Dr. Kussin: Defensive Medicine

September 13th 2012   ·   0 Comments

By Dr. Steven Z. Kussin, MD, FACP

Medical Waste
No, not the toxic effluvium from discarded pharmaceuticals drifting in our water supply, or blood soaked surgical gloves in our landfills. I’m talkin’ medical waste…those tests that are a waste of your time. Rationing effective care will not be necessary if ineffective care can be eliminated.

When up to 10% of medical expenditures are fraudulent and 30% are unnecessary, it’s time to think. First, fraudulent care is not the domain of doctors. We do play a role, but thankfully a small one. It’s still news when a doctor is indicted for fraudulent billing or unnecessary testing that involves felonious misrepresentation of the facts to patients. In a 3 trillion dollar industry, there will be theft, fraud and lies.

Doctors do play a large role, however, in wasteful care. After all, we order the tests. We are now being urged to “cool it!”

Inappropriate care is where the undisputed waste lives. Here, the harms exceed the benefit.  Any test that can’t help you can still hurt you. Complications or false alarms set you off on yet more wild medical journeys. And these too can promote even more testing. It’s called the Cascade Effect.

Defensive Medicine
Defensive medical practice means ordering tests that help us, not you. It’s when a doctor orders a test she doesn’t think you need, but orders it anyway, to avoid being sued.  When it comes to malpractice suits, the thicker your chart, the thicker our armor. No one gets sued by doing too much. We get sued when it’s felt we’ve done too little.

I practiced defensive medicine. We all do. 90 percent of doctors reported practicing defensive medicine in the past 12 months. 92.5 percent of surgeons have ordered imaging tests to protect themselves from lawsuits. How much medical care is wastefully spent protecting us from liability? Estimates vary wildly. 3% to 34% of all care has been identified as defensive.

I think it’s fair to say one out of four tests are ordered by doctors to avoid litigation.

Remember, all it takes is just a ‘flick of the Bic’ and you are off and running. 42% of us who are skilled enough to perform high-risk tests on high-risk patients no longer do so. This is what good doctors must do in a failed medical system.

Will the Nazis Please Rise?
“Your Honor, these two defendants are just like the ones at Nuremberg. They were, they say, just following orders.” Who were these monsters committing crimes against humanity? Why it was me and an associate, that’s who. Two Jewish doctors to boot. Being compared to Nazi murderers is not nice. But the jury heard it before the judge cleared the courtroom. The damage was done.

Just reading through a summons… “willful negligence,” “patient abandonment,” “wrongful death,” and “wanton disregard” would make anyone feel like a criminal, Nazi or not. And yet this is the crazed and craven language that sickened me when I read through the list of complaints in a lawsuit I was involved in.

By the time doctors are 65-years-old, 75% of us in low-risk specialties will have experienced a lawsuit, compared with 99% of physicians in high-risk specialties. It can take six years before a case is adjudicated. During that time doctors are in anguish. Yes, anguish. Families are disrupted. Clinical practice suffers. Nights are inhabited by nightmares. Alienation, depression and finally anger threaten to turn all patients into potential adversaries.

True reform is not just capping the “pain and suffering” awards. Until real change in the system happens, doctors will, and should, look at you as someone who might one day be pointing a finger.  It doesn’t need to be resolved in a courtroom under the current tort system.

What Is Real Reform?
No one suggests that negligent care is rare, or that its results are not catastrophic to those who are injured or the families of patients who die unnecessarily. Mistakes are inevitable and yes, you suffer, sometimes terribly. Patients deserve compensation.

Money should arrive in an amount appropriate to the gravity of the error. It should arrive quickly to assist the patient or the family during stressful times. Lawyers shouldn’t get so much of it. Only one third goes to those that were injured. You deserve better. We deserve better.

Health Courts and Workman Comp-type clones have been discussed. But this isn’t about doctors….

How To Avoid Wasteful Care
This section is modified from an original that was published in the Annals of Internal Medicine. I have changed it so that now it’s parsed as questions patients should ask doctors, not questions doctors should ask themselves. Asking them may avoid a test you don’t need or already had.

Did I have this test previously?

If so, why do we need to repeat it?

Is the result of a repeated test likely to be different from the last result?

If it was done recently elsewhere, can we get the result instead of repeating the test?

Will the test result change my care?

What are the probability and potential of adverse consequences of a false positive result? Tests that come back positive, demand more tests, risks and money in order to determine if it was just a false alarm or the real thing. False positives are incredibly common.

Am I in potential danger over the short term if I do not perform this test?

Am I getting the test primarily because I’ve asked for it or is it to reassure me (or my doctor…or protect him from a lawsuit).

Are there other strategies to reassure me that are safer and less risky? How about I trust your opinion without the need for tests?

Next week: Financial conflicts of interest, profit motive and “money primed.”

By Richard