It has been suggested that 93% of physicians practice defensive medicine today to avoid malpractice lawsuits. Defensive medicine is defined by the AMA as such:
Physician practices just to reduce risk of a liability claim, eg, performing diagnostic tests of marginal value.
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.
A reader writes:
A 28-year old man came into the clinic with right lower quadrant abdominal pain of 2 days duration. The pain was of insidious onset, without evidence of trauma. He went the ER the night prior and was discharged without any blood tests. Abdominal plain films were negative. The presumptive diagnosis was constipation and he was prescribed Maalox. Upon further questioning, he had not moved his bowels in 3 days and denies any blood in the toilet, nausea, or vomiting. He is worried about appendicitis.On physical exam, he was afebrile and had stable vital signs. Abdominal exam showed some mild right lower quadrant tenderness without rebound or guarding. Belly was soft and bloated. Obturator sign and iliopsoas sign both negative. Rest of the physical exam was unremarkable.
Impression:
Non-specific right lower quadrant pain in this afebrile young man. Possible constipation. Appendicitis is unlikely, but I cannot rule it out as the physical exam is often unrevealing in the early stages of appendicitis. Fever also presents late in illness. The patient insists on further imaging tests despite my assurances that appendicitis was unlikely.Plan:
Obtain appendiceal CT scan to rule out appendicitis, although the yield is likely to be low.
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.)
Related posts:
- Reasons why doctors practice defensive medicine
- Defensive medicine op-ed reaction
- Why do doctors practice defensive medicine?
- Defensive medicine in the ER
- Defensive medicine
- And you wonder why doctors practice defensive medicine
- Defensive medicine in the news
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Wow! There are a lot of doctors with anger-managemenet issues. Did ZZ forget his meds today? Well, I’m the clown at 12:26, but I’m afraid ZZ frothed rather than answered.
“Stop blathering about things you know nothing about. It’s not in your place to dictate what sort of clinical exam is performed, or what biochemistries should be ordered, or what imaging studies ought to be done.”
****HMMMM, well I am a statistician specializing in medical issues.
“There is a very simple reason why you shouldn’t be dictating such things to doctors. No, it’s not that docs are egomaniacs. It’s that lay people – like you – are clueless.”
*****Well, in fact, I’m not clueless and I probably understand and can interpret a clinical study better than you can.
“Medicine is hard enough to practice even after 15 years of advanced study and training. Don’t presume to think that you can do a better job. You can’t – not in a million years. Period.”
****Hmm, I guess it’s the sign of bombast that the same answer works for paragraph after paragraph. See above.
The reason Kevin was “justified” is simply that a CT for a patient with a pre-test probability of having appendicitis that’s so low it’s through the floor is going to be uninformative, while also subjecting a patient needlessly to radiation.
***Right–which is why patients can come to same conclusion. I really wonder whether Kevin explained things properly.
To practice medicine you need to know the sensitivites, specificities, pretest and post test probabilities for every diagnostic maneuver for various presentations.
****Ha, ha, ha!!!!! If doctors really knew that, then medicine WOULD be easy to practice. The problem is that these parameters are usually UNKNOWN or only guessed at.
Patients don’t realize the complexity of human physiology and pathology. For example, if you find yourself being momentarily short of breath one day, it could theoretically be almost anything – even a brain tumor. So what are you going to do – perform brain MRIs of every single person who’s short of breath? You will bankrupt America in 1 week. And you’ll help virtually no one.
****Well, no. If the person wants to pay for the MRI himself, there’s no problem; he’ll only bankrupt himself. And, that was the point of my post. The problem is are insurance approach to medicine. Defensive medicine is only a problem when the patient, himself, is not paying for the service. Then, of course, he wants everything–why wouldn’t he? If he were paying for it himself, he would be able to calculate risks/benefit of each test quite effectively.
“Nothing – absolutely nothing – shows how deeply misinformed the public is more effectively than their notions of how doctors treat their families.”
****Ah well, there have been some interesting studies on waiting times in hospitals for doctors’ relatives for certain procedures. They do get better treatment. So sorry reality conflicts with yr hysteria.
Again, re: irradiating 18 year olds and cutting their breasts, I want no such thing. All tests have risks–false positives being among their chiefest. (Altho the radiation risk is a bit of a stretch–by that logic, no one would ever get into a plane or live in Denver, CO) Patients can understand this issues–and doctors should and must explain them to them. That ZZ does not means to me that he is a pretty dreadful doctor.
:”
There seems to be more than one person claiming to be the obnoxious woman who had an appendectomy, and who posted at 12:26 AM.
While I personally cannot imagine why any sane person would tussle for the coveted “honor” of being this especially sad individual (that is, if there actually were more than one person), the fact that its happening implies either issues with honesty or issues with mental health. Neither is surprising, and both predictable.
This/these person(s) do(es) not respond to the myriad problems with their positions and attitudes. As such, further discussion will be fruitless.
I note that no less than three individuals on this thread have been repulsed enough by the rudeness of this woman to suggest that she improve her attitudes or behavior. That is very telling.
I will address some repeated falsehoods and then cease checking back on this thread.
Firstly: This argument was set off by the woman calling Kevin some very unkind things. There was also the direct implication in her post that all doctors who agree with Kevin and would have done the same were equally a bunch of horrible doctors, from whom “heaven” ought to help everyone.
This was a bizzare, extremely rude outburst. For me, it was especially galling since the person making it was very ironically demonstrating Kevin’s point – that lay people often do not understand medical decision making, and some of them insist on demanding things that the doctor cannot recommend even when attempts are made to explain why. When the doctor states his disinclination, threats are made, or he is called names or otherwise verbally abused.
What Ms. 12:26 did above was classic: her entire outburst was vituperative, yet she adduced no argument to show that she understood anything about the disposition of patients with the problem Kevin described.
This is was the main point I tried to make in my first post. This individual seems to imagine that just because she can throw around a few choice medical (slang) terms, that her “argument” (I’m in a generous mood) is effective. It’s actually non-existent.
Second: There is a repeated attempt to claim that I’m arguing that doctors should not listen to their patients, or that they would be justified in not listening to their patients.
This is so fantastic as to be outright delusional. No thinking person, and certainly not I, would say that.
I have been saying that this particular person is talking a whole lot of nonsense, yes. I have been saying that there are some patients who behave the same way, yes. But neither of these equals the above.
If you can’t understand why the doc recommends A and but discourages B, just ask. This is normal behavior most adult humans know how to engage in. If the answer is not understandable or not forthcoming, ask again, or decide you want another opinion. I can’t believe this has to be typed out. If you think he is such a bad doctor, simply discharge yourself from his clinic/practice. If it is an acute situation, ask for a second opinion.
Don’t yell at him, call him a horrible person that the heavens must protect you and all mankind from, tell him he is a pompous jackass, dictate to him that he should order X,Y,Z test that you think is appropriate becuase you heard it on tv somewhere, tell him he treats his patients worse than he would his family, or threaten him with lawsuits and/or bodily harm.
I mean, you could, but it’s kind of stupid to do – I don’t see what sort of “solution” it’s supposed to provide.
Also, stop lying that I have said the solution is for you to “shut up”. I have repeatedly posted that you should do the opposite, and ask questions. But you do not seem to understand the difference beween asking questions, and yelling at a doctor that he is a hell-sent pompous jackass, or threatening him with a lawsuit unless he does your every bidding.
Figures.
Thirdly, you have an odd habit of projecting all sorts of things unto doctors you have never had a real conversation with. Kevin is the heartless fellow who missed your appy 15 years ago, and deserves all your misplaced anger. I am some kind of egotistical maniac who never listens to patients (lol!).
You’re now attributing not treating lawyers to my supposed sins. Extraordinary. If I actually check back and keep responding to you, I’m sure in a short while I’ll be Hitler.
Fourthly: you next post at 2:27 is even more bizzare. If you are the same person, your writing has a strange MPD like quality to it. If you’re not, well, one of you is lying, or fantastically mistaken somewhere. Or less likely, completely nuts.
Anyhow, you now claim to be a statistician who deals with “medical issues”. I’m glad that you think you understand medicine so well, although if this is the case it is difficult to see why you were so hysterical to Kevin, or why you continue with deceitful suggestions about what doctors advocate and how we practice. Incidentally, aside from the MD, I hold a masters in biostats and a PhD (not in stats though – basic science field). I have designed and run trials, and been published in three of the big five. If you really do understand medicine better than me, I’m glad for you, but its terribly saddening to me: if this is how a medically informed woman behaves, we’re done for.
Almost all of your last post is full of the usual —-, so we can safely ignore those. There was one paragraph that was uncharacteristically quite sensible:
If the person wants to pay for the MRI himself, there’s no problem; he’ll only bankrupt himself. And, that was the point of my post. The problem is are insurance approach to medicine. Defensive medicine is only a problem when the patient, himself, is not paying for the service. Then, of course, he wants everything–why wouldn’t he? If he were paying for it himself, he would be able to calculate risks/benefit of each test quite effectively.
I agree completely with this except for the assertion that “defensive medicine is only a problem when the patient is not paying”.
That is largely true, but definitely not completely. Imagine a wealthy patient in today’s climate paying for all his tests. He can afford them so the financial incentive is “removed”. Then the problem remains.
Also, this seems to imply that the correct number of appropriate tests for a penniless patient is zero.
Finally, in your final paragraph you revert to your lies once more. Why do you keep uttering lies about how I and other doctors practice? I’m the sort of doc who’ll pull out the papers to explain my decisions to patients, if they want to understand the data and can follow it.
Anyway, best of luck, and try not to abuse too many docs whose sad job it is too see you.
Quoth ZZ: “I’m the sort of doc who’ll pull out the papers to explain my decisions to patients, if they want to understand the data and can follow it.”
‘My decisions’–? I thought it was called a consultation and the patients made the decisions.
Freudian, eh, ZZ.
ZZ has appeared to have lost it.
“Imagine a wealthy patient in today’s climate paying for all his tests. He can afford them so the financial incentive is “removed”. Then the problem remains.
Also, this seems to imply that the correct number of appropriate tests for a penniless patient is zero.”
What’s the problem?
I don’t know what fantasyland ZZ practices in but the decision to have a particular test is not dictated by clearly understood probabilities and outcomes. It often more of a question of a patient’s willingness to pay and.or risk aversion. Which goes back to the issue of defensive medicine. IT’s impossible to define because there is no uncontroversial standard of what actions should be taken at any given circumstances.
Well, the correct number of tests should be the number that can be paid for–by the individual or the state.
Now ZZ has a masters in biostatistics. Well, good. His bizarre approach to risk managements can now be wholly attributed to his physician’s money.power/ego-lust. His penchant for bluster and nasty ad hominem attacks I’m sure makes him a beloved physician.
Anon. 10:04:
You are offensive and unpersuasive. I have no trouble believing you have negative relationships with doctors. In fact, it would not surprise me that you had difficulty with most people from whom you might have to seek professional advice, so confused you seem to be between your knowledge and your negative opinions. Anyone who tells you what you don’t want to hear must be doing so out of “physician’s money.power/ego-lust”. That has to be limiting.
To Anon 1:25 — or are you really ZZ? The position that “If you annoy or disagree with me, then you must be screwed up and not get along with anyone” doesn’t answer the points raised.
I’ve noticed that part of the responses here, eg critcizing patients for ‘demanding’ a CT when you think it is contraindicated, don’t take into account that the patient’s knowledge of the possibilities and outcomes IS limited, and so they ARE trying to engage you in a discussion of what else can be done. ZZ gripes that patients demand ridiculous things and complains about their ignorance, then says that OF COURSE he is willing to sit down and explain his ‘decisions’ about the appropriate course of action if only patients would ask — without realizing that a patient who says “How about a CT” or even “I want a CT” is in fact trying to engage on the subject of what to do.
This is appropriate behavior, for the patient to seek invovlement in his/her own care and health care decisions, and it is important to recognize that a stressed and ill patient may not present with what ZZ deems sufficient deference. If Dr ZZ says “Take two aspirin and call me next week if you’re not well” but the patient feels much worse and knows that something awful is indeed at work within his/her body, then is the most productive question “Is there anything else?”, or “How about a CT, or an Xray, or some blood tests?” Rather than get offended when a patient tries to engage and call him ‘clueless’ and ‘not your place’, look at it as an imperfect effort to be active in one’s own health care, then go throught the possible tests and procedures and explain why the recommendations [not decisions] are made.
This is simply common sense. We’ve had two family members die from arguable medical neglect — an elderly woman with an intestinal blockage and a middle aged man with meningitis, both of whom were seen multiple times by doctors and admitted to hospital, then discharged to die. This is wrong, and attitudes like those ZZ exhibits are the problem, not the answer.
You know, I really enjoy this blog, and check it fairly often. This series on defensive medicine is a great idea. So, when I went back to Part I and saw there were 35-ish comments, I thought there might be an insightful conversation going on.
Pity about the flame war. I’ll have to wait a bit for the discussion I had hoped to see, eh? Just as well; I have homework I’m supposed to be doing.
No, Anonymous @ 2:20, unlike you I’ve always made it crystal clear whenever I’ve written a comment that it was mine.
The anonymous who replied you is not me. I always sign off properly. He/she is probably just one more individual who saw right through your BS.
In your latest outpouring of rubbish, you write:
ZZ gripes that patients demand ridiculous things and complains about their ignorance, then says that OF COURSE he is willing to sit down and explain his ‘decisions’ about the appropriate course of action if only patients would ask — without realizing that a patient who says “How about a CT” or even “I want a CT” is in fact trying to engage on the subject of what to do.
You are simply lying through your teeth. I guess the reason you’re such a disagreeable person is that it’s not easy to understand why some people lie like that…
It must now be the fifth or sixth time that I’ve pointed out that no good doctor discourages honest questions from his patients.
What is being objected to is ABUSE and THREATS, whether direct or implied.
If you can’t see the difference between,
Say doc, I’m concerned about (disease X), and wonder what you might think of (investigation Y)? Could you explain why you’re recommending Z?
and,
Look, damnit. I don’t care about what you think. I know what I want, and I’m ordering you to get me a CT, ultrasound, bone scan and MRI. How dare you?! “How do you justify calling this practicing good medicine?” You “pompous jackass!” You’re a threat to all patients!! “Heaven save us from doctors like you”!!! If you don’t order everything that I demand, make no mistake, I’ll sue you!
you’re a lost cause.
The difference between the two is that in the first the patient maintains perfect autonomy while also giving being considerate and respectful of others. It’s a meaningful dr-pt relationship. In the second, typified by clowns like you, the “pt” views the doctor as a vending machine for tests and procedures. This would be fine if she also took complete responsibility for all the damage her stupid decisions would cause, but of course that is never the case.
ZZ
Time to go take your meds, ZZ. This thread is over.
ZZ, let it go. No matter how many good points you make, you’re wasting your time arguing with a borderline.
>>>another MD
all non-physicians making coments on this site: go away, you are just jealous idiots that cannot understand the decision-making process and the waste of time dealing with your stupid questions and concerns. just tell the doctor what is wrong and answer the questions he/she has or go to medical school (oh! but you cannot do that b/c you are too stupid).
I can’t believe there is relatively little meanful dialog here. I work in health care with physicians and I don’t know any personally that have the sort of bad attitude that this zz person has. Just in reading zz’s comments, I wouldn’t want zz as my doctor. ZZ may in fact be a fine doctor, but it really doesn’t show here. I am sorry for the people who are writing in because they have had bad outcomes. It is very difficult to balance risk and care. As health care professionals we all try to not practice defensive medicine–Kevin, it was your job as the physician to educate the patient as to what care was appropriate and why. If the patient threatens to sue — let him. The first settlement to end an unjustified claim hurt us all, patient and doctor alike. If you always do what is right–you take a risk–but you put the patient first. Now it could be said that offering the patient the CT would ease his “pain & suffering” maybe it is the way to go(I’m not advocating this-it’s just rhetorical) — I realize we want to keep costs down — but let us get back to the practice of medicine. Please, all of you professionals, our dialog does not need to carry with it hostility.
I wanted to add one thing. When patients come to you as physicians, many are quite scared–probably this man wanting the CT was acting more out of fear than anything. Many patients are uninformed, this is NOT to say they are stupid, or unable to understand, just uninformed–we must educate them. It is not a perfect system, it maybe broken, let’s fix it — together physician and patient. Really we are supposed to be working toward the same goal — health.
Any person that’s for defensive medicine…try having a ruptured appendix because your doctor didn’t perform the right tests. I think you’d beg to differ!
Early appendicitis often lacks specificity in the physical tests, so an appendicular ct scan actually is a logical step in diagnosis. The doctor should do everything that is necessary to diagnose a problem such as equivocal appendicitis. This condition is potentially life threatening! If a doctor weighs life over his pocket book. Then what good is a doctor anyway?
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