Any wide-ranging discussion of cost containment in US health care eventually touches on the subject of "defensive medicine." Most legislators and regulators think they know what it is, but there is quite a diversity of opinion about what it costs and what to do about it.
The common definition of defensive medicine is simple: doctors order or recommend tests (especially) and treatments not because they think they are really necessary but because they are worried about the possibility of being sued if a patient suffers a bad outcome and there is some question about whether the doctor was sufficiently diligent, leaving no stone unturned in the pursuit of the correct diagnosis and omitting no possibly beneficial treatment.
As you might surmise, this way of practicing medicine can be quite a bit more expensive than would be a "less-is-more" approach. Remember that for every diagnostic or therapeutic intervention a doctor might suggest or offer, there is a risk-benefit analysis to be considered.
Let me offer an example. Suppose you are in a car accident. You don't appear to have any serious injuries, but you have some soreness in your neck, and you decide to go to the hospital emergency department to get checked out and make sure you're OK. What do you want the doctor to do? Well, if you've taken my advice from earlier writings, you want the doctor to evaluate you and render an opinion as to your condition. What you should not do is embark upon this visit to the hospital with preconceived expectations, such as that the doctor will order x-rays of your neck. Why not? Because of the risk-benefit analysis.
You see, it is entirely possible - in fact, probable - that the doctor can determine from an evaluation at the bedside that it is extremely unlikely that you have a serious injury to your neck. Adding x-rays to that evaluation will lower the statistical likelihood further by such a slight degree, if they are negative, that you should wonder if there is any risk associated with pursuing a tiny incremental increase in diagnostic certainty. And, indeed, there is. You have a gland in your neck called the thyroid that is quite sensitive to radiation. When you get x-rays of your neck - or worse, and increasingly common, a CAT scan - the radiation exposure carries with it a risk of later development of thyroid cancer. So what is the trade-off?
That is a question to which you should expect your doctor to know the answer. If the emergency physician knows the scientific evidence, the answer will be that the risk of thyroid cancer from getting the x-rays may well be greater than the risk of missing a significant injury by not getting the test.
So why do doctors almost always order the x-rays? Because they are afraid of missing something serious. They know that an undiagnosed injury to the cervical spine that subsequently causes a spinal cord injury and permanent disability will be blamed on the doctor. The bedside evaluation may be very reliable in predicting a likelihood of such an injury that is a tiny fraction of 1%, but would that sway a jury convinced that the doctor was wrong and the patient suffered harm because of physician error?
I believe this qualifies as "defensive medicine." The doctor orders a test mostly out of fear of being sued if there is a bad outcome and the failure to order a test is perceived as evidence that the doctor was less than thorough in evaluating the patient. And the consequence is not only the higher cost associated with unnecessary testing, but also the overlooked and under-appreciated potential harm.
There are many nuances to the discussion of defensive medicine, including what other factors influence doctors to order tests and treatments that aren't really necessary, and how much money could be saved if we could figure out how to change this behavior. Stay tuned to this blog for more of the story.
No comments:
Post a Comment