The following op-ed was published on April 23rd, 2008 in the USA Today.
A recent analysis by PricewaterhouseCoopers concluded that more than half the dollars in our $2.2 trillion health care system are wasted.
Medical errors, inefficient use of information technology and poorly managed chronic diseases were all cited as factors. Dwarfing these reasons is a phenomenon in which doctors order tests to avoid the threat of a malpractice lawsuit. This is known as “defensive medicine.”
At $210 billion annually, defensive medicine is one of the largest contributors to wasteful spending, and it can manifest in many forms: unnecessary CT scans, MRIs, cardiac testing and hospital admissions. A 2005 survey in the Journal of the American Medical Association found that 93% of doctors reported practicing defensive medicine.
When you consider that rampant testing is a major driver of escalating health care dollars, addressing defensive medicine should be a primary goal of cost containment.
Testing to protect the doctor
Why do doctors order these unnecessary tests? The simple reason is that every physician wants to avoid being sued. Win or lose, the ordeal of a malpractice trial is a devastating experience. The American Academy of Family Physicians, citing a study that interviewed doctors who had fought medical liability cases, said 90% “suffered significant mental effects from the lawsuits” and, disturbingly, 10% contemplated suicide.
In an optimal system, every case tried should involve clear medical malpractice “” wrong-site surgery or performing an incorrect procedure, for instance. But the reality is far from that. Poor medical outcomes occasionally occur despite textbook medical care.
A landmark study from The New England Journal of Medicine analyzed more than 1,400 malpractice claims and found that in almost 40% of cases, no medical error was involved. Facing such an unpredictable malpractice climate, a physician’s instinct is to increase testing. When facing jurors and trying to explain a medical catastrophe, who wants to tell them why a specific test wasn’t ordered?
In my experience, patients don’t seem to mind the extra testing, and they often equate defensive medicine with “more thorough” care. After all, if one test is good, wouldn’t more be better?
More harm than good
Not necessarily. Every test has the risk of a “false positive,” which is a positive test in the absence of disease. Doctors generally act on every abnormal result, so a simple X-ray finding could lead to further tests, such as an advanced imaging scan or biopsy. When you consider that a CT scan can expose patients to radiation equivalent to several hundred X-rays, and a biopsy might have serious complications such as bleeding or infection,there comes a point where increasing the frequency and degree of diagnostic studies could lead to harm.
This is what studies have found. Pioneering work by researchers at the Dartmouth Atlas Project concluded that higher intensity medical services have led to worse outcomes, higher costs and an increased number of medical errors.
How do we tackle this problem?
Whenever a test is performed, there has to be a willing patient. Know that more tests might not always be better medicine. Before undergoing a scan or procedure, understand why it is being ordered. This includes a thorough discussion of the risks as well as a sense of what the physician is looking for. Patients tend to decline tests of questionable benefit when appropriately informed of possible complications. Don’t be afraid to ask questions.
For physicians, remove the incentives to order defensive tests. Specifically, the malpractice system needs to do a better job to not try doctors who experience poor medical outcomes despite practicing the appropriate standard of care. Although the majority of physicians win malpractice cases, remember that the trial itself is emotionally scarring and that the statistics do not reflect the vast number of cases settled out of court.
Until the system is perceived as being fairer, physicians will do all they can to avoid being sued. That involves ordering unnecessary tests, which is a shame, because those billions of dollars can be put to much better use.