Bad Medicine

by Dan Summers

I watched President Obama’s speech last night with interest. As an unabashed supporter of health care reform, I was heartened by how clearly the President described the intentions of his reform package, and why the need for reform is pressing. As I mentioned in my discussion with Scott a little while ago, I think the need for insurance industry reform is particularly urgent, so I was glad to see that point hit early and hit hard. (It was also somewhat gratifying to see that doing away with such things as preexisting condition exclusions and rescission could get even Republicans on their feet.)

As a physician, I was also glad to hear that the President is willing to consider GOP proposals for malpractice reform. While the impact of malpractice costs per se on the overall cost of health care in America may be smaller than the Republicans would have us believe, the actual impact may be harder to measure.

My first real exposure to malpractice came when I was a medical student. Over the course of my rotations, I had become friendly with a resident on the obstetrics service where I was training. At some point or another, while providing cross-coverage for another service, he had had a very brief interaction with a particular patient who later had some kind of unrelated adverse outcome, with which the resident had been totally uninvolved. However, since his name appeared at a couple of points in the chart, when the patient filed suit against the hospital, he was named. I remember how, even though he knew he had done nothing wrong and was nearly certain to be dropped from the case, he was utterly dejected and disheartened to have been sued through no fault of his own.

Malpractice hangs like a weakly-suspended sword over all health providers, and it is drummed into our heads that it can happen to anyone. While we are taught that good communication can help prevent lawsuits (and I am gladdened to see a new emphasis on honesty and openness permeating the medical culture), most of us fear it dropping on us. This leads to over-testing and over-treating in an effort to short-circuit any potential criticism that we were not duly diligent and thorough. Because so-called “CYA” medicine is not flagged as such, the actual costs of defensive medicine are very difficult to quantify.

However, those unnecessary CT scans and referrals cannot be attributed to defensive medicine alone. There is no particularly gentle way of saying this, so I will instead opt to be blunt. A lot of health care costs can be attributed to sloppy or lazy medicine. And, if we really intend to reform health care and contain costs, it must be acknowledged and addressed.

What do I mean by sloppy or lazy medicine? I refer to such things as reflexive and routine blood tests being drawn in emergency departments when there is little indication that they will guide management in any way. To providers opting to prescribe antibiotics for viral illnesses because it is easier than taking the time to explain why such prescriptions are unnecessary (or, by increasing the possibility of resistant strains of bacteria, harmful), or to “cover all the bases” when there is little indication that such a prescription will effect any particular benefit for the patient. To doctors who, when faced with an unclear diagnosis, order a barrage of lab studies in the hopes that an answer will emerge.

Again, the impact of this kind of practice is difficult to quantify, since nobody writes “I’m ordering this because I don’t know what’s going on” on the lab slips. However, having now had clinical experience in over a dozen hospitals in two major cities (including some of the premier teaching institutions in New York City) and one rural setting, I can attest that these habits are wide-spread. They tend to be less prevalent (in my experience, at least) in teaching institutions where evidence-based medicine is taught and valued. However, providers also tend to avail themselves of resources that are readily at hand, so major medical centers with their proximate cadre of accessible sub-speciality consultants and state-of-the-art diagnostic equipment are full of their own pitfalls.

What’s to be done about this? We doctors tend to chafe at the idea that we need to be supervised and evaluated for quality of care. After all, we’ve spent years in training, and pride ourselves on our expertise. (I am not immune to these feelings myself, whenever I find myself being questioned about clinical decisions.) But we are just as prone as anyone to getting set in our ways and developing bad habits over time. Indeed, when such simple things as checklists in intensive care units are mandated in order to prevent infections from sloppy practice, they prove to be startlingly effective.

Part of the President’s proposal for health care reform is the creation of clinical boards to maintain standards of care, and to determine if patients are getting care that is inappropriate or unnecessary. This can be easily spun as “bureaucrats” taking away choices from doctors and patients. That prospect sounds frightening, and the exact role of the boards (including how much discretion they would have) is something that must be determined with utmost care and caution. But the truth is that many of those options that we fear losing are costly, unnecessary and ineffective, and we would all be better off without them.

The pill may be bitter, but that doesn’t mean that the medicine isn’t indicated for the condition at hand.

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3 thoughts on “Bad Medicine

  1. We should heed the good doctor’s observations. They are critical. I have long been skeptical that as much of the unneeded treatment and diagnostics we have in the system are a result of fear of lawsuits as is often claimed. Dr. Summers’ suggestion of ways in which excess creeps naturally into physicians’ practices is illuminating and especially persuasive for being confessional. Though he doesn’t say so explicitly, I think he also alludes to the important point that even when out of fear of being sued doctors practice unbeneficial, wasteful ‘defensive medicine,’ they are still partly responsible for that decision — endless waste can’t be justified simply because of the possibility of one day being sued; it is a high-risk profession to enter after all. Moreover, even if a cap on the highest awards (the most likely and most-suggested tort reform) is imposed , the experience of being sued will get no less unpleasant and there is no reason to believe the number of suits filed would come down. It seems to me that unnecessary defensive medicine — regardless of to what extent it really drives costs today — will be with us as long as doctors choose to practice it and are allowed to do so.

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  2. Hi, Dan, interesting read, as usual.

    I’m curious if the various moving parts of healthcare reform might be separated, just for clarity’s sake, when Congress makes bills. Anyone in engineering will tell you that doing several small-to-medium scale projects is much easier than rolling everything up in a big, hard to understand project. For example, tort reform to reduce defensive medicine can stand on its own. No reason to delay tort reform while, say, insurance portability is debated. No reason to back off eliminating waste and abuse in Medicare because consensus on IMAC scope is hard to achieve. I’d certainly prefer to see 8 to 10 50 page bills rather than a single 1000 pager.

    Also, I’d also prefer to know before we cast it into law just what the scope, and ideally the end result, of these clinical boards might be. Are we going to get an IMAC-ish all-or-nothing recommendation? Why aren’t current medical bodies providing recommendations or establishing standards of care? What knotty problems, if any, make such standards require government’s backing rather than, say, the American Board of Pediatrics? I’m not a physician, but inquiring minds want to know!

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  3. I have to differ with you on a couple of points. We as physicians seldom order a test because we are afraid of a malpracetice suit. Rather, there is a prevailing standard of care in our communities such that certain tests get ordered for certain conditions. A classic example is that of chest pain: most ED docs admit patients with chest pain, no matter how low risk. There is no incentive to send these patients home, as missed MI is a top 5 most sued event for ED doc. In addition, community standard of care may dictate ordering of a CT Chest for r/o PE. The ED doc can’t be faulted, nor can the hospitalist who then orders the nuc med stress test. It is the prevailing culture to order all these tests, and the prevailing standard of care. Evidence based medicine doesn’t hold up well against the prevailing culture. Picture: “Well gentleman of the jury, Dr. X didn’t order a CT of the chest because she thought the pretest probability was only 5%.” It just doesn’t fly in the face of community standard of care and culture.
    To that end I must disagree with Dr. Drew as well-Americans DEMAND all the latest tests and technology and are quick to seek lawyerly advice if they preceive they received anything less.

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