Ask the Boss: Two approaches to defensive medicine

When I got out of residency I was a minimalist when it came to ordering labs and X-rays.  But now there is pressure to order every test that I might possibly need on the first go round just to expedite patient flow.  I’ve finally given in and now I shot gun everyone.  But I still feel guilty thinking about the patient’s bill. What do I do?
-Dr. Pan Lab

 

The Pragmatist  |  Mike Silverman, MD
In today’s litigious society, many of us struggle with this exact quandary: how do I walk the line between efficiency and defensive medicine? This is actually a very hot topic among hospital administrators as utilization impacts the bottom line. In terms of practical advice, there are a few truths when working in high volume, high acuity ED’s. Don’t rush to buck the system. Many facilities have standard nursing advanced orders based on chief complaint which help to guide care and speed patient flow. Trying to change this practice as a new doc won’t make you very popular and will slow you down. Second, know that nurses, like EPs, want an efficient patient encounter: in, out and on to the next task. If you order labs, get results an hour later, and then want more labs, the nurses will wonder why you couldn’t have seen that need before. Like a chess player, experienced EPs can anticipate the patient’s work-up two and three steps ahead. The CT scan is ordered on the initial round of tests because they know it’s going to happen regardless of the first round of testing. Considering the cost impact on patients is great and I’m sure your patients appreciate it, but as an attending physician you now have the obligation to keep the entire department moving and to think about all of the patients in the department. And sometimes efficiency actually means additional tests. Some food for thought: if your turn around time is quicker than everyone else’s in your group, your system may work for you. Also, what’s your utilization rate? My company provides a dashboard which can give us this information so we can quickly compare ourselves to others. I once had an attending say, “Ask another question and order one less test.” In today’s high acuity and high volume EDs, that might be easier said than done.

 

Michael Silverman, MD, Co-Director, Johns Hopkins/TeamHealth Administrative Fellowship

continue next for a response from Greg Henry, MD
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The Purist  |  Greg Henry, MD
The concept that ordering tests stops malpractice cases is an urban myth. I have, over the last 33 years, evaluated almost 2,000 cases. It is by far the largest series in emergency medicine. I can honestly say that the doing or not doing of one specific laboratory test almost never influences the outcome or the liability situation. People are more concerned about candor than they are about white counts. The idea that ordering one more useless test is going to save us from a medical legal problem borders on the ridiculous. The nature of medicine is that all testing is subordinate to the history and physical taken and it is secondarily subordinate to the discussion we give the patient as to where they are at any point in time in the work up of the disease. Simply because a patient has a negative CT scan does not mean they don’t have an appendicitis. One has to ask themselves, “Where is the intelligence in shooting CT scans at a child’s abdomen where four hours of observation would clearly settle the situation?” I believe that the new articles in the New England Journal about the long term effects of radiation need to be taken seriously.

In my career I have found that most patients are extremely interested in hearing what I think should be done. They do not want to hear statistics; they all want to know what you would do with your own family member. When I mention that I would not shoot dangerous ionizing radiation at my own child and I don’t wish to do it to their child, it is almost always taken seriously. They want what you want which is a good outcome at the lowest possible risk. They want to be dealt with honestly as to what a laboratory test may mean or not mean. When a lab test will not answer the situation definitively, don’t get it. You never ask a question you do not want the answer to. And I think that to send off gallons of blood and unending requests for X-ray does nothing to improve the health care situation of the United States. What ever happened to H&P and proper observation? I bemoan the new situation where we believe that a test of high variability is better than a concerned physician who has done an excellent examination.