If we equate ordering too many tests with “defensive medicine,” here’s another reason that physicians practice defensive medicine: patient perceptions
Some patients have significant misperceptions about the way medicine is, or should be, practiced. Even if these patients have no basis for their misperceptions, all they need to do is complain about an emergency physician and the doctor will hear about it. There is a constant dynamic tension in the ED: administrators and hospital boards want patients to be happy, but physicians know that patient happiness doesn’t always flow from proper medical care.
Evidence-based medicine often gets thrown out the window in the face of patient satisfaction surveys. The Ottawa Ankle Rules may have a 100% specificity for detecting fractures, but if a patient didn’t get a dose of therapeutic radiation for their sore ankle and writes a letter to administration stating that they went to another hospital and actually got their ankle x-rays done, woe to the ED physician who didn’t order x-rays at the first hospital. Especially in competitive markets, any physician who doesn’t keep patients happy isn’t going to be around very long.
Hit in the head with a whiffle bat and not a scratch on the patient’s noggin? If the patient wants a CT to “make sure” there’s nothing wrong, even despite your lengthy description of the likelihood of no injury, you’re faced with ordering a test or getting another black mark in the “rude, uncaring physician” column.
If you’re a hospital physician, you have the choice of ordering other tests and keeping the patient or family happy versus having someone from Utilization Management leaving you nastygrams in your mailbox and voice mail messages at your office about why you are ordering so many tests.
If you’re in business for yourself in a private office, you’re faced with ordering a test or losing a patient to another physician who will order the test just to keep the patients happy.
In each scenario, ordering excessive tests sometimes becomes a “Hobson’s Choice“: make patients happy or have less patients. Defensive medicine becomes a “defense” of your livelihood.
Medical practice managers have the right idea with patient satisfaction, but are implementing it in the wrong way. “Have it your way” may be OK for hamburgers, but it isn’t always OK for medical practice. In medicine, the customer is not always right. Giving people the allusion that patients are always right just throws fuel on the fire. Just yesterday a parent left angry from the ED because I didn’t do blood tests on her healthy 7 week old daughter to make sure she didn’t have “that superbug infection.” I tried to explain it to the mom and she just tuned me out because I wasn’t going to give her what the kid’s grandmother thought she needed.
How do we get past this type of “defensive medicine”?
Doctors need to learn how to better communicate with patients. But some patients need to accept that doctors have more experience with medical issues than the media, the patients, or the patients’ Aunt Millie and her anecdotal stories. We have to develop trust. Unfortunately, with companies switching health plans, specialist offices on every street corner, families moving from one town to another, doctors moving from one job to another, and families losing insurance, many times the doctors and patients aren’t together long enough to cultivate that trust.
I actually had a defensive medicine #4 post planned, but these posts seem to rile up so many people that this one is going to be it.
So if we want to make a dent in the practice of “defensive medicine” and reign in healthcare costs, this whole communication/expectation/trust thing is where I think we need to start.