It seems that patients are surprised and upset at the amount of defensive medicine and overtesting routinely thrown at them.
What about giving patients a choice? Not realistic, as this physician commenter eloquently summarizes our defensive medicine conundrum. I hope that every patient and lawyer reads this (emphasis mine):
I wanted to address a misconception: giving patients information about risks of diagnostic testing and allowing them to decide if, say, a CT scan is necessary for pain which has, for example, a 4% chance of being appendicitis, simply does not work. The phrase “patient declined CT scan,” does not protect the ER doctor in any way. A signed AMA form is marginally helpful.The ones “over a barrel” are the doctors, who know that their clinical accumen and training allow for 97% certainty. There was a time when that was sufficient. Now, anything less than 100% certainty is grounds for suit, whether you explained the odds or not. Explaining incidence of disease and risks of tests is just polite, and I routinely engage in such discussions with patients who show an ability to understand, but it doesn’t really have a place in emergency medicine, and doesn’t really affect my practice style.
This is why emergency medicine is so expensive. Armed with only a good history and physical exam, I can often exclude appendicitis with 97% certainty. But there will always be atypical presentations, no matter how good of a clinician I am. For each percentage point of certainty, add about $1000 of tests. Thus, lab tests get me to 98%, CT with contrast to 99%, surgical consult with admission for observation and exploratory laparotomy gets me to 100%. I frequently stop at 99%.
If I were to explain this to more patients, more of them would opt out of the scan. Because I see about 11 cases of abdominal pain per night, this approach would miss appendicitis at least twice a year. Therefore, giving patients the option increases the risk to me, because there is no protection except for 100% perfection. Documenting that there was no right lower quadrant tenderness of rebound does not hold up. We are sued not for deviation from standards, but for bad outcomes.
I really wish there was a better way. For patients who actually try to pay their bills (less that 17% at my institution), I feel especially bad. On the other hand, defensive medicine actually does help prevent that 1-2% extra chance of bad outcomes. Unfortunately taxpayers are picking up the tab (for my patients).
Related posts:
- More tests does not mean better medicine
- Appendicitis: CT vs straight-to-surgery
- Defensive medicine
- Value of primary care
- The many faces of appendicitis
- Health care secrets
- Defensive medicine op-ed reaction
{ 36 comments }
← Previous Comments
“But long story short…. it’s true that if you send a girl who came in with acute lower abdominal pain home with no CT, no repeat exam, with a lecture on condom use and an inadequate treatment for PID, and she is found unconscious on the bathroom floor 24 hours later with a ruptured appendix, you will be in the soup.”
Thanks for the advice…you must be a member of MENSA or something…
::eye roll::
Web MD has its place and I don’t knock people who look things up on it. But that has nothing to do with me, and with respect, you are being an ass.
I realize you dont’ know me, but I wish you would, too.
If he’s among their membership, I think MENSA might have a word with the ER doc who did just what I described.
You hang in there, SarahW. I was one of those cases of ignored appendicitis that nearly killed me.
It sounds like you “ignored” it too…or do you not consider yourself to have any responsibility in the matter?
“I was one of those cases of ignored appendicitis that nearly killed me.”
How much money did you make off the settlement?
Remember when they had insurance machines in airports? Perhaps they should put them back in doctor’s offices. Let you buy all the insurance you think you are worth, but limit your recovery to just direct damages. It is the punitive that hurts.
“Ignored” – I love the choice of words – sounds so malicious – those evil docs
Anonymous ER doc who sleeps well at night is a great example of why and ER is a great place to be if you are very sick but not a good place to be if you just have a headache. This doc is willing to spend amazing amounts of money and subject patients to painful tests in order to sleep better at night. I wonder if he/she will sleep well when the system hits such a high proportion of GDP that it becomes unsustainable. But hey, a few of those pick ups over the years justifies it all.
The last post brings up an important issue. Our current tort system demands unlimited care at any cost. By 2015 it’s estimated that health care will represent 20% of GDP. If that’s acceptable to society we should leave the tort system intact and let plaintiff’s attorneys set the standard of care. On the other hand if affordable quality health care is a worthy goal, let evidence based medicine set the standard of care. Not picking up every cancer or appendicitis will then have to be an acceptable trade off. As resources are limited, we can’t have it both ways.
My 29 year old married, healthy daughter, Professional, mother of 3, 5′5″, 130 lbs, woke up AM with cramping which she attributed to her upcoming cycle. 12 hours later, her husband took her to ER with excrucating abdominal pain, nausea, fever. The ER doc perscribes pain meds, no effect, pain increasing, he perscribes a different kind of pain med, ordered blood work and told her he thought she had the flu. Later, ordered a CAT scan to look at her appendix and the CAT was inconclusive because he could not see the Appendix. So he RULED OUT Appendicitis and told her she had a virus and ordered more tests. 24 hours later, her belly is HUGE, fever spiking above 103, in agony she gets a second opinion…2nd opinion Doc says get laproscopic NOW!!…by then her appendix has ruptured and things are a DISASTER. Over 2 weeks have now passed and she is home but so weak she can hardly walk, still in pain. Husband losing time from work, danger of abcesses, what a disaster! So, in my opinion, people going to the ER are treated like they are just going in because they aren’t feeling very well or have flu symptoms and that leads to this kind of missed diagnosis and potential lawsuits. All I can say is that the ER doc that told her she had the flu and left her laying there for 24 hours in agony better not send her a bill. Her insurance will pay him enough as it is. By the way, she never saw him again until the day they wanted to discharge her, still vomiting up her liquid diet, unable to eat, diarrhea, and in pain. So, some people who go to the ER REALLY need to be believed when they say they are sick, because they ARE!
…that is an ADDITIONAL 24 hours after the Doc leaves and after she is there all night until the next morning!
← Previous Comments
Comments on this entry are closed.