A small, unscientific survey to be sure – but I’m not surprised by the results.
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{ 28 comments }
So is it working?
Yes. You were asking me, right?
Yes – I sleep better at night knowing I ordered that CT scan for the headache I saw today.
But does it help avoid lawsuits? How can you tell? Have you ever detected a problem you wouldn’t otherwise have?
for headaches , you need to order an MRI/MRA and maybe LP
Many physicians won’t care whether it’s working on a “macro” level or not. Self-preservation and lawsuit-avoidance behavior will always be strong influences in physician decision making.
Think about it. Why worry about missing that 1 in 100 case by not testing versus sleeping peacefully at night testing for that 1 in 100 case?
There is currently zero disincentive to overtest. Capitation is falling by the wayside, there is a predominant fee-for-service system, and patients positively respond to physicians being “more thorough” by ordering more tests.
Talk about a lopsided risk/reward structure.
What would you do?
Kevin
Well said Kevin. Yes it helps. Yes it has saved my ass and the patients ass before. What idiots.
I have estimated that I spend with a stroke of pen 2-3.5 million dollars a year on defensive medicine. I am far from the most risk averse person in my group. Maybe if my salary was one million dollars I might be willing to take the risk and save the remaining 1-2 million dollars to society and the healthcare system. But as Kevin said there is absolutely no incentive to practice with more risk than you have to.
What is the actual risk to a physician who has typical levels of insurance in a lawsuit?
Kevin nailed it, though. The system makes money for testing. Thus, the tests get ordered.
But has anyone ever discovered anything they otherwise wouldn’t have as a result of what they considered overtesting?
But has anyone ever discovered anything they otherwise wouldn’t have as a result of what they considered overtesting?
Just a guess: probably, including some stuff that would’ve never threatened lives of patients if remained undetected. But because it was discovered they went through possibly toxic treatments. And suffered side effects maybe for lifetime. And a really large number of patients got caught in an endless cycle of more and more invasive and risky tests because of numerous false positives and inconclusive results. So very few win, a lot more loose.
Well, if we don’t know, how do we know all this defensive testing serves any actual purpose? Shouldn’t the doctors know this before doing all the dangers you mention?
“But has anyone ever discovered anything they otherwise wouldn’t have as a result of what they considered overtesting?”
Yes, frequently. Sometimes it means something, sometimes it doesn’t.
Interestingly, when a lawyer or lawyers family is being treated they often ask for the most testing. “Don’t you think we should get a CT, MRI, ANA titre for lupus, etc….”
“Shouldn’t the doctors know this before doing all the dangers you mention?”
Of course we know, self preservation and sleep at night come first.
They do (hopefully); but as they say, nobody ever gets sued for overtesting. You get a false positive – “doctor found something, my doctor is thorough”, you got (maybe) diagnosed with some early desease which possibly would’ve never caused you any harm – “my life was saved”. Because there is no way to say if something they found would’ve ever threatened your life.
Do you think all of the recommended tests are completely risk-free? Think again. The only difference is some evidence that there are people who benefit greatly from it. But the chance of you personally benefitting is extremely small.
“Interestingly, when a lawyer or lawyers family is being treated they often ask for the most testing. “Don’t you think we should get a CT, MRI, ANA titre for lupus, etc….”"
And your point is? If they’re willing to pay for it, or have insurance that is, what do you care?
“Of course we know, self preservation and sleep at night come first.”
You couldn’t sleep at night if you relied on your professional judgment solely?
If you’re not sure it works, isn’t your confidence a false confidence?
if they have a headache , and a few years down the road they have a subarachnoid hemorrhage, or tumor , they can fault you for not ordering mri/mra to r/o aneurysm , tumor, ( take my word for this)
People use to go to doctors and they diagnosed you by “touching you” (odd concept I know) pushing, pulling listening, smelling…RARELY did you get sent to a specialist. If you did you have reason to worry because it was not the norm for that to happen. You young guys act like you don’t really practice medicine. Do you know how? Does med school actually teach how to be a doctor anymore. Or, do they just teach how to order tests and refer to all these specialist to spread around liability?
One has to wonder if you could push on a persons belly and tell is the spleen is swollen. I don’t know if mine is swollen or not but I know it hurts when I read this BS.
“You couldn’t sleep at night if you relied on your professional judgment solely?
If you’re not sure it works, isn’t your confidence a false confidence?”
No, not at all. My clinical judgement gets me to 99+% certainty. The CT, referal, etc… makes the chart lawyer proof.
Suppose a patient presents with a lesion but denies any risk-enhancing behaviors (smoking, drinking, etc.) You do a surgical biopsy, send the results to the lab, and they come back benign. But the lesion recurs within months, you don’t know why, so you do another surgical biopsy. Same results, and again, recurrence within months.
How many times do you repeat the surgical biopsy as a defensive measure? If you elect to discontinue treatment at some point, how do you handle it — considering that you’ve already done multiple biopsies and have probably scared the bejeesus out of the patient by now?
And if the patient begins to suspect that s/he is on the receiving end of defensive medicine and wants to discuss it with you, then what? Do you have that talk? Do malpractice fears skyrocket, causing you to act in some other defensive fashion?
It does cost patients more than just the waste of time in getting unneeded tests, or extra worry, or being sent to specialists when it’s not truly warrented, or being subjected to possibly risky tests or biopsys. All this testing drives up health care costs big time. The tests cost money, and there’s no way around it. Expensive tests like CT scans and MRI’s cost a lot of money. And for what benefit, if they are only done for defensive reasons?
My insurance premiums went up 12% last year. The year before they went up 10%. When people (lawyers, health care consultants) come on these blogs and say that defensive medicine doesn’t contribute to increased costs, I believe they are wrong, and burying their heads in the sand. I believe that are not looking at the whole picture.
The only entities who benefit from all this extra testing are the places that perform the tests, like Quest Diagnostics or Labcorp. Check out their websites, and check out the profits those companies rake in.
I think the 50% number is way low. I’d say more like 95-99% of physicians order defensive tests based on my 20+ years as a practicing radiologist. I don’t blame them for doing it and it has made me a ton of money. It’s a win-win situation for everybody but the patient.
if you order the test, even if they don’t get it , you are still somewhat protected. Also, ANA is a reasonable screening test for SLE most times if they have polyarthralgia, swelling, etc. ; as opposed to a defensive measure
I had to tell a father today that his two children, age 2 and 6, both had tested positive for HIV. All he could say to me was “but I prayed every day this week that the tests would be negative”. I couldn’t help him, and i died inside knowing there’s so little I can do. Then I had to move on to the next patient. And to think I have to spend much of my week ordering defensive tests to keep away the maggots that are attorney’s when instead I could be using my time helping families in need like this. No-one seems to understand (or care) what the maggots are doing to our time and our health care system. This family (poor immigrants) can’t get the health care they need, but I can order an MRI on a mild headache “just in case”. It just isn’t right.
Anon at 1:24 – this is really tragic. How did these kids got HIV? Could it still end up a false positive?
I think another harm of overtesting is that it takes time and resources from the cases where there is a real need.
I have an off-topic question about this topic. Last couple of days it was inaccessible – whenever I click to see it, I got a blank page. Same with statin thread. It happened some time before with other topics. Anybody knows why it happens? Server problems? Powers that be didn’t like something posted? Hackers attack?
11:23,
I’m not sure but I think it might be Bush’s fault.
Anon at 1:24 – this is really tragic. How did these kids got HIV? Could it still end up a false positive?
Their mother was in a car accident in Haiti, went to the hospital and got a blood transfusion. Then got married to the kids father, unkowingly infected him, and they started a family and unknowingly infected both fetuses (or through breastfeeding) Really makes me grateful fo what little I have in life.
Can a Physician “86″ a patient if the patient refuses un-needed medical tests. Sort of like you can afford it why not!
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