An ectopic pregnancy case shows how defensive medicine hurts patients

The next part of this continuing series. A look at how defensive medicine hurts patients as well:

I am not a doctor, but a patient. But I thought I’d write to you about how my recent ectopic pregnancy has driven up the cost of treatment for every single patient at my IVF clinic, most of whom self-pay due to limited insurance coverage for infertility.

Last fall, I had an IVF cycle, and 13 days past ovulation I had a Beta HCG pregnancy test. The result was 5.9. I was informed this essentially negative; that a chemical pregnancy had perhaps started but the number was far too low to be viable and most likely would resolve itself. I was instructed to wait 3 days and if I did not receive my period to return for another blood draw. Sure enough, I received my period within 2 days and thus did not go in for a second Beta.

Over a month later, a 9 week ectopic pregnancy was discovered that must have been the result of the IVF cycle (no sexual activity that month) but had gone undiscovered, with Beta HCG levels around 4800. I was treated with Methotrexate. Beta HCG levels dropped 20% within a week, but 8 days after the shot the ectopic ruptured. Within an hour I lost 2.5 liters of blood, and was saved by my IVF clinic’s doctors via an emergency salpingectomy and a blood transfusion.

I should mention that prior to this, I had several risk factors for ectopic pregnancy, including one prior ectopic pregnancy in 2003, in-utero DES exposure, previous abdominal surgery, and IVF.

My doctors were obviously quite concerned that they had not detected the ectopic earlier. By the extreme amount of attention and concern I received, I could tell they were worried I would sue. While I would never sue them – I did feel properly informed of the risks and besides that I owed them my very life – I was peturbed to later discover that in my chart’s operative report the attending physician wrote “patient chose Methotrexate shot in lieu of surgery, against advice” because this was totally not true. Prior to the rupture, another physician at the clinic (a fellow) accurately informed me of the risks of each course of action, and deliberately told me she was not supposed to make a recommendation, that it was up to me. But after I chose the shot, the IVF fellow told me she thought my decision was a good one.

Anyway, as the result of my case, my IVF clinic has instituted a new policy. Starting 13 days past ovulation, each patient must return every 2-3 days for a Beta HCG until levels are less than 1 or an intrauterine pregnancy is confirmed via ultrasound. This applies to all patients. These blood tests cost each patient $150 each; patients with normal pregnancies now must pay for 4 or 5 blood tests prior to confirming the pregnancy via ultrasound.

While I can understand instituting such a policy for women with multiple risk factors for ectopic pregnancy, such as myself, I feel very badly that my case has increased the cost of cycling by up to $600 for women who only have a 2-5% chance of having an ectopic.

Anyway, just wanted to sum up by pointing out that defensive medicine doesn’t always increase costs for the “system”, but directly increases the costs for other patients. But I do wonder how common it is for physicians to try to CYA by entering inaccurate information into medical charts. I adore my doctors and are so thankful to them, but my trust in them has eroded some as a result.

Defensive medicine is one of the leading factors in driving up health care costs today. The purpose of this series is to breathe some real-life examples into the numbers, and to provide some insight into how the threat of malpractice litigation pervades medical decision making.

Please e-mail me your stories of “how you practiced defensive medicine today”, and it will be posted anonymously as part of this continuing series.

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