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.)