Ezra Klein argues against defensive medicine – but I think he makes some good points here:

DM exists, to be sure, but it’s not caused by lawsuits. It’s caused by patients. If you define DM as procedures that wouldn’t be ordered in a perfectly logical world, there’s plenty of it. But the reason most of these tests are run has little to do with the abstract possibility of a lawsuit that the doctor is insured against anyway. They’re done in order convert probabilistic diagnoses into virtual certainties . . .

. . . We have a medical system largely run off physician say-so, and physicians are human. Since they’re not responsible for the macro (the medical budget) but the micro (the individual), they treat for certainty, not savings. Treatments a computer program would, on the merits, deny, they approve. If conservatives want to kill DM, the way to do so is easy: rationing, bureaucracy, spending caps . . .

I also think that increased high-deductible HSA use will help decrease defensive tests that patients will be unwilling to pay for. Just make sure you document well.

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

  • Anonymous

    I had the same “Americanized” patients when I used to practice in Canada. But I used an entire different mentality and never ordered tests. In the ER (In the US) I figure out what’s wrong with the patient in 5 minutes, the cost of this is minimal and I don’t order ANY tests. Then I have to think “what if” and I order thousands of dollars in tests to cover the “what ifs”, only so I don’t get sued. SO much for the above argument.

  • jb

    Strong disagreement here. “Most malpractice suits relate to care gone wrong — an incorrectly amputated arm, say. They’re not the issue.” Most suits are related to docs doing the best they can under the circumstances, with a poor outcome, sympathetic patient, and hired gun expert with a well oiled retrospectroscope. Cases involving incorrectly amputated limbs and the like are settled early, but these are very rare and not enough to support the malpractice industry.

    “But the reason most of these tests are run has little to do with the abstract possibility of a lawsuit that the doctor is insured against anyway.” I didn’t have to read Mr. Klein’s mini-bio to know that he has no first hand knowledge of medical practice. That statement is like saying that most people would not care if they returned from a trip to find their house burned down because they have insurance.

    A prudent doc will always keep in the back of her mind that if her assessment and plan do not work out favorably, the next person to review the chart will be a plaintiff’s lawyer. In my experience, 3 or 4 years after the incident, they go over relevant parts of the chart word by word, and find alleged discrepancies in retrospect. The only defense against this is to minimize these potential discrepancies by testing for any and every conceivable explanation for the patient’s findings, in the order that a potential plaintiff’s witness would find appropriate. Since that is impossible, we order everything a soon as possible. That’s how your complaint of pain in the upper abdomen turns onto a $20K workup in the ER and subsequent admission when all you needed was some Pepto-Bismol.

  • Anonymous

    “Most suits are related to docs doing the best they can under the circumstances, with a poor outcome, sympathetic patient, and hired gun expert with a well oiled retrospectroscope.”

    This statement is utterly without merit or factual basis. Most physicians, probably including jb, know only about those lawsuits that occasionally make it into the paper. They don’t know about the vast majority that are settled pretrial, much less the ones settled presuit. They don’t know how many claims there are, what the basis for them is, or what the result of 99% of all claims made is.

    As long as physicians like jb believe the above as a matter of faith, they will never have an adequate understanding of how to avoid lawsuits, much less improve their practice and reduce “defensive medicine”.

    Have any of you even asked your insurer what the most common cause of payouts is? What the most frequent error is and what steps can be taken to avoid it? The insurer has the medical records from every claim filed.

    CJD

  • jerry

    CJD,

    Don’t you get tired of the same false diatribe? Stop it. I think you are a reasonable intelligent guy but diatribes like this is what completeley discredits you. We may not know the detail of every single case our insurer has settled, but we know the big picture details. My group is self insured so we know EVERY FREAKING DETAIL about all those things you talk about. A large part of ongoing CME relates to just how to keep plaintiff lawyers away.

    The largest dollar payouts for ER docs are for missed MI. This is usually a young person who had a normal EKG, maybe normal enzymes that subsequently has an MI after discharge. That is why your belly ache or chostochondritis costs 20K and gets you admitted.

    Other large dollar payouts are
    appendicitis
    meningitis
    tubal pregnancy
    wounds

    That is why you get irradiated with CT scans, ultrasounded, spinal tapped and leave the ER with 5k in bills and a headache.

  • Anonymous

    Defensive medicine can be alternatively defined as the use of all available medical diagnostic technology to reduce the risk of diagnostic uncertainty. It is drilled into the head of every medical student that a good history and physical examination should make the diagnosis 95% of the time. Well, I’m not sure how true this is. Especially in primary care where patients present with nonspecific symptoms and very early in the course of an illness, there is considerably diagnostic uncertainty in many patient encounters. We compensate for this by having the patient return for follow-up. ER physicians don’t have the luxury of follow-up, so they tend to order more tests to be more certain of what’s going on. I can’t blame them.

  • diora

    CJD, I’d be curious to see the list of last 50 lawsuits (without names, of course) filed in some place during last 6 months or so just so we can see how many of them are
    – missed rare diagnosis
    – diagnosis missed on some screening test that is not 100% accurate and has only small effect on the desease-specific mortality in the best case
    – some not recommended (and unproven to save lives) screening test like PSA hasn’t been ordered on a symptomless person

    and how many cases are obvious negligence like wrong legs amputated.

    You claim that the majority of cases are the result of real malpractice and not patients unrealistic expectations and their (and jury’s) ignorance as to the inherent inaccuracies of a test, probabilities of benefit/harm, etc, rarity of condition, etc. – could you provide some data? Just a list of last 50 or so trials with cause, effect, trial outcome? Since you say that others’ claims are unsubstuntiated. Because otherwise, we only have your word for it. And from what I read of your posts, your knowledge of benefits/risks of specific conditions is even less than mine.

    I am not a doctor, so I am completely objective, but I’d like to see some data either way.

    I don’t believe, by the way, that having people pay higher share will have an immediate effect. Maybe if the majority of people have to pay it will eventually, but not right away. It may have effect on people who demand tests, but not on doctors’ sending patients for tests. For example, I have high deductible, and 20% co-insurance rather than co-payment. If I go to a doctor for some bothersome symptoms and he tells me “I want to test for X” – I have no way of knowing if this test is clearly indicated or defensive. If the test is realy necessary, money isn’t the issue for me as I am not poor. If the test is for something unlikely than the probability of harm from the test, pain, false positives, stress is more important for me than money; if the test is completely unnecessary than money are also important. At any rate, without doctor’s giving me actual probabilities I have no knowledge. I can ask, and if a doctor is honest, he’ll tell me, but not every doctor will. So, I either have to do the test, refuse or go and do some research on my own. Either way, I don’t know enough to make an informed decision. If I am unconscious, I have no say at all. Just because I pay for some things out of my own pocket isn’t going to change the actions of doctors in this case. When doctors are part of medical groups they often don’t even know what insurance each person has (or do they?)

  • Anonymous

    CJD,

    Do you think that insurers want to go bankrupt? No, they track payouts, settlements, jury awards and therefore has a database from which to help educate physicians how to involve lots of consultants and order lots of tests to help prevent future monetary loss for the doctor and insurer

  • TomMD

    I can answer CJD’s question with some facts. I have been on the board of my state’s physician- owned malpractice insurance carrier and I’m on the peer review committee of my hospital (500 beds).Here they are: 1.About 50% of payouts are to settlements. 2.About 25% of payouts are due to trial-related verdicts. 3. About 25% though is for expenses related to suits that are dismissed by the plaintiff’s lawyer. 4. The “errors” are divided almost equally between failure to diagnose and surgical (bad outcome) related problems.
    Some comments on these numbers.The 25% of monies spent on dismissed suits is a huge amount that is pure waste in my opinion;the problem with the current tort system is that even weak cases from the plaintiff’s side can go forward and be very expensive. This idea that lawyers only take on a “strong” case is not true.Second, my carrier has done a review of errors, and most-greater than 50%-are errors of medical systems yet an individual person is blamed.Hospitals in particular are striving hard to solve these system errors.We also estimate that about half of settlements were defensible but were settled to avoid the cost,MD’s emotional toil, and erratic jury award of a trial.
    Any way that the data is spinned, a huge amount of money is wasted or goes toward legal expenses,and that could be used to pay injured patients or lower malpractice premiums.

  • Lisa

    I have a comment and a question for CJD.

    question for CJD: I have gleaned from reading the blog that you’re trying to convince physicians that the tort system isn’t as evil as they describe it to be. Instead of focusing on their hatred of med mal lawyers you want physicians to lobby the government to enact some other changes in the health care system. What is it that you want? I get a vague sense that you’re not interested in government-sponsored universal health insurance. What’s your stake in this?

    I agree with Kevin that high-deductible insurance policies will decrease tests and procedures of marginal benefit. Here’s a personal take. My husband had a sore throat for over a week. He wanted to go to a doctor. I told him that he would waste his time and money and that the sore throat will probably go away on its own (it did). He went to a family physician anyways. The family physician ordered a strep culture which of course was negative. When the culture was ordered, cost was not discussed. Our 20% share of the path lab’s bill was around $150 (we paid it as we pay all our bills). When my husband saw the bill he said that he would have never agreed to the strep culture if he knew how much it was going to cost and how improbable a strep infection was in his case. We’re not poor but we’re not interested in throwing away $150.

  • Anonymous

    I have been following this blog for quite awhile and now I must contribute. Malpractice cases may effectively be place into 3 categories: 1)Defendant obviously guilty–wrong leg cut off, etc. These are almost alway settled before trial, but frequently get the most press: 2)Defendant obviously innocent–shotgun suits against everone on the chart, no matter the facts. Personal example: I am a radiologist. Moved from MI to GA. Went to the beach for spring break with my family. Return on a Sat. to find a Certified letter in my mail from MI. I know what it is–MI has a 6 mo pre-suit notification law. Can’t get mail until Monday. Approx 36 hrs of living hell. Lawsuit confirmed after wife picks up mail on Mon. and calls me. Anxiety, anguish, etc turn into monumental disgust with lawyers when it becomes perfectly clear that I had done nothing wrong. Plaintiffs attorney could not even get a certificate of merit from another radiologist because I had read the x-ray properly. I guess I am just thin- skinned. I was dismissed from the case before discovery. Were they thinking: Oh, we’ll sue him anyway and maybe get lucky somehow and get some money out of it? This happens way more than anyone knows. But I guess CJD won’t buy it unless there is some “proof” that it happens. This is data which will never be collected, because there is no financial incentive to do so. and 3)Suits where there is a difference of opinion between expert witnesses–those cases that go to court. As a radiologist, one of my great concerns is interpretation of mammograms. Most doctors know that they are EXTREMELY DIFFICULT in many cases. Follow-up views, US are common. Even under the best circumstances, it has been shown that a significant number will be missed. However, in retrospect, well-paid expert witnesses have no trouble seeing them on old mammograms. Of course, the defendant’s expert thinks differently. Therefore, it goes to the jury. A 36 year old woman with three small children dies of breast cancer. Who is going to win that one? The whole process stinks. The best lawyer wins. Just ask John Edwards.

  • Anonymous

    The score so far:
    CJD = zero
    Doctors = five
    The doctors are winning.

  • Anonymous

    “question for CJD: I have gleaned from reading the blog that you’re trying to convince physicians that the tort system isn’t as evil as they describe it to be. Instead of focusing on their hatred of med mal lawyers you want physicians to lobby the government to enact some other changes in the health care system. What is it that you want? I get a vague sense that you’re not interested in government-sponsored universal health insurance. What’s your stake in this?”

    My stake is as a consumer of health care, and as a provider of health insurance for my employees. What I see right now (and by now I mean over the next 5 years) is medicine at a crossroads. In the next five years I believe there will be a radical change in the way medicine if funded and delivered. Most likely it will be to a universal health care system, because no other is being promoted. Politicians being politicians, they’ll take the past of least resistance, and the most votes. The voting public has no other alternative right now, because all they hear is that the current system is broken from their physician, and universal health care in some form is the only option that anyone has put forth in any detail.

    As an advocate of the free market, I really don’t believe that universal healthcare is the way to go. But I don’t see physicians, the people who have the most immediate and important stake in the whole debate, doing anything about it.

    Their whole focus legislatively seems to be on caps on damages. The AMA and state associations have spent millions in conjunction with the insurance industry on tort reform, while physician payouts are reduced by Congress with barely a whimper. Again, the people with the most at stake, and probably the most able to do anything about it, ARE NOT DOING ANYTHING but complaining. Hundreds of physicians can find the time in their busy schedules to turn out at the legislature for tort reform votes, but can’t to protest reimbursement rate cuts? This makes no sense. Are you all wholly owned by the insurance industry?

    My frustration with most physicians is three fold. One, that they refuse to see that this “crisis” is not new, and is merely part of the economic cycle that insurers go through every time the economy tanks. Two, that they expend so much effort on “tort reform” really just out of misplaced anger, because it doesn’t change how medicine is delivered nor does it improve their bottom line.

    And most importantly, because tort reform, at least in the proposals that have actually gone anywhere, just hurts people who have already been hurt. It does nothing for the physician. They think they’re getting back at lawyers somehow, but they aren’t. Lawyers will still make money (not as much as physicians, but plenty).

    Maybe I’m wrong though, maybe you all are willing to take universal health care with no-fault coverage. Because that’s the only way you’re going to get it.

    Personally though, I see that bankrupting the government and really costing the American taxpayer far more than they’ll receive from the benefit.

    Lisa, your comment illustrates another problem – most physicians rarely if ever tell the patient what it costs – of course, the insured patient doesn’t ask, but even so. The consumer has no clue what the cost of health care is. You’ve tried to read some of those statements you get from your insurer, I bet. They are indecipherable, not least because they don’t pay things for months at a time. I don’t know how many clients I have that get collection letters from the hospital for bills six months old that insurance hasn’t paid but they have paid bills 6 days old.

    The one person who has face to face contact with the patient and could explain it, doesn’t, though. Not to say that physicians should be solely responsible for doing so, but again, they have the greatest stake in where we go from here.

    CJD

  • Anonymous

    “The score so far:
    CJD = zero
    Doctors = five
    The doctors are winning.”

    If you think this current system is “winning”, no wonder you were so happy with that 15% reduction in Texas rates after a 150% increase.

  • Anonymous

    “Any way that the data is spinned, a huge amount of money is wasted or goes toward legal expenses,and that could be used to pay injured patients or lower malpractice premiums.”

    No matter how you spin it, insurers aren’t intending to use more of it to pay injured patients. Let’s not kid ourselves that the whole tort reform debate from the “reformers” side is about lowering the cost of health care or getting more money to the actual victims of malpractice.

    It’s about saving insurers money and putting more money in physician’s pockets from (hopefully) reduced premiums.

  • Anonymous

    you guys talk as if what you say matters…you have no power. This situation is unlikey to change in our lifetimes…it is the same arguments that are posted here again and again. I propose a moratorium on debating malpractice…let’s just keep battling in our own ways…the litigious patients can keep suing…and the doctors can sharpen their defensive medicine skills and in the mean time put it to the patients by screwing them with unnecessary tests, copays, exposure to radiation, iv dye, nuclear materials, lumbar punctures, biopsies. Fellow physicians, hang in there! If you follow the plan I have outlined, we will prevail! Unfortunately we will have to deal with nuisance lawsuits and the time wastage and such, but we will come out ahead! What do you think guys?

  • Liz

    If you had sticker shock at the bill for a medical service, that’s your own fault. Sorry but it is the patient’s responsibility to know their own insurance, as far as what it will or will not cover and at what co-pay or co-insurance. It is also your job to inquire about the price of any services in advance, if money is a concern for you. Obviously it would be nice for your doctor to tell you that, say, a strep culture costs $750, but it is not his ultimate responsibility.

    A practice with several thousand patients per physician probably carries dozens of types of insurance, and even within the same insurance company there are typically multiple kinds of plans, all of whose coverage and benefits are constantly “subject to change”. There is no way a doctor or his staff could be aware at all times for all patients what services and facilities are covered or require authorization, how much your co-pays for any kind of service are, who needs referrals, what medications are on your formulary and at what tier, what labs you’re capitated to, etc.

    My biggest pet peeve is patients who leave with a prescription then call back with an attitude four hours later because their insurance requires a prior-authorization for coverage (or won’t cover it at all), and god forbid you tell them doing so takes a business day or two. Sorry, your plan doesn’t cover it- try reading your contract or formulary and you’d actually know. The worst is when you get that crap from the Medicaid patients, who don’t pay a cent for their coverage anyway.

  • Anonymous

    Don’t accept medicaid, those people are probably the most likely to sue, and it is hard to turf them to a specialist to cover your ass because almost no specialist accepts it. Not to mention you don’t get paid diddly…

  • Anonymous

    Being price-conscious is all well and good. The problem is, the information often is not readily available, nor are patients in a good position to dicker about the services they’ll receive and how much they’ll pay.

    Sometimes the price is bundled into the overall cost of the procedure; other times there are ancillary or add-on services that patients have no way of predicting they will need.

    I’ve read my health insurance contract. It’s not your average bedside reading. Knowing what’s covered can be very hard to ascertain. A lot of health plans split their coverage 80/20 but then have exceptions, such as well-child care, where they’ll pay 100 percent. You need to be both a coding genius and a math genius to figure out what your out-of-pocket share will be.

    I’ve turned down diagnostic tests more than once because they didn’t seem to be necessary and they would just have used up money and resources. The clinic people looked at me like I had sprouted a second head.

    So what’s a patient to do? If you ask about the price, you often don’t get an answer. If you question the cost, the physician thinks you’re undermining his/her professional judgment. If you don’t ask about the cost, you’re bashed on blogs for being a spendthrift.

    I agree as much as anyone else here that the system is a mess. I’m just tired of the finger-pointing. IMO there is plenty of responsibility to spread around.

  • Anonymous

    I think the biggest mistake written here (BY MDs and lawyers alike) is using the words “winning” and “win” for physicians involved in Med Mal suits. The doctor never “wins”. He either loses, or loses big. To say he “wins” is to offer acceptance of the med mal system. And the majority of physicians don’t accept this system.

  • diora

    A lot of health plans split their coverage 80/20 but then have exceptions, such as well-child care, where they’ll pay 100 percent. You need to be both a coding genius and a math genius to figure out what your out-of-pocket share will be.
    It’s even worth than that. In most cases what is 100% varies based on your plan and this information is the best kept secret. I have 80-20 split for in-network and 60-40 out-of-network. The problem is, at least in-network it is virtually impossible to find out the base price.

    I have a personal health account where you could put money for medical care but that you loose whatever is unused at the end of the year. In November after our company switched insurance, I tried to figure out how much money I need to put there. I started calling my medical group asking the prices for specific things like an ObGyn visit, so I could estimate. They said, our price for uninsured is so-and-so, but it varies from insurance to insurance and they cannot tell me in advance what the price would be.
    So I called the insurance company. They told me, they cannot really say because they don’t know what code the doctor would write and it is managed by local brunch anyway. I asked if I could have the number of a local brunch and I mentioned a very specific thing like a pap smear. They told me they cannot say.

    So it is easy to say that the patients should find out all about their plan, when the patients have no access to the information.

  • jerry

    “Have any of your CMEs ever involved a plaintiff’s lawyer?

    CJD”

    Yes

  • Anonymous

    An office visit is not the kind of thing you will get blindsighted by if you owe 20%. The staff can quote you the cash price (for a PAP I would guess $100-$200 neighborhood) and you’ll know that is the maximum it can be, because it is illegal to charge cash patients a lower rate than what is billed to Medicare. Yes, the negotiated rate with your specific insurance will most definitely vary (and the office probably cannot tell you for sure in advance) but if you’re covering 20%, than the difference would be ten or twenty dollars at most.

    I think that poster was talking about the “surprise” costs or coverage denials of specific lab tests, radiology studies and/or prescriptions anyway. There is no reason a laboratory cannot tell you the cost of a throat culture, if only approximately. And frankly, I find it hard to believe a doctor or their staff would be offended if you ask about how much a test or drug might run.

    As for insurance riders not being “bedside reading”- no shit. Its a contract, its not supposed to be an easy read. That doesn’t mean you aren’t responsible for knowing what’s in it, just like a homeowner’s policy or auto insurance. (Or do you just make assumptions about what is covered there too because the contract is to hard to read?) The bottom line is- you are paying for the health plan, you are responsible for knowing what you are buying. If you cannot understand, call them and demand they explain or talk to HR. If you can’t be bothered, then don’t be shocked about surprise costs or claim denials.

  • Anonymous

    “Sorry but it is the patient’s responsibility to know their own insurance, as far as what it will or will not cover and at what co-pay or co-insurance.”

    How is the patient supposed to know what deals his provider has cut with each physician? And how are they supposed to anticipate that there is a 30% reduction for X procedure, and a 25% reduction for Y procedure, etc.? Particularly when they meet with their physician for three minutes, he tells them he’s going to order they get an alphabet soup of procedures, all in jargon they can’t understand, and he’s clearly in a hurry to get to the next patient because he’s already 1/2 hour behind for the day?

    You can know your health insurance contract backwards and forwards – doesn’t mean you’ll know what the charge for certain items is. Or what deal the provider and the insurer have cut.

    “To say he “wins” is to offer acceptance of the med mal system. And the majority of physicians don’t accept this system.”

    They don’t have to. Hell, Ken Lay probably doesn’t “accept” the legal system. It still applies to him, thankfully.

  • RL

    anon 9:23 wrote: “And frankly, I find it hard to believe a doctor or their staff would be offended if you ask about how much a test or drug might run.”

    From my experience as a patient, it’s not so much that they are offended, it’s just that they would have to contact the insurer to find out, which takes up their time. Hence – they just put the responsibility back on us patients to find out.

    For a patient to definitively find out from an insurer how much a service/prodecure costs, the patient will have to know the procedure or diagnostic code for the service/procedure. Maybe a provider will give this coding info to a patient, maybe not.

    As for how much a drug costs, and if it is on a plan’s formulary – my HMO doesn’t offer a paper formulary. The coverage and price info is on the HMO website or available through the HMO member 800 number. So, in order to avoid any surprises, the doctor would have to let me use my cell phone in his/her office, before leaving with a new drug script. However, from looking at my HMO website, the drugs that are not on the formulary appear to be those that are brand-new, or very expensive, and which have alternatives in the same class of drugs.

    I myself did once decline to take a brand name drug. It was for a minor but chronic problem. It would have cost me $130 a month, and that’s with insurance, for the lowest dosage. When I told the specialist this, she had no idea that the drug was that expensive. The same specialist has recently suggested another drug to me. Lo and behold, it’s not on my plan’s formulary, I suspect because it’s brand new, expensive and has alternatives.

    I know that doctors here complain that patients don’t know how much things cost, but I’ve seen times where my doctors have no idea how much certain drugs cost.

  • Lisa

    Yes, I should have asked how much a strep culture would cost before agreeing to have one done. I learned my lesson at the cost of $150. Won’t happen again. I am also not going back to that family doc who didn’t bother to tell me either about the price or about the likelihood of having a strep infection given the symptoms, length of illness, risk factors, etc. Sorry if it offends any of the docs out there. Thankfully we still have some kind of a market system in medicine.

    CJD, thanks for your answer.

  • Anonymous

    Apparently Anon 9:23 is responding to me.

    You’re the one who can’t read. I *said* I know what my health plan covers. My point was that the system is structured in ways that make it hard for people to determine the cost up front and often gives them no control over what the final cost will be.

    Hell, I don’t know why I even come here anymore. I thought I would learn something here, but most of you docs would rather engage in arguments and putdowns than have a constructive conversation. A pox on all of you.

  • Anonymous

    I agree with the above poster and also will not be posting here anymore. I have been more insulted, sworn at, called a sodomite (which I can’t possibly be, I don’t have the right equipement) by people in a profession that I have thought to be almost sacred.

    You are making me second guess my own personal physicians and quite frankly, they don’t deserve it. There are a few of you who think you represent the entire medical community and spread your venom as though you have some God given right to abuse people who you don’t even know.

    You don’t represent the medical community as a whole. You may represent the bottom 1% and I’m very thankful I have Drs. who care for their patients..

  • Anonymous

    “I am also not going back to that family doc who didn’t bother to tell me either about the price or about the likelihood of having a strep infection”

    People like you make me ill; it is also people like you that make being a physician miserable rather than the satisfying profession it should be. If you had strep and the physician didn’t do the test, you would be ranting about how you got rheumatic fever or glomerulonephritis from an undiagnosed strep infection, probably contact a lawyer, etc…that is why docs do the test…they would rather have you spend $ and get pissed than take a chance like that…DEFENSE!

    “I’m very thankful I have Drs. who care for their patients.. “

    Your docs think the same way, they just don’t say it to your face…you are so naive to believe this even after we have told you the truth.

    “I agree with the above poster and also will not be posting here anymore”

    Good riddance. See you in hell.

  • Anonymous

    You’ve got to be joking about not going back to the family doc who ordered a strep test for your husband with the sore throat.

    ITA, god forbid he actually did have undiagnosed strep and wound up with some more serious medical problems as a result. Can you honestly say you wouldn’t be in here ranting instead about how your incompetent doc failed to diagnose such a common problem before it got out of hand? If your doc had even a 5% suspicion that it could be strep, he is obligated to test for it. Sorry you have crappy insurance that makes you pay so much for labs, but that isn’t his fault.

    It is not reasonable to expect a doctor to order a test, then turn around and explain to you that you don’t really need it. My staff has been clearly instructed to never imply to a patient that a test wouldn’t be necessary. Even though it would be the patient’s choice not to have a test, if it can be documented that something I said convinced them it wasn’t really needed, there will still be liability from my end if something goes undiagnosed.

    If you were in fact serious about that comment, then I feel sorry for your next doc. Yes, you really are the reason some doctors hate practicing. You don’t even know your own ignorance.

  • Lisa

    I have nothing but respect for the medical profession. But can we please look at the bigger picture for a second. One option is to say let the government pay for all the basic things, ration most of them, and free doctors from the yoke of med mal lawyers. In this scenario, my husband’s strep test would be paid for and I’d have nothing to complain about.

    If this is not what most of you want, then like it or not, cost is a factor for patients. And if we’re trying to move to high-deductible insurance plans to take the middle man out of the doctor-patient interaction, then cost is very definitely a huge factor. Under a high-deductible plan, 100% of the strep culture cost will have to be covered by me. Most people will ask you lots of questions before agreeing to pay $750 to rule out all those 1% chance diagnoses. We have to figure out a way of dealing with this not keep on insulting each other.

  • diora

    For me cost is less of a factor(unless it is in the thousands) than the potential harm of a test (which includes inherent risks of the test, anxiety, false positives, incidental findings, etc.). For this reason, I’d have no problem with the strep test because a) I don’t see any harm in it b) there is a clear potential benefit both in avoiding compllications of strep and avoiding unnecessary antibiotics in case of a negative results c) it is accurate (right?) and d) most people can afford the price. I’d have no problems with any test that satisfies all of the 4 conditions above – clear if small benefit, no harm at all, accuracy, affordability.

    When there is a variation on these conditions, I’d like to know facts and be able to decide for myself.

    I would have problems with unnecessary cat scans or biopsies when the probability of the condition the test is for is low but there is a chance of harm.

    I think what would make more difference in current practice would be better education of general public as to the risks of overtesting. The current perception
    is that “there is no harm in testing” and “early detection is always great and the earlier the better”. The newspapers constantly rave on how scientists are working on test X that can detect some desease Y very early. They always forget to mention that if some tests are very accurate all of us may be labelled sick as there are currently no test to predict the progress of desease Y. Your collegues went a long way – in TV interviews, in articles on the internet to foster this view. If you put as much effort in educating public as to the risks and limitations, you may make a difference. Sure, juries listen to expert witnesses, but it is unrealistic to think jurors can forget what they heard on TV.

    One word to the doctors here who are really nasty. We don’t know much so naturally we may make mistakes. But anyone of us can be called for jury duty. If you are nice while you correct our misconceptions, you may just make a difference. Where I work people often say – you have to be nice to your co-workers, you never know if someone will become your manager in future. You never know, maybe one of us will be on a jury in your trial.

  • Anonymous

    “In this scenario, my husband’s strep test would be paid for and I’d have nothing to complain about.”

    So what you are saying is that if someone else pays for it, you want every test under the sun no matter the probability of a positive test…this is the craziness we have to deal with on a daily basis…I am glad you provided this example of the typical patient.

  • Anonymous

    “You never know, maybe one of us will be on a jury in your trial. “

    I am shaking in my shoes…maybe you should consider that one of us is your doctor!

    I don’t feel the need to placate you; jurors are going to do what they are going to do…we will continue to defend ourselves the best way possible…and hopefully that means putting you through as many tests as humanly possible…

    By the way, all you physicians out there…notice that this patient is so nonchalant about threatening you with a poor outcome if she was on a jury…this is the craziness we are dealing with…test away!

  • Lisa

    Anon 11:00, you’re putting words in my mouth. I didn’t say that I’d want every test under the sun if they were free. But if my physician says let’s do a test, and the test is free, why should I object? How is this crazy? If I were paying, it would be important to me to know the price and the benefit of the test so that I can determine if it’s worth it to me. But you knew all this, you’re just here to rant.

  • Anonymous

    “Good riddance. See you in hell.” Anonymous 12:18.

    Aha! So you admit that’s where you’re going too!

  • Anonymous

    Lisa, don’t let this guy get you riled up. He has to be the worst ER Doc. on the planet. He attacks every body who dares to question anything that spews from his satanic mouth. For the most part we have learned to ignore him.

    He is from the UK (atleast there is one from there who has his exact tone and use of language “sodomites, etc”)and I don’t even know why he posts about American medicine.

  • Anonymous

    “Lisa said…
    Anon 11:00, you’re putting words in my mouth”

    This is what’s so great about a weblog….I don’t have to put words in your mouth…it’s all in print!

    Here it is again:

    “One option is to say let the government pay for all the basic things, ration most of them, and free doctors from the yoke of med mal lawyers. In this scenario, my husband’s strep test would be paid for and I’d have nothing to complain about.”

  • Anonymous

    I teach residents at one of the hospitals I work at. They ask all the time about whether an expensive or invasive test “needs to be done” The answer is very simple — “Only if it is a true positive!!”

  • diora

    By the way, all you physicians out there…notice that this patient is so nonchalant about threatening you with a poor outcome if she was on a jury…this is the craziness we are dealing with…test away!

    Actually, if you look at my posts, you notice that I am often on doctors’ side and that CJD attacks the content of my posts more often than doctors do.

    And no I wasn’t threatening you – nobody would ever select me personally to be on the jury for a malpractice trial (if you read any of my posts you’d understand why) -I was just giving you some common sense advice.

    You sound paranoid at least to an ignorant lay person. Any psychiatrists here? BTW, if you hate ER work so much why don’t you switch to something safer like dermatology? If you specialize in cosmetic stuff like Botox, you’ll have very low risk of litigation.

  • Anonymous

    Diora, I simply disagree with you. Please don’t consider it an “attack”.

    And you’d be surprised – someone might very well select you for a malpractice jury. After all, if you believed there was malpractice, you’d not ignore your beliefs just because the defendant was a doctor, would you?

    CJD

  • diora

    CJD, you are right, “attack” was a wrong word to use. Yes, if I truly believed there was a malpractice I wouldn’t ignore it. It’s just that my standard of what is malpractice may be higher, especially in cases that involve delay in diagnosis.

    Main problem is that I will never be able to trust the words of an “expert witness”. I will not promise not to try to look up the relevant information on the internet (and I usually go to the source such as the journal where a relevant paper was published, USPSTF website; I also tend to read rapid responses section). I am pretty thorough when I research something – comes from working in a research center, I guess. Many of these papers are more about math than medicine, and I have a strong math background. It is kind of funny how sometimes the authors get an elementary school math wrong.

    I think lawyers and judges in malpractice cases want juries to rely only on the words of their expert witnesses; they wouldn’t want somebody who’ll say she cannot possibly stop herself from looking up the information herself.

    I am also not particularly enthusiastic about screening; not exactly against it, just think it is oversold.

    I also heard that lawyers don’t like overeducated people on the jury.

  • Lisa

    “I teach residents at one of the hospitals I work at. They ask all the time about whether an expensive or invasive test “needs to be done” The answer is very simple — “Only if it is a true positive!!”

    This is brilliant advice when it’s not your money being spent. You don’t need to go to medical school to figure out this little rule.

  • Cathy

    CJD,

    I would have difficulty being on a med mal jury. I have very strong beliefs about what I think constitutes malpractice. Delayed diagnosis would be a hard one for me. I feel that people get sick for many many different reasons. I also believe that our own lifestyle habits creates most of our medical issues. Most of the time we don’t like to except that idea and if we think we can pass the buck then why not?

    I just don’t think Physicians should be blamed and held accountable when the reasons so many illnesses happen is because of the things we, ourselves, do to our bodies.

    It would take alot more than expert witnesses to get my vote.

    That is not to say that I couldn’t find malpractice present in the case where it truly was..Wrong leg cut off, etc…those are the easy ones though that usually dont even go to trial.

  • Cathy

    ps…Thats also part of the reason why I adamantly fight against this defensive medicine. Personally, I’m covered for any tests they want to run on me, I just dont want them to do it. I want it suggested to me, I want to know what the percetage is of this test actually showing something. I want my Physician to deliver medical care based on his education. I want to sign a paper or form or something that releases my Doc. from liability, if he would just agree to not use all this defensive medicine.

  • Anonymous

    Somewhere back there someone had suggested universal health care. I am a general surgeon and would whole-heartedly welcome universal health care. On a personal note, I would at least get paid for every patient that I see, rather than writing off many of those patients who don’t have health insurance. For the patients, everyone gets whatever level of “standard of care” that would fall out (major organ transplants, bone marrow transplants for non-hematological cancers, etc. – may no longer be readily available) and the many patients that I see – ages 55-65 who were factory workers or laborers – would finally get the health care that they deserve. I foresee a multi-tiered health care system in the future – the basic level universal health care and then additional coverage for those who want more expensive tests and procedures. But let the buyer beware – who is going to pay for this (the taxpayers) and there will be rationing as a result.

  • Anonymous

    “I also heard that lawyers don’t like overeducated people on the jury”

    What a humble person you are…

  • diora

    What a humble person you are…
    No I am not humble – humility is for those who don’t have anything else.
    Seriously, I used “overeducated” ironically, to refer to anybody with an advanced degree. I was told lawyers prefer people without any college education because they are supposedly more “objective” (or if you prefer easier to manipulate). Do not know if it is true.