Physicians practice defensive medicine to avoid malpractice lawsuits

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.)

Comments are moderated before they are published. Please read the comment policy.

  • Curious JD

    It would also be interesting to know whether a non-economic damage cap of $250,000 would have kept you from taking the “defensive medicine” steps that you did.

  • Anonymous

    Can’t speak for anyone else, but the non-economic damage cap of $250K or $500K will persuade me to take on patients I could help, but won’t, because of malpractice risk.

    There are patients I send away – I mean 50 miles away – because I won’t accept the risk.

    As I’m sending them away, I make sure to let them know why I’m doing it, and they can take their concerns to the state trial lawyers association.

    Neurosurgeons in my area that we don’t have (they left the state) or left trauma hospitals to work in smaller hospitals.

    The “defensive medicine” that is REALLY going to make the difference is when docs decline to take the risk of certain medical practices, certain patients, because the risk is not worth it.

    It finally started to dawn on the people of southern Illinois when they had to ship more and more patients to St. Louis.

  • Curious JD

    Anonymous, did you know that between 1996 and 2003, there were only 11 malpractice trials in that “judicial hellhole” of southern Illinois, Madison County?

    7 verdicts for the doctor, 4 for the victim. The largest verdict was $1.7 million, followed by $450,000, $75,000, and $25,000.

    Perhaps you should educate your patients with the truth, rather than scare tactics not based in fact. Just because you believe something doesn’t make it true.

  • Anonymous

    Yawn.

    Somebody give CJD a map. There’s more than one county in southern Illinois.

    You’re reading off ATLA talking points again. I’m working off eight years in Illinois, one in St. Louis. Long since out of the area, though we just got a new doc in our town, from the “judicial hellhole” now that you mention it. Yeah, it’s just a mass hysteria why the doctors are leaving and the patients are getting flown into St. Louis for lack of local access.

    I used to feel sorry about turning such people away. After reading obnoxious ignorance from people like….take a guess….I’m not sorry anymore. In fact, it’s why I don’t just say NO, it’s NO AND HERE’S WHY.

    When we get tort reform in my state, as found in my neighboring states – hard limits on noneconomic damages – then and only then will I reconsider doing the high-risk work.

    And it’s not negotiable.

  • Curious JD

    You’re a rock.

  • Anonymous

    You’re scissors.

  • ZZ

    Kevin,

    great idea.

  • Anonymous

    Doctors:
    Do you realize how absurd this whole defensive medicine debate is? There is no proper level of risk–it all depends on individual’s risk aversion.
    IF medicine worked like any normal service industry, the doctor would ask patients which tests/procedures s/he wanted based on their known effectiveness. The patient would decide which tests would make sense in light of how much s/he wanted to pay/value his/her health.

    THAT is the only rational way to allocate resources.

    Of course, we don’t get this because we are all addicted to insurance (and tax policy subsidizes employer provided healthcare) and think that we really shouldn’t have to see what medical costs truly are.

    Doctors like it too. Ego reasons I suspect. Not only are the experts on what goes on in our bodies–but they presume to tell us wise ways to spend our money. Perhaps state peonage of doctors is the answer?

    IAC, question for original poster: if it was your father–or your favorite professor in medical school or Bill Gates and malpractice were not an issue–would you have run the test.

  • Anonymous

    Why in god’s name would you sit on a potentially hot appendix? What do you have to gain by doing so and refusing to ‘rule out appy’?How is this taking ‘care’ of your patient? How do you justify calling this unnecessary defensive medicine? How about calling this practicing good medicine? 15 years after I nearly died from a ruptured appendix because I didn’t ‘look sick enough’, I still suffer the aftereffects and do NOT understand this mentality. You pompous jackass! Heaven save us from doctors like you. If it were your family member, gee I wonder if you’d change your tune.

  • Anonymous

    Medicine is NOT a service industry, it is a profession and a service. As such, physicians are responsible for providing information and recommendations regarding problems or issues that are,by definition, too complex for a non-professional to address without professional help.
    Thus, it is ludicrous to suppose that patients should simply be presented with a pricing structure and a menu of options. Witness the usefulness of patient-requested EBCT and whole body CT.
    IAC, the question isn’t whether the patient is your father or Bill Gates. The question is whether the patient in the original posting would have so adamantly required an imaging study if he/she would have had to pay it’s entire cost?

  • Anonymous

    My submission:
    every shift in my ED. 20 last month, 18 (projected) this month.

    Haha! Curious JD is your problem!

    GruntDoc

  • Anonymous

    I am reviewing a case right now of missed appendicitis resulting in a burst appendix in a young female.

    It’s pretty clear the ER doc screwed the pooch.
    Though the history, signs and symptoms as documented were more suggestive of appendicitis than PID, and were without question equivocal at best for PID, he ordered no imaging, not even an ultrasound, and failed to observe and repeat the exam.

    To add insult to injury, he lectured her on use of condoms and emphasized her need to use them in the chart. Then he discharged her with sub-standard treatment for PID with an instruction to follow up in a few days time with a gyn.

    Yes, her appendix burst within 24 hours and she had a complicated stay in (another) hospital.

  • Anonymous

    An ED Doc:

    Seems to me the patient described did not want the good doctor’s opinion, he wanted a CAT scan. Is it right to order the scan (which has certain costs and risks associated), or is it right to refuse to order the scan (which has a different set of costs and risks)? If the patient came in for a scan, then no advice to the contrary will do. He already was at the ER and got good advice. Is it defensive medicine to order the scan, or is it just customer service?

    I order an awful lot of tests that are not needed (meaning that the test result is not expected to and ultimately does not change my action), but make the customer happier, less anxious, and more confident. By coincidence the testing makes the chart much more defensible. Is that defensive medicine?

    Regarding the ruptured appendix suffered 15 years ago by Anonymous above, I am sorry for the suffering endured and to come. I would love to know more, and to be able to make the right decision every time. Life is not like that, and in the ER we continue to limp along making momentous decisions with inadequate information.

    But hey, I would scan him too, and do blood work, and consult a psychic if one was available. If I don’t order tests and lab and lunch for the patient, well then a complaint letter folows…He didn’t do nothing for me, not even any blood work… Will a $250,000 non-economic cap change my practice, well I figure I pay my malpractice carrier to lie awake nights and worry about such things so I don’t have to. If malpractice gets too expensive, well I will retire.

    In the mean time I try to mostly do the right thing.

    Thanks

  • Anonymous

    Anonymous ED doc –

    I posted about the missed appendicitis case just above your post.

    There really is no excuse for the missed appendicitis in her case by present standards of care . He’s lucky he didn’t kill her. He didn’t even give her a proper warning about returning to the ER…

  • Anonymous

    It’s difficult to argue that a med mal cap wouldn’t cut down on defensive medicine. You merely have to ask the physicians and its a resounding yes, that’s why their lobbying groups keep bringing up defensive medicine when they talk about caps.

    The only real argument is over the cost of defensive medicine.

  • Anonymous

    ED Doc:

    Sorry for confusion, I was refering to the poster at 12:26 AM, not yours Grunt Doc.

    Thanks

  • Curious JD

    I guess I don’t understand how, since a judgment that would hit caps in terms of pain and suffering would likely have millions in past and future medical care, it would cause you to change.

    If the judgment has $10 million in economics, how does the fact that the non-economics cause you to change your ways?

    Putting aside that caps fall disproportionately hard on children, the disabled, the elderly, and stay-at-home mothers, of course. I know you’ve already resolved that moral dilemna in your minds.

  • Anonymous

    Plus it would be unfair to lawyers, who want to help these poor people so much ! :)

  • ZZ

    The clown who wrote at 12:26:

    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.

    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.

    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.

    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.

    To practice medicine you need to know the sensitivites, specificities, pretest and post test probabilities for every diagnostic maneuver for various presentations.

    Real medicine is not like an episode of ER or Grey’s anatomy. There’s actual thinking involved.

    What Kevin had to do is clearly defensive medicine – ie. doing a useless test that will not make a difference to management – because he was pressured by his patient, with the threat of lawsuits or other vindictive action hanging over his head.

    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.

    No one is saying that CTs for appendices or MRIs for brain tumors should never be performed – only that everything you do in medicine should have good reasons, and investigation should proceed in a logical, well thought out way. Not shot gunning every test in the book. You will always do more harm if you practice that way.

    The kicker of course is the final comment about family members. Patients always assume that doctors have one set of rules for their own, and another set for everyone else. If doctors could practice medicine as it should be practiced, there wouldn’t be. But in truth, they can’t, so this suspicion is correct – there is often a difference. Except it’s the exact opposite of what most of these anti-doctor, anti-science type folks think. Because with your immediate family, you can practice truly scientific medicine without fears of threats influencing your decisions.

    Nothing – absolutely nothing – shows how deeply misinformed the public is more effectively than their notions of how doctors treat their families.

    If my 18 year old daughter came to me and said she was scared because she’d just found a lump in her R breast, what do you think I’d do? From your silly comments, you probably imagine I’d send her for immediate surgery.

    As always, you’d be wrong. With my own daughter, I’d sit her down and have a good chat. I’ll take a history about what she’d noticed about the lump. I already know the family history, the social history, the past medical history. Every decision we take we’ll be based on a thorough evaluation of the options, based on her history and the characteristics of the lump as revealed by a thorough exam.

    But if this were your daughter, you can’t imagine thoughtful medicine practised that way, can you? No! For you, who are so expert in medicine, “good medicine” means getting that mammogram. And an ultrasound. And that MRI. And if these suggest low probability of disease, you won’t stop there! After all, you know from your high school biology classes all there is to know about breast malignancy. What do these docs know anyway, right? “Pompous jackasses.” BIRADS 3, schmirads 4 – idiots. “Heaven save us from them,” indeed!

    So, on you move to the biopsies. FNAs. CNBs. Even excisional, if need be. Cut her breast open. Everytime. Anything that needs to be done just so you can rest easy with the knowledge that instead of a 0.0001% chance of cancer, she now has a 0.0000% chance.

    And what if we don’t want to do it? You will squirm. You will resist. You will cajole. You will yell. You will threaten lawsuits. You will say “You give my baby that test now, OR ELSE!”

    All right then. So be it.

    So be it.

    For your daughter’s breast, we will irradiate her. We will scan her. We will pass a rotating knife into her. We will cut her open. We will scar her.

    And we will do all this knowing the risks we are subjecting her to.

    But that’s “good” medicine, isn’t it? “Taking care of the patient.”

    Fools.

    ZZ

  • Anonymous

    ZZ get a grip. what is this attitude that patients are idiots and fools? The dripping condescension in your comments is rather frightening. If I’m supposed to trust your judgment and never ever ever question you, I’d do so more easily if you didn’t think patients are stupid and have no ability to understand and make rational decisions about their own bodies. Just because you can’t explain how a jet engine works doesn’t mean you give up your ability to decide whether to fly or drive.

    Why does it prick your ego so badly to be questioned? You sound just like the jerky doc who lectured the young woman with appendicitis to use condoms next time: bitter, judgmental and ill-tempered. If your judgment can’t be questioned, then will a patient be able to tell you you are missing something, or are they supposed to just go meekly home and die? Your obnoxious rant about a breast lump proves my point: you say you would sit down and talk with your daughter about symptoms, history, circumstances and options, and then you’d be on the same page and a meeting of the minds would have occurred. But do extend the same courtesy to your patients? Doesn’t sound like it — you trust and respect your daughter enough to work the situation through with her, but not those stupid patients. So yes, it does sound like you would treat your own family members differently. You proved my point.

    I’d be more in favor of caps on med mal damages if your reaction to medical errors were something other than to blame the patient for holding you to account, and your attitude toward patients other than one of seething anger. If you could admit your error instead of condemning the patient for having the bad manners to not have what you told them they have…well, maybe we’d have something to talk about. But as it is, there’s no other way to get your attention before it’s too late, except for you to know you can get sued. The problem is, docs who make honest mistakes get snared in the process. That’s the part that needs fixing. But you, ZZ, you need an attitude transplant before you kill somebody.

    And a note to the [doctor] who said in comments above that you are sorry for my suffering — thank you for your kind words; they are much more than I got from the jerks who did this to me [not ER docs by the way, but a GE and a surgeon who lectured me and sent me home WITH a ruptured appendix, after a week of watching me work my way up to the rupture. It was an ER doc, a radiologist and another surgeon at another hospital who saved me late one awful night 4 days later, but the physical damage lives on.] You actually made me feel a little bit better. Thanks.

  • ZZ

    Anonymous,

    The person who was rude, judgemental, and ill-tempered here is you.

    Read what you wrote of Kevin:

    “Why in god’s name would you sit on a potentially hot appendix?
    What do you have to gain by doing so and refusing to ‘rule out appy’?
    How is this taking ‘care’ of your patient?
    How do you justify calling this unnecessary defensive medicine?
    ///

    You pompous jackass! Heaven save us from doctors like you. If it were your family member, gee I wonder if you’d change your tune.

    You were so rude and hysterical it could scarcely be believed; even on this blog, where the rhetoric can be quite passionate sometimes, people are not that poorly behaved. Worse, you’re displaying such poor behavior to the author of this blog, who you’ve probably never even met, and who has probably never treated you.

    Your comment was very rude, and you really ought to be ashamed of yourself. Of course, no one will be holding their breaths for any remorse.

    There are several points that I’d like to make clear though. I am not – ever – condescending to my patients. The doctors who post here all have great relationships with their patients for the most part, or they’d be out looking for another job.

    I freely admit to an enormous condescension for one type of individual – deceitful, rude, and who display no respect or consideration for others but astonishingly expect heeps of it in return. (Ring a bell? It really should). I am very, very thankful that I’ve never had the misfortune of having to deal with more than three such individuals over a long career.

    There are two more deceits of yours that I’d like to clear up.

    1. You say that we do not like being questioned. This is of course an absurd twisting of the facts. Any doctor worth his scalpel expects intelligent questions, and if he doesn’t get it he encourages them, and if they are still not forthcoming he discusses the main issues as he best can and tells the patient to call if they have any questions. Anyway, that’s what I do.

    What I was objecting to above was NOT patient questions.It was your uncouth, hysterical outburst at Kevin and by extension, all good doctors. Folks who have to make difficult decisions about things you know virtually nothing about, but which never seems to stop you from calling them all sorts of names.

    You are one rude lady, ma’am.

    2. The next instance of your dishonesty is your incredible attempt to twist the story I related about my daughter to your own ends.

    As I clearly wrote, that is how we all try to treat our patients. But a small minority of people (like you) never let that happen. They know nothing, but they demand that the doctor do this, order that, and perform the other. And if you try to explain the reasons for your recommendations and why the guidelines are the way they are, they get rude (for example… “pompous jackass”) ( Ring a bell? ). Some of them even threaten. That line I wrote above (…Or Else!”) was actually uttered to a very nice young doctor where I was working. The most harmless guy you’ve ever met, good worker, knowledgeable, technically very strong. I heard it from the next room. Everyone, nurses included, was shocked. Needless to say, that lady was politely discharged from the clinic and referred elsewhere.

    These people have major attitudinal problems that will not be cleared up over the course of their consultation. They will call everyone “pompous jackass” everywhere they go.

    But all you can do is try to treat them like the adults they are supposed to be. If despite the data, they still insist on doing things their way, all the extra useless tests… it is ultimately their choice.

    That is what I was saying, and no amount of twisting on your part will change it.

  • ZZ

    By the way, anonymous, don’t presume to know my stand on issues like malpractice. Even though I know that healthcare has gone haywire thanks to the machinations of the lawyers, I don’t really support caps.

    I am not convinced they are a good solution, and there is potential for some victims to really get short-changed, because you can never, ever expect lawyers to do the right thing the way docs do every single day – docs will go on treating you even when you are not only not paying them but costing them their earnings, but lawyers can never be trusted to take a case, no matter how meritorious, if they didn’t believe they could make substantial amounts of money from it.

    So with tort reform, real malpractice victims can get shafted by lawyers who don’t want to take the cases because the cap will prevent them from milking the system.

    But the system IS broken and has to be fixed.

    The fairest and most effective solution, I feel, is the British one, where whoever is shown by the courts to have no case, pays the cost of the trial to the other party. This way, guilty docs pay the patient for damage as well as the cost for having to bring the case to trial.

    People who lodge silly, frivolous lawsuits that have no basis will have to pay innocent doctors the cost of having to defend themselves after being dragged into the mess of the legal system through no fault of their own.

    This way, true victims have their day in court, frivolous lawsuits will not be brought, guilty docs will still be successfully sued, and innocent docs have much less risk of being put through a nightmare thy dont deserve. And lawyers will still make their killings, only not as much.

  • Anonymous

    Anon. 11:10: “Doctors like it too. Ego reasons I suspect. Not only are the experts on what goes on in our bodies–but they presume to tell us wise ways to spend our money. Perhaps state peonage of doctors is the answer?”

    Sorry dear poster, but the reason you can’t have things your way isn’t always the fault of someone else’s “ego”. Where may I ask is your own sense of responsibility in making rational economic decisions regarding your health care? Imposing peonage on someone else from you might want to extract labor, or worse, having the state act as your proxy in doing do, sounds like naked tyranny to me. Tell me, do you want to extend your wrathful wish to impose peonage on others from whom you might want services you would rather not pay: your builder, your accountant, your plumber, or your lawyer? Thank you if I decline your offer to walk to the Gulag with you. Better you pony up with a more genuine vote of your desires and interests: your money.

    Anon. 12:26: “You pompous jackass! Heaven save us from doctors like you. If it were your family member, gee I wonder if you’d change your tune.”

    You might find more sympathy for your plight and more ears willing to listen to the reasoned arguments you might make if you adopted a less shrill and insulting tone. As you now write, you are only repelling. Try to think that those who have opinions different to yours might have good reasons for having them, and if they are physicians, that those reasons might not be ones you yet understand. Expressions of outrage ought to have equally compelling reasons to justify them, and not
    just (and please don’t take this as insensitivity) pain and disappointment.

    CHenry

  • Anonymous

    You still haven’t engaged on what I said: when a patient knows you’ve missed something, when you send him home telling him he’s fine and he’s not, what recourse is there? Because patients go to you trusting you will listen and do your best, the other half of the bargain has to be that you will trust the patient to tell you when something isn’t working with your diagnosis and treatment. Once into a course of treatment, having trusted the doctor to listen and respond and revise course when needed, pulling away and finding another dr is difficult and sometimes impossible when critically ill. Which makes it even more important that you listen to the patient who is telling you you missed something. How can patients do that without offending you and having you blow a gasket about ignorant, demanding patients. What recourse is there besides to shut up and die? You simply ignore this issue and instead tell me I’m the problem. You call me deceitful? I’m not. I’ve said nothing but the truth of the facts and my honest opinion. Rude? That’s a judgment on your part. I think you are the one who is rude, and worse, you have the power of life and death.

    I obsequiously kiss the behinds of every rude, pompous doctor I encounter, because like you, they won’t be questioned (much less challenged), and they hold my life in their hands. Engage on that issue. You’ve been dodging it by slinging invective at me. I can’t tell you what I think of you when you are treating me, doc, but I’m surely not the only patient who is thinking it.

    Kevin sorry if you were offended, but it’s a real hot button with me when a patient who knows something is not right with them is told it’s all in their head. Last I heard in high school bio, appendices are not in the head. The tone of your comments was casual, that of COURSE the guy was just constipated…but what was the outcome? Were you right, or was he? The downside of missing the dx of appendicitis is so enormous. Ask the young woman who went home from the ED with condoms for PID. Ask ME. She and I both did what we were told, as good compliant patients will, and paid the price. How to change this? ZZ’s solution is to tell me to shut up. Shutting up nearly killed me.

    On another note, I am appalled that there are so many of you doctors out there who won’t treat lawyers. There are lots of lawyers who are just as upstanding and honest at you think you are, and to take the judgmental stance that you do is narrow-minded and doesn’t speak well to your supposed dedication to help humanity…even those you consider scum. I know a lawyer, a meek and kindly patent lawyer who never sued anybody in his life, who got whiplash in a car accident, went to the ER, and had LAWYER written in large letters all over his chart, while being subjected to all manner of arch and snide comments like “He SAYS he can’t hear out of his left ear, and SAYS his face is numb,” with much eye rolling by the staff. What’s up with that?

    I suppose the answer is that you all are only human, asked to do superhuman things. A little humility, ZZ, would serve you well. Maybe a little therapy too. And I hope I never ever need to rely on you to save me.

  • Anonymous

    “You still haven’t engaged on what I said: when a patient knows you’ve missed something, when you send him home telling him he’s fine and he’s not, what recourse is there?”

    Well, if you know so much, why don’t you go and get a second opinion?

    “Rude? That’s a judgment on your part. I think you are the one who is rude, and worse, you have the power of life and death. “

    As another observer, I also think you are rude and disagreeable. Frankly, it is an effort to read your posts to address the points you say no one wants to address. If you treat the people you consult the same way, who can blame them for not wanting you around? You seem to bring out negative responses in others. So, yes, it is about you.

    “I obsequiously kiss the behinds of every rude, pompous doctor I encounter, because like you, they won’t be questioned (much less challenged), and they hold my life in their hands. Engage on that issue.”

    What issue? If you don’t like your doctor because of the way you think he/she treats you, then find another. But if all you do is whine and be disagreeable, don’t expect to be appreciated for it.

    ” . . . you have the power of life and death. “

    I don’t know you, but when your hyperbole gets to this level of drama, I begin to wonder whether you have a personality disorder. Doctors are painted as gods and pompous jackasses, to quote you. Is there no middle ground here?

  • Anonymous

    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.

  • ZZ

    :”

    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.

  • Anonymous

    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.

  • Anonymous

    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.

  • Anonymous

    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.

  • Anonymous

    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.

  • Febrifuge

    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.

  • zz

    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

  • Anonymous

    Time to go take your meds, ZZ. This thread is over.

  • Anonymous

    ZZ, let it go. No matter how many good points you make, you’re wasting your time arguing with a borderline.

    >>>another MD

  • em

    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).

  • rs

    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.

  • rs

    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.

  • Anonymous

    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?