly or fictionalized.)
Comments
-
Elliott
I know it's wrong of me, but I am enjoying the thought of an anaphylatic reaction to the dye with a subsequent medical malpractice lawsuit. I don't care who wins. Sweet justice it would be for both the idiot M.D. and the uninformed patient. A plague on both their houses.
-
Anonymous
Yes, It is wrong. Unless you are the patient having the reaction.
-
Anonymous
Yes, It is wrong. Unless you are the patient having the reaction.
-
Anonymous
As nasty as the initial comment.
-
Jordan
I don't see the problem here. The patient has a condition, the doctor explains what the likely situations are, his opinion that severe problems are extremely unlikley, and what tests are available and what they cost. The patient hears the advice, but is willing to spend a few hundred bucks for peace of mind to get the gold-plated test. Where's the foul?
-
Elliott
The first problem is that neither the physician or the patient is paying a significant part of the excess cost.
-
Anonymous
Is it normal for any person to suffer chest area pains that last for hours at a time? I don't understand what the problem is with ordering the tests. In 1990 when I didn't understand near enough about heart disease and testing I witnessed my father pass away because of "assumptions" that were wrong. He had reflux disease and hiatal hernia. 4 times we went to ER with severe chest area pains. It was always attributed to the HH. Raise the tagamet and send him home was always the advise. His blood work and EKGs always looked good. He suffered a severe MI followed by coronary rupture While being told his pains were from a hiatal hernia. Following his MI he was transfered to a bigger hosp. where they did the cath and told us he had suffered many heart attackes, the last one destroying over half of the R ventricle. His heart ruptured that evening. We were also tole that he had to have been severing severe angina for years. We didn't sue anyone but I sure wish someone had offered him a heart catherization.
-
Elliott
The test is not invalid. A stress test for imaging is the problem since this represents increased expense. The stress test was fine as an approach. The doctor is all proud of how he burdened the healthcare system with an imaged EKG to make sure he doesn't get sued. She would have got the stress EKG without the dye if he had been doing the standard thing.
-
Kevin
Elliott,
-
Anonymous
Comparing Kevin and Elliot, I have to say the difference is miles apart.
-
Elliott
Anonymous, you cannot read. Kevin is a class act. The doctor described in this scenario is not Kevin. The doctor described in this scenario is a bozo. Based on what I have read, I would be glad to have Kevin treat me. Based on what I have read, I would greatly fear many of the anonymous commentors who appear to be physicians treating me. My participation in this forum continues to lower my opinion of doctors. It is happening in real-time.
-
Anonymous
Background: I am a gyn (former ob/gyn who quit ob after being sued. the baby was severly damaged when the mother had a ruptured uterus, compounded by the failure of the nurse to call me for 30 minutesafter the heart rate dropped. I saved the mothers life and (unfortunatly) the baby's. the kid was blind and paralized and severely retarded. We settled for about 350k, the hospital for 750k and the mother blew her share up her nose. We settled because the insurance company was afraid that the jury would go a lot higher. I gave up ob and got a life for the first time in 30 years. Thank you brother lawyer. But, I digress. I think that lawsuits come from two sources: 1. Gotcha-jackpot. Something went to shit and it looks like a jury could be convinced to give the poor injured a bunch of money. 2. an angry (not necessarily injured) patient who has not had the treatment or the outcome that she wanted and the doctor was not seen as nurturing or sympathetic, or even as an arrogant asshole as many of us are. One of the most incompetent surgeons I know has a bad outcome almost weekly, but he is so smooth and soothing that his patients all believe that it is just bad luck. He has been reported to the board but the patients will dont complain or cooperate.
-
Anonymous
This case is bad in terms of money, but at least in this case the patient insisted on the test. It is bad that it drives the cost up, but at least it is better when the doctors just order unnecessary tests making patients pay and go through unpleasant procedures for no real reason. Many ObGyns, for example, order yearly ultrasounds (both abdominal and intravaginal) for healthy women, average risk factors, no complaints, everything feels normal. OK, sometimes they cannot feel something, but wouldn't just internal suffice in most cases? Abdominal can be quite a torture if they are running late which is most often the case.
Post a Comment5:49 PM
2:41 PM
You should clarify that. It can be read in a few ways, and one of them is downright nasty.
3:10 PM
4:51 PM
9:13 AM
The second problem is that the physician is totally irrational to think that the patient as described could ever sue for malpractice if the stress EKG (non-imaging) failed to reveal heart disease. Seriously, it's more rational to me that she was attractive and he didn't want to disappoint her than the totally irrational assertion that this is "defensive medicine".
The third problem is that an imaged EKG as opposed to a regular one takes one to two hours longer at least.
The fourth problem is that a reaction to the dye is rare especially the one used here, but it does happen.
In summary, the physician overestimated the chance of being sued, then provided care that is going to waste time and money and has more risk of harm than the more reasonable practice of a simple stress EKG.
If the physician had been arguing that the stress EKG which is standard and within the bounds of "normal" for the situation as described was defensive medicine then I would have some sympathy. It is arguable whether even a stress EKG is warranted in this case, but if heart disease were missed because he only did a resting EKG, I could see a possible risk of a lawsuit. I can't see one in the situation as described.
Finally, if he is so interested in practicing "defensive medicine", how come he didn't describe the extraordinary interventions he was going to do to find and treat the root cause of the problem which could be a broken bone or severe heartburn.
11:20 AM
12:44 PM
The differences between the patient you described and your father are significant.
1. Age. The bozo reports the patient is 30. I suspect your father was older.
2. Level of pain. Your father visited the ER 4 times, this woman was seeing her PCP. That certainly implies that your father's pain was probably greater.
3. Other clues that the test is inappropriate overkill is no mention of family history, the fact that it doesn't get worse with exertion (or other changes), and that it does not radiate.
The PCP tells the patient directly that it is unlikely to be heart disease, but he doesn't tell her just how unlikely it is. With that history, I think it would be one for the journals if she were to have heart disease especially heart disease that didn't show up on a stress EKG.
Do the math. Let's say that there is a one in 10,000 chance that this is heart disease. I don't think I'm exagerrating there given the history. The stress EKG will pick up 2/3 of the heart disease (and that's an old study; things have probably improved by now). So there is a 1 in 30,000 chance that the woman benefits from this procedure at an additional cost of about $500 (this is on the low side of the difference in cost and does not include the extra time nor the risk of side effects). This is $15,000,000 per additional heart disease detected and it's not even a life saved, just detected. That number shows how mind-bogglingly wasteful this doctor is with his resources (especially when you throw in the extra time and the extra risk) and the patient is fully complicit in this.
3:59 PM
It is good to see that you fully understand the ridiculousness of defensive medicine.
Many doctors feel it will be the 1 in 30,000 that comes back to bite you. If you'd ask a physician to trade the $15M per heart disease detected for the assurance of picking up that 1 in 30,000, they would make that trade more often than not.
Doctors are sued for missing that 1 in 30,000 - not for spending the $15M per heart disease detected.
It doesn't make sense, but this is the reality that physicians are working in today. I appreciate that non-physicians are starting to realize how the malpractice climate is pervading medical decision making today.
Thanks,
Kevin
4:30 PM
This troll calls Kevin a bozo. Look at Kevin's response. Class act.
Elliot, you have much to learn, and not only about thinking rationally.
2:16 AM
9:53 AM
3:42 PM
Very few ObGyns told their patients that after 3 consequitive pap smears they can do them less often. Most continue doing them every year, even if their patients are at very low risk like virgins.
At the same time, when the test is really needed, it is cheap, accurate and painless, doctors often fail to order it. It took 2 ObGyns and 6 years of complaints to diagnose my POF. I had real symptoms, my time to have a baby was quickly running away, yet they failed to order a simple blood test. Now what harm is in ordering a hormone test for an early-30th woman who complaints about delays and irregularities year, after year, after year?
Instead, they ordered ultrasounds -- certainly more expensive than a hormone test, not to mention useless in this case and unpleasant (in one of these cases they were running 2 hours late - I wish my doctor tried drinking all this water and then waiting for 3 hours).
By the time they ordered the blood test, my chance to have a baby was long gone. No, I do not plan to sue (although I certainly wish that something will make ObGyns more aware of POF), even though I am very bitter because if they had ordered the test sooner, maybe I still had a chance to have a baby.
In spite of the fact that I hate groundless lawsuits and hate the idea of having to do all these tests that may be unnecessary; I am hoping that sometime in future some woman with POF will sue her ObGyn for failing to diagnose it.
4:38 PM