Treating conjunctivitis using defensive medicine

in Uncategorized | 28 responses

The fourth part of this continuing series. Defensive medicine isn’t all about ordering more tests. A reader writes about this recent telephone conversation:

Patient
I have a red eye for about 1 day and awoke with crusty discharge. My son has recently been diagnosed with conjunctivitis and is on antibacterial ointment.
Doctor
Any trauma to the eye, visual changes or light sensitivity?
Patient
No. Can you prescribe something over the phone?
Doctor
We have a strict policy where every patient has to be seen prior to prescribing medication.
Patient
That’s ridiculous. I’ve had bacterial conjunctivitis before, and my symptoms then were identical to this. Besides, you’ve prescribed antibiotics for me over the phone in the past.
Doctor
The symptoms certainly sound consistent with conjunctivitis, but without examination it is impossible to be certain. Unfortunately, the clinic is closed today, so you may have to go to the emergency room for evaluation.
Patient
What!? I’m NOT waiting 5 hours in the ER for a simple conjunctivitis. Why can’t you call something over the phone?
Doctor
Unfortunately, due to today’s liability climate, we have a strict policy of not treating patients over the phone – no matter how small the problem is. If you’re not comfortable with this policy, you are welcome to change practices.
Patient
Unbelievable! I think I may just do that. (hangs up)
I may have lost a patient, and drove up costs by advising a probable conjunctivitis to go to the ER, but at least there is zero possibility of being sued over this. It’s a trade I’ll make every 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.

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.

Comments

Anonymous
Question: If the patient had offered $250 to cover the possibility of lawsuit or any value that would reflect the possible damages resulting from a lawuit (in higher premia, lost time, etc.) * the likelihood you would have a lawsuit * time value of money–would you have accepted?
I.e., if the patient said I’ll give you $10K cash as a gift (not reportable to the IRS) for the prescription, would have given it to him/her.
jb
Either a reasonable amount of money to compensate me for the risk, or a legally-tested waiver of the right to sue (which would cost the patient $0) would be acceptable to me. It would not have to be your suggested $10K (that seems way high). In this low risk scenario, a straight $250 would be adequate, but the patient could go to an urgent care center for his Rx for a lot less than that.
Anonymous
I agree with your decision. The patient wanted treatment for the cost of his prescription and the time and cost of his phone call to you. Your time and your liability would have been compensated at zero. That is not fair. (He did not want to trouble himself with an ER visit, which for a minor complaint is understandable.)
If your patient had retainered you, and you had offered to see him at a higher cost (given the off-hours emergency factor) or called in a prescription at a lower cost (billed against the prepaid retainer, not in arrears), with a near-term followup, explaining the possibility of alternative disorders that might be missed (dacryocystitis, corneal ulcer), would you have been willing to treat over the phone?
CHenry
Anonymous
The patient wanted the convenience but he would have still hold you liable for missing a more serious condition. Plus, once you have a policy you have to be consistent in following that policy.
Anonymous
When a doctor is signed up to accept patients through XYZ Health Care Insurance Company, and I have that insurance, and the doctor has accepted payment for my treatment from XYZ before, is the doctor permitted to treat me for cash outside the XYZ plan? I would certainly pay more to have some extra time with a doctor.
Curious JD
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.
Anonymous
It may look like common sense for somebody who has no clue about medicine but IT IS defensive medicine for somebody who has enough experience to treat simple things over the phone.
Curious JD
I stand corrected. I was just curious.
Anonymous
Hmmm, this looks like dumb-itis to me…
Curious JD
Yeah, how crazy of me to think that prescribing medicine without any kind of examination at all might be a bad idea regardless of the liability issue.
Why do we even need doctors if we can self-diagnose? Maybe we could set up a touch screen at Walgreens where we could all input our symptoms and doctors could input the “If X then Y” info and then we could eliminate office visits altogether?
Kevin
Regarding the comment at 4:25.
Please keep the discussion on topic and refrain from personal attacks.
There is an obvious disconnect into how lawyers and other medical outsiders view what goes on behind closed doors in a physicians’ office (and vice versa).
The whole point of the defensive medicine series is to provide needed insight for non-physicians as to how physicians make the decisions they do.
The fact that many physicians diagnose and treat over the phone for minor complaints (UTI, cough etc.) may not be appreciated by those outside the medical community.
Thanks,
Kevin
Anonymous
“Yeah, how crazy of me to think that prescribing medicine without any kind of examination at all might be a bad idea regardless of the liability issue.”
As another doc said, you have no clue about this. Lots of medical problems can be treated safely over the phone without a face to face visit but it may not be wise to do so these days with know-it-all lawyers like yourself out there passing judgement on medical practices that they know nothing about.
Curious JD
I don’t profess any knowledge of medicine. It was truly surprising.
Can you tell me which ones physicians would diagnose over the phone and prescribe medicine for? Becuase I’m tired of going to the office when I don’t have to.
Anonymous
Any doctor in primary care, probably a lot of specialty care for that matter, does treatment over the phone.
My patients ask me to do it every day.
With liability concerns, I do less and less of it. When I’m on call for the community docs, I do it essentially zero. On-call for myself, by definition they’re all people I know; on-call for the community docs, I don’t know them. I send it all to the ER or a local walk-in.
And yes, they complain, but that’s still another service they lose because of liability.
Anonymous
I think the last poster has it right. Many generalists, and some specialists, do treat some patients over the phone, but probably fewer than would want that kind of service and fewer than they treated that way in the past, precisely because of liability concerns.
I do this rarely. When I do, the complaint has to be of a minor nature that cannot be confused with anything more serious. Other questions I ask myself are “do I know the patient myself?” If they are a patient of my group but not one I see regularly, I answer that “no”. I also have to have seen the patient recently for the same complaint and I have to believe that they will follow up with me in the very near term and reliably, If I don’t think they will comply, I decline.
Some patients don’t understand. This is potentially a source of aggravation and even ill-will. I suspect annoyance at the request to take time to be seen in the office and the cost of the after-hours visit is a factor, but the way I see it is that any problem worth calling about after hours should be important enough to set aside other activity to have evaluated.
That is hard to accept in a society accustomed to drive-up all-hours ATM-style convenience. So be it.
jb
Something important is happening here. The docs reading this blog are all aware of it, if only at a subconscious level. C-JD is having his consciousness raised, and maybe some others will learn something. The important thing that is happening is that the Standard of Care is beings shifted, out in public, by non-medical personnel, with no medical justification. For you civilians out there, the SOC is a somewhat nebulous legal concept that is defined by the spectrum of interventions that a prudent physician would take in a given clinical situation. A bacterial infection could be treated by any one of a number of antibiotics, all of which would be within the standard of care, but treatment limited to saying a prayer or chanting would be outside the SOC of modern medical practice, and a physician could be legally liable for failure to do more than that. Without a violation of the SOC, there can be no legal malpractice.
I’ll wager that ~99% of practicing physicians in the 1980s would have prescribed that eye medication over the phone in that situation (known patient, same presentation of same disease as before, with known history of good response to a time-tested safe effective remedy). Docs were happy to do that sort of thing, at no charge, as a service to their patients, and a physician who insisted on an office visit for that type of prescribing would have been at the very least viewed as money-grubbing. Today, the poster who declined to do the same thing is viewed as prudent. Note that nothing in the clinical realm has changed. Same patient, same disease, same treatment. Note that the doc’s impulse, to do what he thinks is best for the patient, and call in the Rx, is the same. What has changed is that docs now have a sense of self preservation. Instead of clinical judgment, we have arbitrary rules- “Unfortunately, due to today’s liability climate, we have a strict policy of not treating patients over the phone – no matter how small the problem is. If you’re not comfortable with this policy, you are welcome to change practices.”
The SOC changes one doctor at a time. It has changed for the posting doctor, and it has changed for me in a similar fashion, and it is gradually changing for the rest of us. Little by little, it will become professionally unacceptable to help patients in this way. Previously, the doc could call the pharmacy, and the patient could pick up his Rx for $10-20 an hour later, and effective treatment would be started. Now, it will require an office visit, $40-100, possibly several hours’ delay, plus the cost of the Rx. If you go to the ER or Urgent Care, they do not know you, and it may be necessary to run additional tests, just to be sure, or even call in an ophthalmologist if you seem the least bit unusual. Nothing different about the ultimate treatment, no improvement in the outcome, just significantly more expense and time wasted.
Note that the SOC was changed by forces outside of medicine. This is actually a fairly trivial example; it would be easy to show how what was formerly a $150 ER visit is now up to $1000 as fewer leave the ER without high tech imaging. Less obvious, but no less costly, is that the OBs in my town will not do high-risk pregnancy management, and the definition of high risk gets lowered every year. I feel sympathy for the 3rd trimester pregnant women who have to drive a couple of hours every week for their OB checkups, and then make the same drive when they go into labor, when we have 5 well trained, board certified OBs in our hospital who could do the exact same job as the folks at the university. It’s that SOC thing again, driven by risk management. You get less. You pay more. It takes longer. But at least you have the right to justice in the legal system.
Curious JD
“C-JD is having his consciousness raised, and maybe some others will learn something.”
Actually, I have my consciousness raised in most every post in here, which is why I read this blog. Healthcare is one of the most fascinating, yet least understood, aspects of our society. And what’s more, it’s likely about to join Social Security as the biggest issue in American politics. These blogs provide an inside look at the industry, and a fascinating one at that. I read every post, even the ones I don’t comment in.
My only disappointment is that physicians don’t approach the legal system with the same desire to understand. Many prefer to condemn lawyers relentlessly, regardless of the facts. Rather than ask pointed questions of their lobbying organizations and insurers, they take at face value everything they say. Was there a lawyer involved and was there a verdict for the plaintiff is all that many need to know that an injustice was done. The actual evidence is a secondary concern.
What’s more, they buy into this climate of fear that the AMA and the insurers have created. Every state is a crisis and physicians are leaving every one of them! JB’s comment about the physician who would get sued even if the woman didn’t follow his instructions to follow up is a perfect illustration. He knows of no case, yet he’s certain that has happened and a big verdict resulted. It saddens me that victims are the ones who are really hurt (after all, everyone knows someone in their profession they wouldn’t dare let treat them or work on their case) by all this “reform”, but as long as physicians believe they are getting back at lawyers, it’s OK. They’re ready to march on the state capitol.
But I do learn, and I do enjoy the education.
Anonymous
“It saddens me that victims are the ones who are really hurt (after all, everyone knows someone in their profession they wouldn’t dare let treat them or work on their case) by all this “reform”"
And just who is responsible for the necessity of this reform? I submit that is the lawyers who have abused the system for so long. You guys have frivolously sued so many times that something had to be done to reel you in. Society will benefit as a whole from reform though a few legitamately hurt patients might not.
Curious JD
OK, whatever you say. I know you’ve done some exhaustive research on all suits filed and are very qualified to judge the “frivolous” ones from the “non-frivolous” ones. You know how many were filed each year, how much they were settled for, the injuries involved and the treatment given, the average amount of the verdicts, etc.
And what’s more, that you know exactly how much your insurer has paid out over the last decade and how much it has collected, as well as what it’s investment income was, whether it made intelligent financial decisions, etc. And of course, what its overhead is, and how much that will be reduced and how much of those savings will be passed on to you, not to mention the consumer, now that you have “reform.”
And of course, you’ve also measured the societal benefit by determining exactly how many physicians will return to these places as well as how many left, exactly how much and for how long rates will decrease, and how much your insurer is going to save? And of course, how these savings will be passed on to society in the form of lower health care costs?
I know you’ve done that kind of rigorous analysis, because otherwise, you would never make such vague and unsupportable statements, correct?
But of course you have.
Anonymous
Yes I have!
Medical Spas Online
Among the findings of the survey:
* 59% of respondents said they ordered unnecessary diagnostic tests — most often imaging studies. Seventy percent of emergency physicians said they ordered unnecessary scans.
* 52% of all physicians said they referred patients when referrals were not medically necessary.
* A third of physicians said they prescribed drugs that weren’t medically necessary, and the same percentage said they performed unnecessary invasive procedures.
* Breast cancer was a particular target for defensive medicine, with radiologists either referring questionable results for biopsy or refusing to perform mammograms altogether.
* There was no link between physicians’ actual experience of litigation and their practice of defensive medicine, but physicians who lacked “confidence in their liability insurance” and those who expressed concern about the financial burden of insurance premiums were more likely to practice defensive medicine.
* Physicians are more likely to refuse care to workers’ compensation patients and obese patients, both groups perceived as potentially litigious.
Medical Spas Online
Oops. The link to the article:http://www.medpagetoday.com/tbindex1.cfm?tbid=1130&topicid=61
Anonymous
How come when my mom had me 30 years ago she felt nothing and remembered nothing after getting a simple IV in her arm, but last week when my wife gave birth it was like a medieval torture chamber and the incompetent medical staff could not get the epidural or anything else to work–trying several different chemicals. She suffered SEVERE pain for over an hour, and I suffered the very real fear that she might bleed to death due to them not being able to sew her up–and these things are compensable.
-Doc T. Rsardum
Anonymous
“How come when my mom had me 30 years ago she felt nothing and
remembered nothing after getting a simple IV in her arm”
IANAO
(I am not an obstetrician, just a psychiatrist) not even an American rather a curious observer from across the Atlantic.
There are many possible explanations.
1) Were you a smaller baby than your child? It is my understanding that babies are getting heavier on average.
2) Was your mother a bigger woman than your wife?
3) Differences in the anatomy of the pelvis between your wife and your mother?
4) Different age and parity status. Was this your wife’s first baby and your your mother’s 2nd or 3rd? Maternal age at first baby rising in some Western countries.
5) Recall bias. You weren’t there (in an observational sense) at your own birth. Your mother’s generation probably more stoical than ours. It could have been bloody awful for her. She might not have wanted to make you feel bad.
6) Bad luck. **it happens.
These are a range of alternatives to the implicit “doctors are getting more incompetent” hypothesis you advance. That’s not to say your hypothesis is not correct, just that your study design is flawed.
My understanding of the stats in this area (hazy at best) is that, this side of the pond anyway, there has been no steady rise in maternal mortality and morbidity as your hypothesis would predict.
Best wishes
Fionn
Rich, MD
As an Internist, I’ll make three observations:
1) I never treat eye disorders sight-unseen. On several occasions I have agreed to meet patients in the hospital er or lobby to examine the eye – the no- show rate on these meetings was 50%.
2) The delivery 30 years ago also may have been aided by the use of amnestic medications, which are no longer used today (and may be harmful)
3) If I call my attorney on the phone and ask for and receive advice over the phone, do I not get a bill?
Rich, MD
Anonymous
In case anyone wants some insight from a partner in medical malpractice defense in NYC…
More than 50% of malpractice is caused by less than 1% of doctors.
Medical malpractice insurance is primarily set to go up or down with the stockmarket because insurance payments are invested. Low stock market = higher insurance rates.
If we could get rid of lousy doctors and have a robust stock market, insurance would certainly be manageable.
That said, defensive medicine certainly has some relationship to insurance rates. The important question is whether this is right. The problem with treating over the phone is that there is always a chance of misdiagnosis. If you think the patient should accept this slim risk, this would lower insurance rates a little bit.
On another note, yes there are many frivilous law suits. They rarely, if ever, succeed. My firm frequently sees them and frequently gets them dismissed. This still costs several thousands $ though and I can understand doctors frustration with this, but to suggest that frivolous lawsuits dominate is a gross exaggeration. I personally can see no better way to do things…
Just my thoughts…
Anonymous
Here’s a better way. Have one expert for both sides with questions submitted in advance and a screening process to get the right expert which can be agreed upon by both sides. Neither side gets to ‘PREP’ the expert and guess what lying would be kept to a minimun and many cases would never be filed. Heres another idea loser pays. How about one more? No contingency fees. You know the US is the only country with contingency fees?
Anonymous
Here’s my take on the whole defensive medicine argument. You’re willing to risk your patient’s eyesight in the event that your phone diagnosis is wrong. You’re just not willing to risk your own financial health.

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