Thursday, July 14, 2005
More defensive medicine: A study suggests that the fear of lawsuits is leading to more hospital admissions
This is stating the obvious and merely an extension of over-ordering tests:
Is this good medicine? Well, that is debatable and beside the point. This is today's reality. All it takes is sending one "low-risk" patient home who later has a heart attack that will generate a lawsuit. Most will accept a $1200 admission every time rather than risk being sued.
Update:
I have been asked to back up my last statement, where "low-risk" patients sent home who later have a heart attack will generate a lawsuit. Here is one case:
This is stating the obvious and merely an extension of over-ordering tests:
Emergency room doctors who are the most fearful of malpractice suits are more likely than their colleagues to order tests and admit patients for chest pain or other heart symptoms, according to a study led by a University of Iowa researcher.A hospital admission can cost as high as $1200. Most everyone with chest pain are now admitted, their cardiac enzymes cycled, and then undergoes stress testing the next day.
The study found that such doctors admit even those patients who are low risks for actual problems, said Dr. David Katz, an associate professor of internal medicine at Iowa.
The findings were based on a surveys of 33 emergency room doctors who participated in a study of 1,134 patients at two teaching hospitals. The results appear in the July 13 online issue of the Annals of Emergency Medicine.
Nearly 7 million Americans seek emergency care for heart-related symptoms each year, according to the university's school of medicine. Almost half of those patients are admitted to the hospital, yet it's later found that most did not have a serious problem such as a heart attack or unstable angina.
Is this good medicine? Well, that is debatable and beside the point. This is today's reality. All it takes is sending one "low-risk" patient home who later has a heart attack that will generate a lawsuit. Most will accept a $1200 admission every time rather than risk being sued.
Update:
I have been asked to back up my last statement, where "low-risk" patients sent home who later have a heart attack will generate a lawsuit. Here is one case:
On April 19, 1980, Phillip was treated at the St. Luke's emergency room on two separate occasions, once at 12:22 a.m. and again later that day at 10:55 p.m. On the first occasion, Phillip sought treatment at the emergency room for chest pain. He was examined by Doctor Ellison, tests were performed, and he was then sent home. Later that day, Phillip was brought to the emergency room in an ambulance with symptoms of chest pain. He was again examined by Dr. Ellison and more tests were performed. Dr. Ellison conferred by telephone with Dr. Ehlen, Phillip's personal physician, and Phillip was again sent home.The jury found for the defense, but the point was, a lawsuit was generated.
Within eight hours after Phillip's second visit to the St. Luke's emergency room, he experienced a heart attack at home and was taken by ambulance to St. Ansgar Hospital in Moorhead where he was attended by Dr. Carlisle. Phillip sustained severe injuries, including brain damage, as a result of the heart attack.
Phillip and Dorothy filed an action against the defendants alleging that, by failing to hospitalize and continue observation of Phillip, the defendants violated applicable standards of care causing Phillip's serious injuries and resulting damages.
Posted by Kevin |
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Comments:
"All it takes is sending one "low-risk" patient home who later has a heart attack that will generate a lawsuit."
Kevin, can you back this statement up?
Kevin, can you back this statement up?
This is a no-brainer. As an ER doc, I agree that almost all chest pains are admitted. When I work as a hospitalist, I don't argue with the ER doc when they want to admit a CP for r/o MI protocol.
Kevin is right. It would be simple for a plaintiff to find a witness to testify that you should have admitted the patient. We understand that there is no way to prove that the patient was not having the MI at 10pm when you sent him home if he presents at 4am with an MI, or that your admission may have prevented morbidity.
Kevin is right. It would be simple for a plaintiff to find a witness to testify that you should have admitted the patient. We understand that there is no way to prove that the patient was not having the MI at 10pm when you sent him home if he presents at 4am with an MI, or that your admission may have prevented morbidity.
Dr. Tony, I don't believe you. Myself, my wife, and my father-in-law all went to the ER with chest pain. Result was that my wife and I were negative for enzymes and not admitted. Father-in-law was positive and admitted followed by a double bypass.
Based on your personal sample of 3, you don't believe me?
I didn't say that all CP patients are admitted, but I hold firm in my statement that "almost all" are.
I have been called, as a hospitalist, to admit patients that had spent the night in the hospital two days earlier for rule out. You know what? I admitted him again.
If you were sent home after a single set of negative enzymes and no specific non-cardiac diagnosis for your chest pain and you are over 30 years old, your ER doc practiced differently than most I know.
I didn't say that all CP patients are admitted, but I hold firm in my statement that "almost all" are.
I have been called, as a hospitalist, to admit patients that had spent the night in the hospital two days earlier for rule out. You know what? I admitted him again.
If you were sent home after a single set of negative enzymes and no specific non-cardiac diagnosis for your chest pain and you are over 30 years old, your ER doc practiced differently than most I know.
Curious JD -
If I am was 30 year old who went to the ER and had atypical chest pain, and 3 negative sets of enzymes, normal cholesterol, non-smoker, no risk factors, and was sent home when ECGs and enzymes were negative, and reappeared the next day with chest pain and new sets of enzymes were now positive, and I was in serious CHF and had significant myocardial damage, requiring medication for the rest of my life, would you represent me as plaintiffs attorney?
If I am was 30 year old who went to the ER and had atypical chest pain, and 3 negative sets of enzymes, normal cholesterol, non-smoker, no risk factors, and was sent home when ECGs and enzymes were negative, and reappeared the next day with chest pain and new sets of enzymes were now positive, and I was in serious CHF and had significant myocardial damage, requiring medication for the rest of my life, would you represent me as plaintiffs attorney?
# posted by 
: 2:22 PM
: 2:22 PM
Kevin, you find a single example from 25 years ago where the plaintiff LOST and you call that backup. I think it's more like an "own goal".
Dr. Tony, you said "almost all". That's very loose use of the English language when the study itself uses the words "almost half" meaning less than half.
The issue is not whether or not the plaintiff won, but that a suit was filed at all. When the defendants "win" the case, they have lost time at work and with family and suffered emotionally as well. (Of course, I do not mean to minimize the suffering of the patient and his/her family, either).
Doctors don't alter behavior to avoid losing a lawsuit (to do so would admit that their behavior would otherwise have been substandard), they alter it to prevent lawsuits from being filed in the first place.
Doctors don't alter behavior to avoid losing a lawsuit (to do so would admit that their behavior would otherwise have been substandard), they alter it to prevent lawsuits from being filed in the first place.
# posted by : 3:21 PM
: 3:21 PM
Assume that "almost half" of the 7 million admissions were not found to be heart related, and assume that only 5 percent of them were "low risk" - hmmm... "almost" 175,000 unnecessary defensive admissions.
Assume they only stayed in the hospital one day and did not get a stress test - (@ $1200/day) -"almost" $210,000,000 in unnecessary healthcare spending yearly.
Assume they only stayed in the hospital one day and did not get a stress test - (@ $1200/day) -"almost" $210,000,000 in unnecessary healthcare spending yearly.
# posted by : 3:44 PM
: 3:44 PM
Anonymous,
I couldn't possibly tell you if I would take your case based on a one paragraph description. I'm not a doctor - I can't determine malpractice (or the lack thereof) with that little info.
Kevin, thanks for the link. Out of millions, if not billions, of ER chest pain visits, you've found one from 1980. Clearly, it's evidence of an epidemic.
I couldn't possibly tell you if I would take your case based on a one paragraph description. I'm not a doctor - I can't determine malpractice (or the lack thereof) with that little info.
Kevin, thanks for the link. Out of millions, if not billions, of ER chest pain visits, you've found one from 1980. Clearly, it's evidence of an epidemic.
It's a little thin on details, but here's a case on a law firm's website, FWIW:
http://hillboren.com/settlements/medical.html
MISDIAGNOSIS OF HEART ATTACK
$300,000 SETTLEMENT
Fifty-nine year old female goes to a local ER complaining of chest pain. The plaintiff is sent home with a diagnosis of reflux and indigestion. The next day she is rushed to another ER and dies of a heart attack. Case settled for $300,000.00.
http://hillboren.com/settlements/medical.html
MISDIAGNOSIS OF HEART ATTACK
$300,000 SETTLEMENT
Fifty-nine year old female goes to a local ER complaining of chest pain. The plaintiff is sent home with a diagnosis of reflux and indigestion. The next day she is rushed to another ER and dies of a heart attack. Case settled for $300,000.00.
# posted by : 5:41 PM
: 5:41 PM
Elliott, "the study" didn't reference a number. The "almost one half" was in the article, but the article didn't say what percentage of patients seen by the interviewed physicians were admitted.
I can assure you that, in my experience, not just me but the docs I work with, many more than half of patients who present to the ER with CP are admitted.
I can assure you that, in my experience, not just me but the docs I work with, many more than half of patients who present to the ER with CP are admitted.
CJD and Elliott,
Tough crowd - I didn't realize that I was under such strict, time-sensitive criteria when you asked me for proof.
I found that case in about 6 seconds on Google. I'm sure both of you must realize that similar, more recent, cases exist with the proper amount of research and time. I'll leave that research up to others.
Thanks,
Kevin
Tough crowd - I didn't realize that I was under such strict, time-sensitive criteria when you asked me for proof.
I found that case in about 6 seconds on Google. I'm sure both of you must realize that similar, more recent, cases exist with the proper amount of research and time. I'll leave that research up to others.
Thanks,
Kevin
Kevin, the point is that your few cases aren't evidence of anything and certainly not proof of a rash of "defensive medicine" in these situations. They are anecdotes, nothing more.
You should apply the same skepticism to claims of "defensive medicine" that you did to the Mirapex-gambling link. Your standards of what constitutes proof sufficient to form an informed opinion seem to depend on whether you already agree with the underlying premise or not.
You should apply the same skepticism to claims of "defensive medicine" that you did to the Mirapex-gambling link. Your standards of what constitutes proof sufficient to form an informed opinion seem to depend on whether you already agree with the underlying premise or not.
This link doesn't mention much about defensive medicine, but it points out the high prevalence of malpractice claims due to missed cardiac events. Two studies - one by the Armed Forces Institute of Pathology and one by the American College of Emergency Physicians - show that 10% of ER malpractice cases are of this nature.
http://www.afip.org/Departments/legalmed/openfile92/er91-2.pdf
I've worked as a hospitalist and as a community family physician, and I agree with those who say they are loathe to refuse a patient that the ER doc wants to admit for "rule out myocardial infarction". In my experience, about 1 in 30 of these has a positive stress test or enzymes. Yet, we all play CYA with these cases.
http://www.afip.org/Departments/legalmed/openfile92/er91-2.pdf
I've worked as a hospitalist and as a community family physician, and I agree with those who say they are loathe to refuse a patient that the ER doc wants to admit for "rule out myocardial infarction". In my experience, about 1 in 30 of these has a positive stress test or enzymes. Yet, we all play CYA with these cases.
# posted by : 9:34 PM
: 9:34 PM
I am in the pits, practicing "defensive" emergency medicine. To be a lawyer and say there is not a rash of "defensive medicine" is absolutely absurd. In The ED, Defensive medicine is what we do for a living. No, I don't admit every chest pain. Some of them I AMA if they won't stay. Why would I send home a chest pain, where if there's a 1/10th of 1% chance i'm wrong, I'll have to spend 2 weeks in court, having some moron tell everyone what a moron I was. $1200? WHo cares!! I have to worry about one of those morons taking my house away. I have a pending case of a missed PE where the patient didn't even have chest pain...I even tried to admit her but she refused to stay...it's at the point where if a patient is well-educated, I even tell them I think it's unlikely they have serious disease but I have to admit them to cover my ass. All I can say to other Emergency Physicians out there is: DEFENSE!! DEFENSE!!!
# posted by : 10:22 AM
: 10:22 AM
I look forward to reading the study. The things to remember is that it was only 33 physicians at only 2 hospitals. Also, the study showed that physicians' variability in practice was correlated to their fear of malpractice. It didn't actually look at whether fear of malpractice correlated with being sued. It didn't look at whether fear of malpractice correlated with better outcomes. It observed that high fear physicians admitted more medium risk and high risk patients so that presumably better outcomes might result. Here's an innovative approach (from 2002). Why not advocate for such a unit in your hospital, but I'm sure you would rather talk about malpractice.
http://www.hopkinsmedicine.org/dome/0203/to_admit_or_not_to_admit.cfm
http://www.hopkinsmedicine.org/dome/0203/to_admit_or_not_to_admit.cfm
Elliot -
You urge caution when looking at the study because the sample size is small - good for you.
You also say:
...so that presumably better outcomes might result...
Do you have evidence that medium- and high-risk patients admitted by high-fear physicians have better outcomes than those that are not admitted?
BTW, why are you so angry?
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You urge caution when looking at the study because the sample size is small - good for you.
You also say:
...so that presumably better outcomes might result...
Do you have evidence that medium- and high-risk patients admitted by high-fear physicians have better outcomes than those that are not admitted?
BTW, why are you so angry?
# posted by : 11:18 AM
: 11:18 AM
