Defensive medicine starts early in residency training

Part of a resident’s job is to learn the ropes in preparing for independent practice. While you’re a resident, you get the benefit of having someone looking over your shoulder to critique you as you determine how you are going to manage patients.

I frequently tell residents that different attending physicians practice medicine in different ways. Some practice defensive medicine more than others, some prescribe antibiotics more than others and some work harder than others. The resident’s job is to figure out whose practice they are going to emulate when they begin practicing on their own.

That being said, I usually practice conservatively. I don’t tend to shotgun a lot of cases. When residents present cases to me, I make them give me a differential diagnosis and justify why they order the tests that they order. If they can’t justify why they’re doing the tests, then I won’t approve the tests.

A resident rotating on the first day in our emergency department presented a case to me and his comments made me think.

A woman in her 40’s came in complaining of tender lymph nodes to her neck for the previous 36 hours. That was it. She had pain in her neck when she turned her head to one side and thought she had cancer.

The resident ordered a CBC, comprehensive metabolic panel, cardiac enzymes, coags, chest x-ray, urinalysis, influenza swab, and strep test. He wanted to know whether I wanted to do a soft tissue x-ray of the neck or a CT scan of the neck.

“So what do you think is causing the swollen glands?”
“Maybe strep, maybe cancer.”
“Why the cardiac enzymes and coags?”
“If it is cancer and she needs surgery, the surgeons require a baseline.”
“Any other symptoms besides the swollen glands?”
“Nope.”
“Why the urinalysis?”
“I figured they could do that while they’re getting the pregnancy test.”
“Why the pregnancy test?”
“She’s going to need x-rays, right?”
“We can’t do an abdominal shield?”
“Sure.”
“Is a $200 flu swab going to be worthwhile?”
“It could cause the swollen glands.”
“In a patient with no fever, no cough, no pharyngitis, and the incidence of influenza sporadic according to the CDC?”
“Didn’t think of that.” He was obviously getting annoyed. “Fine. What do you want me to order?”
“Anything else on the physical exam?”
“Not really. No nodes anywhere else. No signs of infection.”
“Let’s go look.”

I’m typing this case up on the fly and was going to finish describing the interaction, but then I thought that maybe you all would like to take a crack at guessing what was causing the bilateral tender lymphadenopathy in the patient’s neck.

Here’s what it was.

The point of the post was not to belittle the resident, but was more to make a statement about how another resident felt that residency training was lacking.

Another resident in our program lamented that most of their didactic teaching doesn’t involve close physical examination or a thorough history any more. She felt that the overwhelming teaching points during the residency program were to perform procedures and to work up patient complaints to avoid being sued: Take the patient’s chief complaint, order tests that can rule out all the things that doctors commonly get sued over, and have them follow up with their family physician.

You make the diagnosis – great. If not – that’s why they have family practitioners. Patients with high risk complaints and any risk factors for bad outcomes get admitted.

I actually got pegged as someone the residents like working with because I make them think about what they’re doing  – although the resident above avoided me the rest of the day.

If defensive medical practice is as entrenched in our residency programs as this resident seems to believe, our system will get worse, not better with health reform. More “insured” patients will be dumped into the system, health care access will become more disjointed, and patient will end up bouncing from emergency department to emergency department getting shotgun testing that will rule out remote life threats and protect the physicians from lawsuits but that will never really get to the bottom of the patient’s problems.

This patient probably would have had a high WBC count if labs were ordered. Maybe she would have been discharged on antibiotics and improved without making the diagnosis. The cost to the system for the proposed workup, though, would have been immense. Is this the way we want to spend our health care dollars?

Until we address the fear of malpractice that drives defensive medicine (and I’ll even cede that some of that fear is irrational), we’ll never reduce our healthcare spending.

WhiteCoat is an emergency physician who blogs at WhiteCoat’s Call Room at Emergency Physicians Monthly.

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