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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  • http://Drackies@blogspot.com Frank Drackman

    Rule #1 of Emergency Medicne: “X-ray everything that hurts”

    Rule #2: See Rule #1

    that was about the extent of teaching during my 4th year ER rotation, and they used to have a “X-ray Viewing Box of Shame” for missed fractures/tumors/ and the occasional KUB with a fetal skeleton where the “B” was supposed to be…

  • JimmyZee

    This is what is awful about academic medicine. As a student/resident it seems you are either too thorough(expensive) or not thorough enough. In a 20 minute patient interaction, 2 minutes are spend with the patient and 18 minutes writing the note (since I was told on two occasions that a “good” doctor has extensive notes). Shouldn’t it be the other way around? Do we only write a lengthy note to practice defensive medicine and impress our peers? I would think that 18 minutes should be spent with the patient and 2 minutes on a note. I am sure the patient would appreciate it, a better history and physical would be performed, yet the short 2 minute note would be viewed as “inadequate” by peers and attendings. Medicine is completely backwards and screwed up.

  • paul

    wait. are you telling me i shouldn’t blindly believe the people that make the rules when they claim that

    1) defensive medicine doesn’t exist
    2) besides, it makes us better doctors

    ??

  • http://www.themusicwithinus.com Lisa Chu

    WhiteCoat, I love how you are shaking it up and making residents THINK!

    It takes extra time and energy to do real teaching and it sounds like you really enjoy it. Woo hoo!

  • Matt

    Paul,

    Who has ever told you either of those things? Defensive medicine does exist, but defining it is next to impossible. Whether it makes you better who knows? We don’t even know if it actually “defends” you.

  • Outrider

    One of my veterinary school professors emphasized that diagnosis is most likely to be found using the history and physical exam, not the tests ordered. Just for fun, I consulted Dr. Google and found this oldie but goodie: Br Med J. 1975 May 31; 2(5969): 486–489. “Relative contributions of history-taking, physical examination, and laboratory investigation to diagnosis and management of medical outpatients.”

    80 new patients. 66/80 diagnoses made after reading referral letter and taking a history. (The article is available in full text; I’m not doing it justice here.)

    Now to improve reimbursement and convince everyone involved that taking an excellent history is of the utmost importance…

  • Joseph W. Blackston, MD, JD, FACP

    As a prior academic physician (BC Internist) and attorney who has practiced ER medicine full or part time for > 20 yrs, and someone who reviews potential med-mal cases (about 1 in 10-20 are “valid”) for attorneys, please let me say this is a fantastic blog entry!!

    Or, to quote my hero Yogi Bera, “you can observe a lot just by watching.”

    I will admit that I often practice “defensive medicine.” I feel the majority of doctors do also. Some clearly take it overboard. (I knew an ENT physician who would not operate on a patient until he had obtained an anti-acetylcholinesterase antibody test to rule out the obscure possibility of a reaction to anesthesia!!)

    However, I would like to think that I simultaneously take a common sense approach to clinical issues like this one, and while a good, focused physical exam will often give you the answer, if I didn’t find it in this patient I probably would have ordered a CBC, but that’s about all. My usual response to “swollen glands” is that they almost all go down in a few weeks and if not, THEN you can start the workup.

    It IS important to document your thinking. If you feel a patient doesnt’ need a million dollar workup (few do) then document why. Many of the blog responses illustrate the appropriate thinking, i.e., “what is the most likely cause of this problem,” and simultaneously “what is the WORST case scenario for this problem,” and go from there. If your appropriate clinical impression is that malignancy is unlikely because the patient had tender nodes, and were present for a short duration, and had no other associated symptoms (weight loss, or “B-cell” symptoms like fevers, sweats, etc. if you are worried about Lymphoma) then I don’t think you will be deemed negligent even if that patient later DID have a malignancy, because you would have done a proper history and physical, and documented your clinical decision-making.

    As a physician you are not expected to be perfect. You are expected to be competent, and practice medicine like you would for your “favorite aunt,” and if you do that and document your reasoning, you should be fine.