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.