IN DEFENSE OF DEFENSIVE MEDICINE?

I was surfing through some medical blogs the other day and found this Emergency Physicians Monthly - White Coats Call Room – A blog from inside the emergency department http://www.epmonthly.com:80

The doctor writes that “During a recent ED shift, just for the heck of it, I started taking notes as I went from room to room treating patients. I wanted to try to show myself whether or not “defensive medicine” was a figment of my imagination. It isn’t a figment of my imagination.”The ED doctor gives these examples which do not serve his purpose of showing up “defensive medicine as bad.” In fact if f I were judging by this doctor’s examples I would defend the indefensible. I would defend defensive medicine.
See if you agree.

His Example 1.
A patient in her 60s fell and hit her head 5 days ago. She was having a headache. I couldn’t find a mark on her and was inclined to send her home with pain medications. But she was on Coumadin which put her at risk of bleeding. So I did a CT scan of her head to “make sure” that she didn’t have a bleed. She didn’t.

But she could have! Couldn’t she? Remember the late Catherine Graham owner of the Washington Post who died post fall cerebral bleed. And how about the beautiful actress daughter of the famous Redgrave clan - Natasha Richardson--mother of 2 children who also died post a skiing accident of a subdural hematoma—even without Coumadin to precipitate and prolong the bleeding inside her head.. The only way to help these patients is early diagnosis by x-ray. When clinical findings occur it’s usually too late-- which this doctor, seems to disregard.

Example 2 given by this ED doctor as defensive medicine.
An out of town patient in her 40’s who had a long history of smoking and a history of COPD came in for coughing and shortness of breath. She was at a baby shower and had forgotten her albuterol inhaler. Her oxygen saturation was 92% on room air. Her heart rate was 105. She got a couple of treatments and steroids and was marginally improved. Her symptoms were most likely explained by her underlying COPD. I was inclined to discharge her with a prescription for steroids and another inhaler. Instead, I did a CT scan of her chest to “make sure” that she didn’t have a pulmonary embolism. She didn’t. She went home on steroids and an inhaler. We made sure to recommend that she stop smoking so that we wouldn’t get dinged by CMS for failing to meet a “quality indicator.”

This patient could very well have a pulmonary embolus kicking in a bout of SOB.

His third Example.
A patient dropped a TV on his foot. There was only a little red mark on the back of his foot, but the patient stated that he could not bear weight on his foot. I was inclined to wrap him up and send him home with pain medication and crutches, but I did an x-ray of his foot to “make sure” that there was no fracture. There wasn’t.
Only a little red mark of his foot-but he could not bear weight on his foot? Sounds like an x-ray certainly is indicated here.

Example 4.
A 94 year old demented lady was brought in because she was not “acting right.” Her daughter tried to wake her from sleep and had a more difficult time than usual waking the patient up. The daughter stated that the patient was “acting different,” even though nurses who had seen the patient before and the nursing home staff stated that the patient was not acting different. The patient got a bunch of labs and a head CT just to “make sure” that the allegedly incremental increase in her dementia wasn’t caused by a metabolic problem or a spontaneous bleed in her brain. It wasn’t. She was discharged back to the nursing home to finish her nap.

The most common causes of sudden dementia or worsening of dementia in the elderly are medication problems, metabolic causes and infections. This lady certainly deserved these “defensive medical tests.”

Example 5.
Then there was the suicidal patient. She was drinking, became upset with her boyfriend, and used a piece of broken glass to cut her wrists. Her alcohol level was in the mid-200s. She was drunk and she “was going to f***ing die.” But no psychiatric institution would accept her in transfer until she had a complete laboratory and toxicological workup, including an EKG and a urinalysis just to “make sure” that a whacked out chloride level or a raging UTI wasn’t really behind her suicidal tendencies.

That’s right. How many “psychiatric” patients die in the psychiatric unit not from psychiatric but because of drugs and metabolic causes? Too many.

This particular ED doctor obvious from his remarks, thought that he had to do all the “extra” studies because of “defensive medicine.”

“Why,” he asks, “was I ordering all of these things when my clinical judgment led me to believe that they would “probably” not lead to any changes in the patient’s management?

Hello! Clinical judgment is great where indicated. These examples however do not prove this doctor’s point. In fact the opposite.

The answer, he gives is that “because in our culture, “probably” doesn’t cut the mustard any more. Clinical medical judgment has been supplanted, he says, by the demand that physicians disprove the improbable. Society has made it so that physicians are more concerned with proving that unlikely diagnoses with the possibility of a “bad outcome” don’t exist and with maintaining good Press - Ganey scores. Many physicians are afraid to practice rational medicine based upon clinical judgment and physical examination skills. No one wants to face the liability. For those who would assert that I was practicing inappropriate medicine for ordering all of the “unnecessary tests” above, tell me which conditions that it would have been acceptable to “fail to diagnose” on the possibility that my clinical examination alone missed an unlikely disease process. That, my friends, is defensive medicine at work.”

Doctor, your case would be better made with better examples.

And doctor, I would further reply ---how about this case?

40 yr old indigent street guppy shows up to the ER with altered level of consciousness. Blood alcohol was .3 (almost 4 times the normal intoxication limit 0.08). ER Doc runs CBC, metabolic panel that shows only elevated liver enzymes, no surprise for chronic alcoholism. ER Doc decides to wait it out, and discharges patient after almost a full shift, alert and oriented. (No discharge blood alcohol done). Said patient returns 1 hr later, again altered LOC. Being a bounce back, this time he gets the full work-up. Blood alcohol 0.12, CT shows subdural hematoma.

What really is defensive medicine? Defensive medicine eludes easy definition

Definitions include:
“Medical practices designed to avert the future possibility of malpractice suits.”
“ In defensive medicine, responses are undertaken primarily to avoid liability rather than to benefit the patient.”
“Doctors order tests, procedures, or visits, or avoid high-risk patients or procedures primarily (but not necessarily solely) to reduce their exposure to malpractice liability.”

“Medical practices designed to avert the future possibility of malpractice suits.”
Some defensive medicine, however, presumably helps patients. Some paradoxically puts the patients in harm's way (the more you do, the more you are likely to "break something.")

As the blog complained, many believe that sound clinical judgment has been supplanted by disproving the improbable. Failure to diagnose, no matter how improbable, can, and often does, evolve into a multi-year odyssey narrated by "a plaintiff's attorney telling everyone how the patient's injury is an example of why [the physician] is a bad doctor and why clinical examination alone is simply not good enough." But the problem with the definitions are that defensive” medicine - ie medicine done to avoid the risk of liability, remains undefinable, because you don’t know if your liability is actually reduced by each “unnecessary” test you order.

COMMENT:
If I were judging by this doctor’s examples I would defend the indefensible. I would defend defensive medicine.


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