In 2009, Emergency Physicians Monthly polled 5,000 readers online to determine if and when EPs altered the tests they ordered out of fear of litigation. The poll, which garnered 385 responses, may not have been scientifically valid, but it confirmed what most of us know intuitively – that there is a significant cost to defensive medicine. Now, the Pennsylvania College of Orthopedic Surgeons has added fuel to the fire, publishing a study that confirms the very same thing.
In 2009, Emergency Physicians Monthly polled 5,000 readers online to determine if and when EPs altered the tests they ordered out of fear of litigation. The poll, which garnered 385 responses, may not have been scientifically valid, but it confirmed what most of us know intuitively – that there is a significant cost to defensive medicine. Now, the Pennsylvania College of Orthopedic Surgeons has added fuel to the fire, publishing a study that confirms the very same thing.
Pennsylvania’s prospective study – the first to examine defensive medicine among orthopedists – asked the 600 members of the Pennsylvania Orthopaedic Society to audit their own practices for a single day, reporting whether they ordered images for clinical care or defensive purposes. The 72 responses, presented at the 2011 Annual Meeting of the American Academy of Orthopaedic Surgeons, revealed that defensive imaging comprised 19 percent of all the doctors’ imaging orders. Defensive imaging also turns out to be disproportionately expensive, with the orthopedists identifying MRIs as the study most often ordered for defensive purposes. MRIs comprised 49.7 percent of defensive orders but accounted for 86.2 percent of defensive costs and 30.1 percent of total imaging costs. In total, defensive imaging accounted for 35 percent of overall imaging cost.
John M. Flynn, lead researcher for the study and associate chief of orthopedic surgery at the Children’s Hospital of Philadelphia, said researchers were surprised to see doctors admit they ordered unnecessary tests. But the results matched almost exactly a December 2009 Gallup survey commissioned by Jackson Healthcare. In a poll of 462 random U.S. physicians, physicians who said they practiced defensive medicine in the last 12 months (73 percent of respondents) estimated that 21 percent of their practice was defensive in nature. The study defined defensive medicine as “the practice of diagnostic or therapeutic measures conducted primarily not to ensure the health of the patient, but as a safeguard against possible malpractice liability. This may include tests, prescriptions, hospitalizations and referrals that may not be medically necessary, but are viewed as providing protection from a potential lawsuit.”
Not surprisingly, doctors in the study were more likely to practice defensive medicine if they had been sued in the last five years. Less obvious was the connection between defensive medicine and time in practice. Doctors who had practiced medicine for longer than 15 years were more likely to practice defensively.
If emergency medicine were to repeat the Pennsylvania study, would it find the same trends among young physicians? Jim Antinori, an emergency physician at Salt Lake Regional Medical Center, said he sees younger doctors relying on imaging more often: “That’s just what they know.” Christopher Carpenter, Director of Evidence-Based Medicine at Washington University School of Medicine, sees the needle moving the other direction, suggesting that younger doctors may be absorbing more studies that suggest testing is not always necessary. For instance, the Ottawa Ankle Rule tells physicians exactly when to order an X-ray for someone with ankle pain, and recent research gives specific guidelines for when to remove a C-collar from a patient with a spine injury. But does this change after they or a colleague has actually been sued?
The next question to ask is whether physicians overreact to the fear of litigation. For instance, it is understandable that a physician might over-order CTs in patients with abdominal pain after he had been sued for a missed appendicitis. But what about over-ordering cervical spines or ankle X-rays? How many EPs have been sued for missing a chip fracture in an ankle sprain? “Over time, what sticks in your head are not the hundred cases that went right but the one case that went unexpectedly wrong,” said John Saad, medical director of emergency services at the Medical Center of Plano in Texas. “It comes down to that tiny chance – that 1 in 1,000 chance – that your diagnosis could be wrong.”
Studies like the one conducted in Pennsylvania, the Gallup poll, and the EPM straw poll are all subject to a great deal of interpretation as these are all the result of asking physicians how they practice. Honesty is a major factor, noted Antinori. How willing is a physician to admit that he or she does something that is not necessarily in the patients best interest? Further, any response is very subjective – two physicians can look at the same patient and disagree as to whether a test would be clinically necessary. Definitions can also confound results. The Pennsylvania study did not define “defensive purposes” but left it up to each surgeon instead. According to Dr. Carpenter, this lack of a definition is one of the study’s flaws, along with the low 12 percent response rate.
Skeptics might question whether the results in one geographic area can be generalized to the entire country. Dr. Flynn calls Pennsylvania, a “toxic environment” when it comes to medical malpractice laws. The Pacific Research Institute ranks Pennsylvania as one of the least successful states in enacting tort reform.
Even in states that have enacted tort reform, however, the practice of defensive medicine continues. A September 2010 study published in Health Affairs found physicians have high level of malpractice concern even in states where the actual malpractice risk is very low. This may stem from the fact that for many physicians, the damage of litigation is tied less to the amount of the award or settlement, and more to the fear, humiliation, and wasted time caused by being sued, regardless of the outcome.
Addressing defensive medicine within emergency medicine is a long road with no short cuts. In the meantime, Dr. Carpenter encourages emergency physicians to consciously calculate the probability that the test they’re ordering will help the patient. If you order a test based on a 1 percent – or a 0.1 percent – chance that the diagnosis is wrong, says Carpenter, then you are practicing defensive medicine and shifting the benefit “away from the patient, onto ourselves.”
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“If you order a test based on a 1 percent – or a 0.1 percent – chance that the diagnosis is wrong, says Carpenter, then you are practicing defensive medicine and shifting the benefit away from the patient, onto ourselves.”
If a one percent or one-tenth percent chance event occurs and results in a 100% chance of litigation, then is it defensive to order whatever test is necessary to insure that the patient is completely diagnosed or ruled out, even when the odds of an adverse outcome are small? What benefits the patients more? Ask the patients. They want testing to rule out even low risk/low occurrence possibilities. They are unsatisfied if you don’t test (or over-test) unless and until they are paying out of pocket for the test. And, an unsatisfied pt who has an adverse event will sue. A patient with a twisted ankle wants an xray to rule out a fracture. No xray, unsatisfied. Bad Press-Ganey scores. Arthritis in ankle a few years later and someone will say it is because of that Ottowa rules negative probable missed fracture a few years back. “What? No xray when you went to the ER for your ankle injury? They should have xrayed it then and saved you all of this pain and suffering.” Actual scenario. ER ankle Xray defensive? Maybe. Xray necessary? Absolutely. And that is a well defined highly studied topic. Missed appy? Perf? PE? Intracranial Hemorrhage? Ligament tears in knee? Who is ready to roll the dice?