The Cost of Defensive Medicine
A recent complaint letter involved the cost of a chest pain workup in a healthy young woman. She presented with a one week history of substernal chest pressure and shortness of breath that were worse both on exertion and inspiration. She was a cigarette smoker who took no medications and had no family history of heart disease or premature death. She denied cough, fever, or leg pain. Her vital signs and examination were unrevealing. She was basically just young and healthy.After her ECG, chest X-ray, complete blood count, blood chemistries, and cardiac enzymes were reported as normal, I went back into the room and explained the rationale for CT scan of the chest (to rule out pulmonary embolism, primarily). She refused the test, and she was discharged against medical advice after I carefully documented our conversation, her awareness of the potential risks, and her acceptance of the risks of death or disability.
After receiving her medical bills, she was shocked at the charges and filed a complaint with the patient relations department of our hospital. As an uninsured patient, her bill for my level 5 evaluation and management charge was $500. The addition of the ER facility fee, laboratory studies, X rays, and Radiologist's professional fee brought the total bill to almost $4000 even without the CT scan of the chest (which would have probably added another $1500 or so to her tab, I imagine).
She also included the obligatory charges that I was rude to her and that I never performed a physical examination. I appreciated her suggestion that I take a remedial course on how to relate to patients. She claimed that she discussed her symptoms with a relative in Guatemala who is a physician, and he told her to take some ibuprofen, and of course she got better. Why didn't I think of that? Time for me to start looking for some CME, I suppose.
If I was a physician in Guatemala, I wouldn't have ordered any tests either, and I would have only charged her a couple of chickens, or maybe a young goat. In America, unfortunately, we are required to overcharge, overtest, and overdocument in order to keep the hyenas at bay.
Zero defect.... you nailed it, Uncle Panda.
Labels: defensive medicine, ER, medical, rants
posted by scalpel at 3:32 PM
34 Comments:
I think a couple of chickens or a goat would be way too cheap for your services. Here in Podunk's barter system, a decent payment would be the above plus a Saturday of digging a vegetable garden, a hog for a hog roast, and maybe a decent saddle...
I got a complaint letter from a patient recently that was asking me to please revise my ER physician charges (which amounted to about $600) for a complex hand repair I had done.
He said he had already paid the hospital and the plastic surgeon (who didn't really have to do anything) and he didn't have any money left to pay me. I certainly understand, but I had spent almost 2 hours repairing this guy's hand after having called the plastic surgeon in the middle of the night who said "just do the best you can and I'll see him on Monday".
yes anon 4:45. But remember specialists always come in to help us out at night, just as a vascular surgeon mentioned 3-4 threads ago.....not.
Scalpel, no one "required" you to do any of those things. You, or your employer, choose to.
"Scalpel, no one "required" you to do any of those things. You, or your employer, choose to."
Geez, I thought there was some law called EMTALA....
Lawwuits are powerful conditioning devices. If there are two paths to choose from, one covered with velvet pillows and one with broken glass, you could argue that nobody required me to take the easier one. But I would still blame the vandal who broke the bottles in the road.
Lawsuit is a powerful reason, but why should a patient that has never sued anybody pay for your fears? It is one thing to pay a doctor for services that are done to benefit a patient, but why should she be required to pay for the services that only benefit you? This is different from what hallwayfour said because he actually performed a service that benefitted the patient. You have ordered a bunch of unnecessary tests (as you yourself admit) not for the benefit of your patient but for your own benefit. Had you ever told her why you were ordering the test and how likely she was to have the condition you are testing for? Don't you think she had a right to know? (BTW - after reading these blogs for a while, I will never agree to a test until I know exactly why it is ordered and how likely it is to benefit me. And I have insurance).
What about potential harm of any of these tests? How high was the probability she'd have a false positive and a complication of the evaluation of said false positive? Was it significantly lower than the probability she'd benefit or did you also risked to harm her to protect yourself?
I am not telling you that you shouldn't order the tests to protect yourself, but the patient has a legal right (ever heard of "informed consent"?) to know that you are doing it.
Every patient who files a lawsuit was once a patient who had never sued anyone. And if we never picked up an unexpected pulmonary embolism with a CT scan or a 1/1,000,000 MI in a 26 year old then it would be bordering on criminal to order all these tests.
But occasionally, we do pick up an unlikely but potentially fatal diagnosis by overtesting, yet if we don't do the test and we miss that diagnosis, we WILL get sued. An unlikely diagnosis is not a good enough defense against getting sued for malpractice in this country. Even if we win the suit, the hassle and stress factor makes it not worthwhile to rely solely on clinical judgement.
I would personally accept a 1/10,000 missed MI/PE rate if it didn't mean getting sued, but paradoxically the threat of a lawsuit is an even bigger negative reinforcement than a rare bad patient outcome.
"BTW - after reading these blogs for a while, I will never agree to a test until I know exactly why it is ordered and how likely it is to benefit me. And I have insurance."
As often as not most of the tests are ordered before you even see the physician. If you come in to the ER with chest pain, you are going to get an ECG, chest x-ray, and labs drawn while you are still in triage waiting to come back to a room. We'll usually talk to you before ordering a CT scan, but not always.
Defensive medicine is cookbook medicine. Tests are more important that history and physical exam....not because they are more sensitive necessarily, but because they are "hard" data that provide a stronger defense against suits.
"Lawwuits are powerful conditioning devices. If there are two paths to choose from, one covered with velvet pillows and one with broken glass, you could argue that nobody required me to take the easier one. But I would still blame the vandal who broke the bottles in the road."
So it remains your choice. There's a difference between choice and require.
And, since you have no idea if doing all those things will make it any more or less likely you'll be sued, much less win the suit, apparently you're making an uninformed choice. At the end of the day, you can't say "I am X% less likely to get sued, or X% less likely to lose at trial" if you do any particular test which you wouldn't otherwise do. Don't blame that on others.
If physicians focused even 1/10 as much on improving their communication skills as they do demonizing the victims of negligence and their lawyers, they'd probably have more direct effect on their chances of getting sued than anything else.
There are different levels of "require." Stop trying to make it black and white. A speed limit of 20 MPH in a school zone is "required," but you can go faster than that, often without adverse consequence. That doesn't mean that it's a good idea to do so. Buying your girlfirend a birthday present is a similar "requirement." Sure you don't really HAVE to, and nobody is MAKING you, but if you want to continue to have a happy peaceful existence, you do so. As required.
And I do have a very good idea that if I do full cardiac workups and admit 1,000 35 year old women with chest pain, perhaps one of them might end up having something life-threatening, and that if I hadn't admitted that one (and she died), then I have a very good idea that I would get sued. So your argument makes no sense.
You can be the nicest touchy-feely communicator in the world, but the husband who isn't in the room to appreciate the brilliance of your dialogue and the wonder of your amazing communication skills is 100% going to freaking sue your ass, guaranteed, if you send his wife home and she dies.
The best way to prevent lawsuits is to not have any bad outcomes. Being nice doesn't matter in the ER.
Why are all the tests obtained before the patient is examined by the physician. If the "chest pain" is easily reproducible with pressure on a cosotochondral junction then why order cardiac enzymes, CXR and an EKG?
"There are different levels of "require." Stop trying to make it black and white. A speed limit of 20 MPH in a school zone is "required," but you can go faster than that, often without adverse consequence. "
Huh? The word "required" is black and white. You're trying to avoid the fact that you have a choice by changing the meanings of words. If that's what you have to do to justify deviating from your professional judgment, fine. But don't pretend anyone is making you do that. As for speed limits, just because you're not always caught doesn't mean it's not still a requirement to go the speed limit.
"And I do have a very good idea that if I do full cardiac workups and admit 1,000 35 year old women with chest pain, perhaps one of them might end up having something life-threatening, and that if I hadn't admitted that one (and she died), then I have a very good idea that I would get sued."
This "very good idea" - what statistics is that based on? What is the percentage? And what is the percentage of those cases you'll lose? Presumably this "very good idea" has some hard statistics behind it, right?
"The best way to prevent lawsuits is to not have any bad outcomes. Being nice doesn't matter in the ER."
And yet, the evidence, not just "very good feelings" say otherwise. Evidence gathered by physicians, no less!
Stop trying to blame everyone else for the fact you are doing things which are in your medical judgment are not required or are not requested by the patient.
"If the "chest pain" is easily reproducible with pressure on a cosotochondral junction then why order cardiac enzymes, CXR and an EKG?"
Because reproducibility of chest pain with palpation does not exclude MI or PE. I vividly recall diagnosing a young woman of 26 with a pulmonary embolism who had chest wall tenderness over the site of her pulmonary infarction. With normal vital signs, normal exygen saturation and a normal ECG and chest x-ray, no less.
And to the argumentative anon, I'm not going to discuss semantics with you anymore. Perhaps you should read the definition of required I provided for you.
And you haven't provided any statistics either, I note.
i'm a moron and can't understand being between a rock and a hard place.
"And I do have a very good idea that if I do full cardiac workups and admit 1,000 35 year old women with chest pain, perhaps one of them might end up having something life-threatening, and that if I hadn't admitted that one (and she died), then I have a very good idea that I would get sued."
Assuming your estimates are correct, in what percentage of this cases your diagnosis actually makes a difference? Just because something is detected earlier doesn't necessarily changes the end result.
At the same time, in which percentage of this cases, these tests resulted in a false positive and in which percentage of false positives additional test has serious, potentially fatal complications?
So you ordered a bunch of expensive tests on a woman on a slim chance that she would benefit and at a small chance that she would be harmed by the tests. You failed to inform her of why the tests were ordered, so in a sense you violated her right to informed consent.
Even if I understand your reasons, it seems she has a perfectly valid reason to refuse to pay. She wasn't informed why the tests were needed, she wasn't given an opportunity to refuse. Why should she be required to pay for your peace of mind? She is not an insurance company to provide your malpractice insurance.
It really doesn't matter if it makes a difference in her outcome. But it looks better from my standpoint to make the correct diagnosis and admit a patient to the hospital, even if she dies, than to not make the diagnosis and send her home to die.
At least I have a better chance of winning the lawsuit.
And who said she wasn't informed? I generally explain the rationale for the tests, and the patient can either agree to them or not. If not, then she signs the AMA form releasing the hospital and myself from liability, or at the very least I document the discussion in the chart.
Many patients want to be admitted and want the entire gamut of tests done so they can be as certain as possible that they aren't about to die, even if it isn't very likely.
Other patients don't want to run up a big bill. Why should I face any extra liability because they are trying to save a few bucks?
"And to the argumentative anon, I'm not going to discuss semantics with you anymore. Perhaps you should read the definition of required I provided for you."
I read that definition. It is incorrect. You can define the sun as a rock, it doesn't make it so. You should stop trying to avoid taking responsibility for your actions.
"And you haven't provided any statistics either, I note. "
I'm not the one saying I am deviating from my medical judgment because of outside factors which apparently you can neither quantify or really even identify.
When you refuse to accept the authority of dictionary.com, the game is over. You are a lost cause.
"re·quire /rɪˈkwaɪər/ Pronunciation Key - Show Spelled Pronunciation[ri-kwahyuhr] Pronunciation Key - Show IPA Pronunciation verb, -quired, -quir·ing.
–verb (used with object) 1. to have need of; need: He requires medical care."
You do not "need" to order tests you don't feel are necessary. You choose to.
"choose /tʃuz/ Pronunciation Key - Show Spelled Pronunciation[chooz] Pronunciation Key - Show IPA Pronunciation verb, chose; cho·sen or (Obsolete) chose; choos·ing.
–verb (used with object) 1. to select from a number of possibilities; pick by preference: She chose Sunday for her departure.
2. to prefer or decide (to do something): He chose to run for election "
You prefer or decide to do those tests. Stop blaming everyone else for your choices. Either accept responsibility or don't do them.
Other patients don't want to run up a big bill. Why should I face any extra liability because they are trying to save a few bucks?
From the uninsured patient's (or insured with high deductible) perspective "why should I pay to protect my doctor from a potential lawsuit? I am not an insurance company". From (very few, informed) insured patient's perspective "why should I risk harm from the test if the probability of my benefitting is not significantly higher than risks of test?" (when applicable).
You are saying she was informed. Was she informed how likely it is for her to have the condition you are testing her for?
I understand your point of view. Maybe if I had been a doctor I'd have done the same - I don't know. But this patient has a point too. Why should she pay for tests that were ordered for your benefit and not for hers?
First you say the definition is incorrect, then you quote from it. LOL.
I used the word in this context, btw: require: 6) to place under an obligation or necessity: The situation requires me to take immediate action.
Or, "the current malpractice climate in this country requires me to order tests that have a low percentage of abnormalities in order to protect against the inevitable lawsuits for "missed diagnosis."
Is it ever OK to not diagnose a heart attack? Can you say that heart attacks NEVER happen in 30 year old or younger patients, so we don't have to even bother testing for them? Or are their numbers low enough that even if we miss say one or two of them per year, that that number is acceptable?
The only acceptable number of missed heart attacks or pulmonary embolisms in this country (meaning, the number that avoids lawsuits) is zero. Until you understand that fact, you will never understand my position.
No, as I've repeatedly said, your application of your fact pattern to the term is incorrect. You are not REQUIRED to do anything. No one makes you do it.
You claim the "current malpractice climate" requires it, but you don't define that climate because you don't know what it is. As I stated earlier, it's a risk/reward ration that you haven't even bothered to quantify.
Tell me, am I "required" to eat jello pudding 24/7 if I believe it will help me reduce the chances of getting cancer? That's effectively what you're doing.
"The only acceptable number of missed heart attacks or pulmonary embolisms in this country (meaning, the number that avoids lawsuits) is zero. Until you understand that fact, you will never understand my position. "
Wait - I see your problem. You think that simply because you believe something it is a fact. As long as you think that, further discussion is impossible.
Good luck. I hope you can one day realize the importance of taking responsibility for your life.
So if I'd used the word "induced" instead, your panties wouldn't have gotten so bunched?
Induced would have been appropriate, but bear in mind that there is often a fine line between an inducement and a requirement.
So if a relative of yours comes in to the ER and her chest pain is poo-pooed away with a Motrin prescription and a fare-thee-well, I'll take your word for it that you won't sue the physician or the hospital if she dies of a PE.
Thanks!
I laughed when I read the part about the pt suggesting you take a remedial class on how to relate to patients. That reminds me of a day I had. This patient kept disappearing off the floor. He was super nice until I pointed out that each time he came back there seemed to be problems with the PCA pump(and once the entire history was cleared). Isn't that odd. Anyway, he told us we all needed a class on how to work a PCA pump. He knew we were on to his game, and it pissed him off.
"So if a relative of yours comes in to the ER and her chest pain is poo-pooed away with a Motrin prescription and a fare-thee-well, I'll take your word for it that you won't sue the physician or the hospital if she dies of a PE."
I'll only sue if the phyisician's actions fell below the standard of care - a standard set by physicians. That fair?
Gee, that sounds swell. But in practice, that isn't what really happens. In reality, you will only sue if it is financially attractive for you to do so. The exact same diagnosis and treatment process could be applied to your 20 year old daughter and your 70 year old mother, but it wouldn't be financially lucrative for you to bother filing a lawsuit in the latter case.
The possibility of a windfall is greatly increased in the former case because of the earning potential and life expectancy, so the "standard of care" becomes much higher. If a bad outcome occurs, you will scour the chart for any possible angle to file a suit, because you know that even the threat of a lottery verdict will at least extract a juicy settlement.
The standard of care is a fictional creation by attorneys. Physicians have nothing to do with it. The new standard of care is to do whatever it takes to not get sued, whether it means ordering the extra couple of thousand dollars in tests, admitting a couple of extra patients per shift, documenting a few extra lines of legal CYA bullshit in the chart, or turfing as many high risk patients as possible to another service.
You don't have to believe me, I don't really care if you do or not. I'm just telling it the way it is.
And this ladies and gentlemen is why medicine is the mess that it is....
"Good luck. I hope you can one day realize the importance of taking responsibility for your life"
Spoken by amon who can't even take responsibility for his own words by putting his name down. I smell CJD scalpel.
Posts like these make me really really happy that I am studying medicine in the Netherlands and not the USA. I have never met a doctor here that will order a CT scan because he is afraid to be sued. Btw. in low risk patients the chances of causing cancer from CT radiation will sometimes be higher than the chances of picking up that one PE.
I blame the attorneys frequently (because I hate them) but really it is the American public who are to blame.They are the ones who want the megaworkups (as long as "someone else" is paying for it). Their families are the ones who will not accept the reality of death and who seek the lottery verdicts. The malpractice attorneys are just capitalizing on the situation and giving them what they want.
"I blame the attorneys frequently (because I hate them)"
Why would you hate thousands of people simply because of a license they have to do something? Particularly when they'll probably be the only ones who can help you in a time of great need? Are you impervious to all forms of harm? Or maybe you just think the other guy's insurance company is just itching to do the right thing by you after he runs you over in the crosswalk?
Oh, and standard of care is set by physicians. Hell, the expert requirement was put in there by physicians. Talk to the attorneys who do this for a living. It's not an easy way to learn a living -it's expensive and stressful - you don't just file suit and get rich. You ought to be able to working really hard on things that are really very intellectually difficult, don't you think? Plus, you get paid win or lose, so you don't even have that stress! But maybe you don't need to talk to the people who actually try cases to know what's going on in a lawsuit - after all, you've probably watched lots of Law and Order!
But people still need the service, because however honorable you might mistakenly think yourself, when you hurt someone as a result of your negligence, your insurer ain't rushing to write a check to cover their lost wages and medical bills. And I've yet to see a physician's personal check for any of it.
It's not their license I hate....it's their actions.
So far in my life, yes, I've been impervious to all forms of harm that I haven't brought upon myself. And even those events haven't been significant.
Standard of care is not established by physicians. There may be an attempt by physicians to explain or define it, because we are induced to do so by the legal system, but there is no established standard of care. It is completely an artificial construct of the legal industry.
The quality of care in an ED, for example, varies greatly depending on how busy it happens to be at a given time. If there are a handful of simultaneously crashing patients, for example, one of them might not meet the target goal for administration of antibiotics (door to drug time). If that patient happens to die even days later, the attorneys will pounce on that time lapse as if it were the immediate cause of death and nothing short of absolute incompetence by the treating physician, when in fact that patient might have gotten the best possible care given the situation.
Each ED physician has to treat multiple patients at once, and often there are dozens in the department at any given time. And yet your "standard of care" assumes we can give the same level of care to each individual patient no matter the circumstances in the department at the time.
Is it really negligent if while I'm trying to save a kid's life that granny doesn't get her antibiotic for an extra hour? Or if two gunshot victims come in at once, and one dies before I can stabilize him?
In your world, I guess. I'm just trying to do the best I can with what I have, every single night.
And I don't get paid half the time. I see patients who aren't required to pay, who are legally entitled to my services without regard for their ability or desire to pay anything whatsoever, and who are also entitled to sue me anyway if you find the tiniest deviation from your standard of care.
So I'd appreciate it if you wouldn't suggest that I am dishonorable, because you have no freaking clue.
Well, I think your initial mistake is assuming this patient had such a low probability for PE. As an Emergency radiologist I've seen plenty of "unepected" PEs in younger patients. Remember that today's young obese coach potatoes are getting diseases that were previously unheard of in this age group.
Yes, I sometimes curse the ED docs who are sending me PE study after PE study but I don't blame them one bit. This is a disease which has historically been very tricky to diagnose and now we have a fast and reliable test. I just shudder to think when the Coronary Artery CTAs start rolling off the scanners.
The rest of the studies which were ordered seem like standard chest pain work up to me. You come to the ED with CP and thats what you get.
Appropriate care given. Move on.
Post a Comment
<< Home