Defensive Medicine: The Truth Is Out There

You wouldn’t think that “defensive medicine” would be so existentialist a question.  But constantly, we pose the question as to whether it exists – as though it were Bigfoot, little green aliens or any other paranormal activity tracked down by Scully and Mulder with serious faces and dire consequences.  The latest entry comes from blogger White Coat, an Emergency Room doctor.  He’s got great personal stories that yes, physicians practice defensive medicine all the time.  But he also demonstrates that we’re asking the wrong questions.

White Coat posts about an average day in the E.R. and gives a number of examples where his instincts told him he didn’t need to perform an extra test, but the patient or a niggling fear of an unlikely secondary ailment caused him to order the test anyway.  I highly recommend the whole thing, but this exchange is pretty typical:

A patient came in after being hit on the wrist with a metal bar at work several days ago. The back of his wrist was swollen. From his clinical examination, it appeared that the swelling was a ganglion cyst, but there was also some pain beneath the cyst. He mentioned several times that his boss wanted him to get an x-ray. So I did a wrist x-ray to “make sure” that there was no fracture. There wasn’t. Then I used a modified “Bible technique” (i.e. I used both of my thumbs to apply sudden pressure) to rupture the cyst. Problem solved.

The doctor has a pretty clear indication of what the problem was but ordered an extra test “to make sure,” usually at an instigation of the patient or someone with the patient (ranging from the aggressive nurse daughter who called the administrator when initially told her mother didn’t need an X-Ray, to the overly helpful “little bitties” claiming the likely inebriated patient had a heart problem that needed to be checked).  In each case, White Coat says, “I was getting annoyed with myself because I kept second-guessing my decisions to order tests that would most likely be normal.”

Ask any doctor what defensive medicine is, and they’ll tell you it’s ordering a test or procedure not because it will help the patient’s problem but to “cover their butt” or appease the patient.  From talking to doctors, I’ve heard hundred stories like this.  So it seems like an odd thing to debate when doctors themselves tell you it’s happening.  When medical societies like the Massachusetts Medical Society run surveys that say 22% of X-rays, 28% of CT scans, and 27% of MRIs were self-reported as being ordered “for defensive reasons,” they're designed to get our attention.  Doctors are waving their hands at us saying, "This happens."

But we debate it endlessly.  Why?  Because it’s a proxy fight.  We’re really fighting about whether there needs to be a cap for damages in medical liability lawsuits.  It’s the major source of Post-Traumatic Stress Disorder for health care providers.  It happens with stunning infrequency – the Center for American Progress reports only 5% of medical liability cases even go to trial, 80% of the time they are decided for the defendant, and in only 0.1% do you get the eye-popping damage rewards that are the not-so-secret terrors for hospitals and providers alike – but has an over-sized effect on our debate.  Some, like Tom Baker in The Medical Malpractice Myth argue with some persuasiveness that the data shows the real culprit for the panic is more malpractice insurance industry-based than jury-based.

Because our kneejerk debate is “if defensive medicine exists, then we must have a cap; if it does not exist, we do not need one,” we spend our time on questions of existence rather than what it should be all along – the safety and health of the patient.  Let's check off existence and move on to the really hard stuff.  What is very much open to debate – is all defensive medicine the same?  How do instances of defensive care relate to the projected 100,000 deaths by preventable medical error per year?  Do they even relate?  Where is the Institute of Medicine report on MRI Scans, CT Scans and specialist referral use in general and how the accessibility of these tests modifies our medical behavior?  Where are the studies that help define in a more objective way the difference between “normal caution” and “excessive caution?”  Are there geographic or social/workplace factors that make defensive caution more likely (we already know it’s more prevalent depending on specialty)?   When we jump right from "there is defensive medicine" to "we need a cap," we're not unlike the nurse daughter who jumped from "my mom has a scrape" to "she needs an X-Ray."

We waste too much time asking, “Does defensive medicine exist?”  We’ve barely scratched the surface on “How does it compare to other waste in our system?” and “What can we do about it that will actually make a difference?”  But the truth is out there.

(Photo credit:  Chiceaux on Flickr.)