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Defensive Medicine.
Defensive medicine as the cost of an aggressive tort industry - John Edwards cited a Congressional Budget Office report that the medical malpractice tort industry adds less than 1% to the total cost of health care in this country. But every physician I know would scoff at such a low figure as it does not take into account the practice of “defensive medicine”. This is when doctors order expensive tests and procedures even when the odds of finding disease are very low. A heated discussion is going on at DB’s Med Rants about this subject and I thought I’d add my two pesos.
Defensive medicine can be difficult to define (hence leading detractors to claim that it does not exist) but according to a 2002 Harris poll of 300 physicians, 79% say that they order what they consider to be unnecessary tests. “Unnecessary” in this context would mean a test that has a very low probability of finding disease (usually far less than 1%) given the clinical presentation of the patient. A less common definition would be getting a test, the results of which would neither change the diagnosis or prognosis nor change the treatment of a patient.
Defensive medicine has become so ingrained in our clinical culture that excessive testing has become the faux standard of care. When the real standards of care call for a few simple initial tests to evaluate symptoms, physicians regularly order a “battery” of advanced and often expensive tests. From a medical-legal aspect, the reasoning for this approach is straightforward. It is easier to defend against a lawsuit when a test or procedure has been performed then if it wasn’t, even if such testing would not have made a difference in the outcome of the case.
Even though it is difficult to measure defensive medicine there are some aspects of medical practice where legal defense against potential lawsuits has an undue influence over medical decision-making. Earlier this year I took a look at the rates of Cesarean section in various parts of Texas and I found that the rates of this obstetrical procedure were higher than the state average in three areas that happen to correlate with known areas of increased rates of medical malpractice lawsuits and tort abuse. The higher C-section rates in these areas also correlated with higher average costs of obstetrical care than the rest of the state. This example is just a small part of how defensive medicine adds to overall medical costs.
But all this increased diligence on the part of physicians must improve patient care despite the costs . . right? Well, no. There is no evidence that intrauterine peripartum fetal monitoring has decreased rates of cerebral palsy (the primary reason for obstetrical lawsuits) and even though C-Sections are credited with some of the decrease in neonatal mortality over the last 30-40 years there is plenty of evidence that the current high rates of C-sections in this country can be significantly lowered without affecting maternal or fetal mortality or morbidity.
Another example is the high rate of cranial CAT-scans of children in the emergency department following head injuries. Every year thousands of children receive minor head injuries as a result of typical play and sports but every year thousands of these children receive CAT scans despite the fact that they have normal neurologic exams and normal mental status (i.e. no indication of serious intracranial injury).
As a result, thousands of children are exposed to very high levels of radiation despite the fact that there is no data that aggressive scanning changes head injury outcomes and very few of these scans show any intracranial pathology. One of the reasons many of these physicians give for ordering one of these scans is because of “pressure from worried parents”. The real reason for these excess scans is that ER physicians don’t want to sit in a court room and try to explain why they didn’t order a CAT scan for a child who is now dead or severely disabled. A single CAT scan can cost over a thousand dollars. This certainly adds to the costs of medical care.
What we need is a tort system that is driven to seek truth rather then personal fortune and to use rational bases for proper compensation. We need a system where the actions of physicians are judged based on accepted standards of care by nonbiased expert witnesses using clinical evidence and evidence based medicine, and where the entire system is not run like a emotionally driven lottery a-la John Edwards.
If such a system existed and physicians felt that they could defend their decisions then maybe we would see much less excessive health care utilization and health care costs would actually drop. After all (as liberals love to point out) there is no evidence that the excessive amount of health care utilization we see in this country improves public health or affects mortality rates.
Then again, we live in a time when too many people believe that a multimillion dollar jury award is equivalent to justice served and such awards and the threat of such awards do not have any measurable effect on the health care system. These people live in a fantasy land but ironically they pay hefty health care insurance premiums as a result of excessive health care utilization that is in part caused by defensive medicine.
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So, You Want To Be A Doctor…..
Lately in the media, others have said and appear to express concern about the apparent shortage of primary care doctors in particular. Typically, the main reason stated and speculated for this decline of this health care profession that historically has been the apex of our health care system is lack of pay of this specialty when compared with other specialties chosen by potential physicians while in training.
Yet considering the additional attention of shortages of students in some medical schools as well, one may ask the question as to whether or not people want to be any type of doctor in the first place in the United States. About one third of their lives are spent achieving the requirements of this profession. Reasons for not choosing to enter this profession are several and valid and include the following:
There is the issue of long hours- with primary care in particular because of the apparent lack of doctors of this specialty. Such doctors may be over-worked without an expected pay reflecting the work they do. Furthermore, those doctors employed by health care systems are required to see a certain number of patients a day, and receive a monetary bonus if this expectation is exceeded. It seems that most doctors are members of such health care systems. So burnout never anticipated certainly may occur. And I consider such a requirement mandated by health care systems demeaning to this profession, and leave the doctor without the control that the doctor is entitled to due to their training and experience, and this competes with the other adversary of doctors, which is managed care. In fact, even government healthcare programs provide financial incentives in relation to the pay-for-performance system to improve the quality of care.
However, the recent increase in hospitalists, who are those doctors that are usually Internal Medicine doctors who care for patients presently under hospital care, and they have lessened the load for all doctor specialties for the work they do that the admitting doctors would have to do without their presence. This in itself makes a doctor possibly more effective and efficient in their practice outside of the medical institution.
All doctors, I presume, face a high degree of emotional and physical stress associated with their profession, as stated in the previous paragraph, for example. And this is not to mention the incredible stress associated with patient care in the first place, with some patient cases causing more stress than others. Patient care duty is a noble and great responsibility.
Doctors, due to the changes that have occurred recently in the U.S. health care system, not only have the issue of money to deal with, but also a loss of autonomy regarding patient care combined with loss of respect that may be due in large part to the others previously mentioned who dictate how they practice medicine. Ironically and often, these others who direct these doctors are not as qualified as the doctor in the first place. This is complicated by the perception that the public, with some who view doctors as having the easy life with their pay and profession, which does not seem to be the case presently. Another frequent occurrence is the doctor’s patient directing their care with their doctor from either DTC ads or researching medical disorders on the internet themselves.
There are also reasons of malpractice insurance, which is why doctors choose to join health care systems, it is believed, to pick up the tab for this necessity, along with eliminating the concerns of running a practice in a private manner, which historically has been the case, as their offices are owned by the health care system as well. Yet having another pay their malpractice premium does not eliminate their concern about being sued for error perceived by one of their patients. To protect against this, defensive medicine is implemented by doctors, which basically involves copious amounts of documentation and ancillary diagnostic testing regarding the doctor’s adherence to recommendations and guidelines.
It has been said that up to 90 percent of malpractice cases against a doctor are baseless and without merit, so they are unsuccessful for the plaintiff, yet this still affects the rate the doctor or another system has to pay for malpractice insurance of a wrongfully accused doctor. This is combined with the amount the doctor has to spend to defend themselves in such cases, which separates them from their focus on the restoration of the health of their patients completely. Furthermore, malpractice lawsuits cost about 100,000 dollars over the course of about 4 years for such cases. A tort reform in Texas in 2004 resulted in annual malpractice premiums reduced by about a third of what they were. Soon afterwards, claims against doctors remarkably dropped by about 50 percent. Some specialties of doctors pay more premiums for malpractice than others. For example, OB/GYN doctors have been known to pay around 300 thousand dollars a year for this insurance. Certain types of surgeons experience a similar high rate of malpractice premiums. Malpractice flaws are catalysts for doctors to practice the inappropriate defensive medicine mentioned earlier to avoid potential litigation, which is a waste of health care resources with ordering unneeded patient methods or procedures to cover themselves against such lawsuits.
Also, about a third of the U.S. is insured by Medicare, which progressively has lowered what they will reimburse a doctor for regarding the care doctors give a patient they treat. This fact is recognized by other insurance companies who will eventually follow the recommendations of Medicare, usually, regarding the reimbursement issue, so it seems. This will lead to a doctor having to see even more patients in order to make it financially with their profession, as this has resulted in the overall income of a doctor experiencing a decline of about 10 percent over the last decade or so.
Further complicating the financial state of a primary care doctors is that doctors normally have to pay off the debt acquired from attending medical school and training, which averages well over 100,000 dollars today after their training is completed. About 20 years ago, that debt was only about a fifth of what it is today. Paying this debt off is typically about 2 thousand dollars a month that doctors on average is what the doctors choose to pay in order to eliminate this debt in a timely fashion.
Conversely, there are some who believe that doctors in the U.S. are over-paid. This may be true, but they are not absent of financial concerns as with any other profession. And as mentioned earlier, clearly doctors accept more responsibility involved with human health than other vocations, so this should be kept in mind perhaps more by others.
Most doctors do not recommend their profession to others for such reasons stated in this article so far presently, and perhaps other reasons not mentioned. This is somewhat understandable, yet extremely unfortunate for the health of the public in the future. There have been cases where doctors do in fact change careers, and get into vocational fields such as medical communications or corporate medical companies. Also, expert witnessing is another consideration for those who choose to leave their profession. Finally, other choices considered include consulting and research. The training of doctors fortunately leaves them with options not involved directly with the flaws of medical care, but this is bad for us as citizens, overall. The etiology of their departure from their designed profession is largely due to the negative state of mind that occurs as a doctor in today’s health care system, which is expressed by them at times in apathy, cynicism, and vexation regarding their limitations coerced by others.
Conversely, not all doctors are deities. Like others, some are greedy and corrupt, which complicates others in this profession. Personally, I believe that the intentions of most physicians are bonafide. Yet in time, due to the nature of the current health care system, doctors frequently and really do become cynical, demoralized and apathetic. This may be considered a significant concern to the well-being of those in need of restoration of their health, understandably.
Not long ago, the medical profession that has been discussed had overt honor and a clear element of nobility. Such traits are not as visible or recognized anymore, which saddens many intimate with the profession and importance of public health that is needed by many.
“In nothing do men more nearly approach the Gods then in giving health to men.” — Cicero
Dan Abshear
Author’s note: What has been written has been based upon information and belief.