An issue that raised its head briefly in the last presidential campaign was defensive medicine, in relation to the malpractice crisis and tort reform. The president's argument was that the US could save ~$100 Billion per year in defensive medicine expenses if tort reform were passed. I don't know about that -- I think he may have misplaced a decimal there. The culture of defensive medicine is so engrained that I suspect even sweeping malpractice reform might not change practice very much, and the data from states that have passed tort reform seem to back that up.
But it's a little maddening to see otherwise excellent health policy boggers such as Ezra Klein and Kate Steadman claim that defensive medicine does not exist. Hard to measure? Damn straight. But every day of my working life, every patient I see, every diagnostic/therapeutic decision I make, the specter of "what if" haunts me. The decision-making for every single patient encounter is driven by three factors:
- What does my gut tell me this person likely has wrong with them?
- What do I need to do to reasonably establish the diagnostic impression?
- What do I need to do to cover my ass in case I am wrong?
For example, the "Standard of care" in ruling out an aneurysm in someone with the worst headache of their life is a CT scan and a lumbar puncture (spinal tap). This is something every ER doctor will agree on to near-unanimity. However, with modern high-resolution CT scans, the negative predictive value of a CT scan is something like 99.8% -- yet every single ER doctor will still do that LP, because if you don't and you are unlucky enough to have that one person in 500 who had the false-negative CT any ER doc will testify that you fucked up. That's defensive medicine. What's the cost? Well, a spinal tap costs maybe $300-$500, and you are doing 499 unnecessary spinal taps for each aneurysm you diagnose by the tap -- that adds up (in dollars as well as pain inflicted on patients who didn't need the LP).
There are examples of this kind of defensive practice for most any presenting complaint in the ER. Like chest pain. Good lord, how many people with atypical pain and no risk factors wind up staying in the ER six to eight hours (or admitted) for cardiac enzymes and a rule out? And it's because the acceptable percent of patients discharged with myocardial infarction is zero.
Don't just take my word for it; there was a lovely study recently published in AEM:
Emergency Physicians' Fear of Malpractice in Evaluating Patients With Possible Acute Cardiac Ischemia, Annals of Emergency Medicine, 46,6, 525-533 (abstract only)
Which documents that the more fearful a doc is of malpractice the more likely s/he is to admit a patient with chest pain, and the more likely s/he is to order extra tests or admit the patient to the ICU. And, as imporantly the diagnostic yield of the extra admissions/tests was nil. So this is not "better medicine" being practiced, it is CYA medicine.
Those of us who work in the pits call this "proving the inherently obvious."
So it makes me a little crazy when it's claimed that doctors aren't motivated by fear of lawsuits -- we are. Now if you want to claim that the overall fraction of healthcare dollars spent on defensive practice is low -- 1-2% of all spending -- I might agree with that. But bear in mind that the healthcare expenses in the US are in the trillions of dollars, so we are talking many billions spent on unnecessary care. If you want to argue that tort reform won't change doctor's practice patterns, I would be open to the possibility -- doctors don't want to be in the NPDB whether it's for a million dollars or for fifty thousand. But don't tell me that defensive medicine doesn't exist.