CBS Evening News, defensive medicine, and me

Nice work Kevin!
I enjoyed the piece.

But do you always take patients’ blood pressures yourself or does your nurse to it?

Medical Imaging costs are completely out of control. Medico-legal implications aside, the fact is medicine is no longer a profession but a lucrative business -at least for some. The parallel with the Military Industrial Complex is uncanny. Medical equipment manufacturers roll out almost on a daily basis newer, better, and obviously more costly gadgets that dazzle doctors and patients. As industry would have us believe, we are just one more multi-million dollar machine away from perfect health and happiness. The deployment of this equipment in the community is usually a revenue-generating enterprise, and has nothing to do with the health care needs of the public at large.
The public health implications of medical radiation have barely been
touched. Every patient who receives an unnecessary CT scan is another data point in a massive, uncontrolled and unsupervised experiment in the effects of radiation on a large human population (in this case the United States). Responsible governmental bodies look the other way, perhaps for lack of adequate funding, authority or interest.
After all, the prevailing philosophy is that government is the problem, private equals good, and corporate profits rule.

“I just think between the drug company ads, the insurance companies and the ” medical ” websites, patients are too often second guessing their doctors. They forget that there is alot more to being a doctor than reading a book and as a nurse, I wish patients would have more confidence in their physicians skills.”
This is correct in part, but if we know that doctors practice defensive medicine i.e. order tests that we don’t really need, why should we be nice and quiet and comply? How can I not question my doctor if he routinely orders a non-recommended urinalysis on a physical exam (AGAINST recommendation from USPSTF, risks likely to outweight benefits). Why shouldn’t I refuse the test that is more likely to harm me (false positives, overdiagnosis) than help me? What about an ObGyn who routinely orders ultrasounds (every year) I have to pay her out of my deductible for no symptoms? Pray tell me how can I unquestioningly trust my doctors when they admit in ordering tests that I don’t need? I know that most people want every test in the book, but I am not one of them.

What about a doctor that wanted to prescribe statins for my LDL about 4 points above guidelines for my risk factors (if you go by numbers, not by absolute risk) even though my 10-year absolute risk of heart desease is under 1% (which doctor forgot to mention because either he doesn’t understand the difference between absolute risk and relative risk himself or he thought I don’t understand it, and this is in spite of my math degree)? Don’t you think I have a right to decide if .3 percentage point of risk reduction worth going on medication? I am a woman by the way, and the evidence for primary prevention in women is ever so overwhelming… NOT. Are you denying that some doctors overprescribe?

On the other hand, in some cases the doctors may indeed not know something and not order a test when it is indicated, especially if you have a rare condition that only affect a very small percentage of people. I happen to have POF, and starting at the age of 32, I’ve had 2- and 3- months delays in periods. At the time I wasn’t doing any research on my own, so I trusted my doctor. When my doctor ignored my complaints (”How are your periods”, “I’ve had some delays, 2- and 3- months”, “when was your last one”, “two weeks ago”, “OK”) or when I came with 4- months delay checked my thyroid, did a pregnancy test and sent me home with a prescription for Provera, I thought it was fine. I switched doctors at some point, but when the next doctor assured me that I cannot possibly be in menopause and that my hot flashes were all in my head, I believed him. It is only when I was 38 and the Provera failed to work, that he ordered a hormone test. Surprise, surprise – estradiol of 20, FSH of 70. It didn’t get there overnight, don’t you think? Had I done some reading on my own, maybe I would’ve asked to check my hormones sooner. It is not like this is expensive – it’s a simple blood test. Maybe it wouldn’t have changed anything, but maybe it would’ve helped my bones. I certainly regret not insisting on hormone test. I don’t blame my doctors, at least not anymore (although I was bitter for a while) – this is a rare condition and it is often undiagnosed for years, but I do blame myself for not being assertive and not insisting on hormone test. I am not yet 50 and I already have osteopenia. Maybe had I insisted on a hormone test at 33 or 34 or 35, it wouldn’t have made a difference, but maybe it would’ve. Maybe at the age of 33 I was still ovulating occasionally and could’ve rushed to have a baby (I am single which is why I hadn’t had a child sooner). Oh maybe it was already too late. I would never know, would I? Not to mention all the sleepless nights and all the symptoms that are a lot more severe when you experience them in your 30s and not in your 50s.

I realize that some people seem like pain in the .., insisting on every test they see on TV or on antibiotics for common cold. But simply following your doctors suggestions unquestioningly is not always the right answer.

Questions for Dr. Kevin:

1. Have you been ever sued in your life time? How many times?
2. Did any of those above go to trial? how many settled? how many dismissed? how many you lost? how many you won?

Till you answer all the above, you are no different another Joe doctor whining.

I am a radiologist for over 30 yrs. we are the ‘guys behind the tree’ which other physicians actively encourage their patients to sue for their errors of omission and commission. I got trained as a physician first before became a radiologist. The original art of ‘ listen,look, feel and think’ have gone way of the dodo bird. Who is responsible? Multiple sources beside tort/medico legal. But the FIRST culprit is ‘US’ Look in the mirror. Medical Education(Amer Med colleges, AMA, Amer Hosp association – the usual suspects) in USA needs another Fleschner study and over haul. Next tort reform, health education in elemenatary, middle and high schools. Alas, there is no money in it! So nothing is going to happen. Business as usual.

As a reply to the obstetrical comments above, may I emphasize that here in Long Island NY, the 2007 medical liability insurance for an OB/GYN is over $200,000 while Insurance Companies are paying, or trying to reimburse less.

Many such doctors are leaving the State. Others are just abandoning the OB part of the practice.

They are repeatedly being sued, after the birth of an imperfect child, even if the mother is a smoker, an alcoholic, a drug user, or all three. The “privacy” of personal habits is respected in our courts of law.

Thank you for making me laugh Anonymous Esq. Even if what you say it’s true, do you want me to believe that the suing attorney will allow his client to acknowledge smoking and drinking alcohol during pregnancy or using drugs ?

By the way: how many honest medical malpractice lawyers does it take to change a light bulb ?

Answer: BOTH OF THEM.

Dear Dr. N, O.K, I think I’ve come to a way to stop the all malpractice suits.
When every physician stops practicing medicine at the risk of a friviolous lawsuit, then nurses will no longer be able to care for patients ( we work under the direct instruction and supervision of the doctor).
These same lawyers will now have a MORAL and ETHICAL responsibility to care for very patients that they sued for.
Yes, since they already know more about the care and treatment of patients than the doctor does, I’m sure they wouldn’t mind.
Bedpan, anyone??????? mudpuppyfarms JP

7K for a scan and a read? WTF Radiologist’s better enjoy this gravy train because it is not going to last. Once malpractice issues are worked out, these scans can be read overseas at a fraction of the price. Nighthawks is just the beginning.

Great idea Mudpuppyfarms !

Here is another one: statistically speaking, the unsafest place in America is a hospital bed. More people die in a hospital bed than in any other location: restaurant, shopping mall or ice-cream parlor.

I had my bed for 40 years already and, so far, nobody dared dying in it. Therefore, if American get sick, let them stay home in the safety of their beds.

BEST,

Dr. N

P.S. I would love to have your opinion on my above mentioned novel.

Dear Dr. N, I will gladly read today and post. And yes, you are correct about the hospital beds, as the old saying goes- If you want to stay well, stay out of the hospital.
If more people would go for regular check-up’s with their physicians, things would be caught before a hospitalization was needed. Again,the ER is overused in place of seeing their doctors, but many of the people are uninsured for whatever reason.
We have a local clinic here, that people are encouraged to use and it’s based on a sliding scale fee, no one pays more than 30.00 a visit, but it’s staffed by a NP ( who I know and is quite competent)and nurses. But alot of the people prefer to see a real doctor, even if it’s in the ER.
By the way after further consideration of my last post, I didn’t think it through throughly.
It came to mind that after all the lawyers are busy taking care of these patients, who is going to sue them for malpractice? Maybe they can pay back the money they won (notice not earn) into a program that decreases insurance for physicians and sign an agreement- no more friviolous lawsuits, and let doctors and nurses get back to work, helping and healing patients just as we should. mudpuppyfarms JP

Dear Mudpuppyfarms,

Your ideas are great ! Why should I write them down for you ? You have literary talent. DO IT !

I was thinking to quit writing and become an executioner. After all, in the post-electric chair era, who knows better than an anesthesiologist how to administer intravenous drugs ?

But the lawyers scare me. What happens if “the patient” survives ?
Will I have to buy “Executioner Malpractice Insurance”….?
(If you read my book, you’ll find this idea in it -SORRY !)

Dr. N

Kevin,

I wish I would have seen this 1 month ago.

I have had what I thought was an abdominal muscle strain that just kept getting re-aggrevated. I finally went to a doctor at the Cleveland Clinic and he diagnosed me with an Inguinal Hernia. He was wrong. He sent me to the surgeon. The surgeon could not find the Hernia and casually sent me for a CT Scan. No discussion about costs or what this test was about. I did not have the background or frame of mind to ask about costs. I figured it could not be much because I am just getting diagnosed for simply either a aggrevated muscle or a hernia. Medical 101. Nothing else was discussed. The CT scan showed that I did not have an inguinal hernia. I do have an aggrevated muscle.

My bill came the other day and they charged me $3500 for 2 CT scans. ????? I am at wits end.

The Clinic is telling me I should have asked for the costs. I am telling them they should have let me know this is an expensive procedure and that it is not really necessary. Am I supposed to ask for the costs and how many pictures they are going to take? I am just an ignorant patient who goes to see a doctor about once every 5 years. The Cleveland Clinic posts a patients bill of rights but I say it is lip service. I did not experience world class treatment nor customer service.

What can I do to fight this?