January 25th, 2013

Appropriate Use or Defensive Medicine?

One of the most popular buzzwords we hear in cardiology circles lately is “appropriate use.” Gone are the days of unlimited testing and reimbursement as we are increasingly asked to provide an evidence-based rationale to justify our decision to order tests. As cardiology fellows, this is becoming a key part of our education; a lecture on stress testing, for example, would not be complete without at least a few slides addressing the spectrum of appropriate use criteria for various indications.

The concept of appropriateness is important for two reasons. The first reason, which  is getting so much press in the “Obamacare” era, is that ordering inappropriate tests is a colossal waste of money, and we are finally being asked to recognize that we operate in a world of limited resources. (Note that I expressly avoid the term “rationing”, despite the exhortations of various fearmongers, as rationing has taken place in some form or another since medicine became a profession. It is just now that we are debating how we should ration it differently in perhaps a more equitable or efficient fashion.) However, I would argue that the second, and even more compelling, reason to limit testing to truly appropriate use is that inappropriate testing often leads to incidental findings and false-positive results that at best lead to more inappropriate testing and at worst lead to unnecessary treatment with potentially deleterious complications. Simply put, inappropriate testing is suboptimal patient care.

So what is the problem? As so often is the case, there is a hidden curriculum that drives a wedge between theory and practice. As a cardiology fellow, I have been repeatedly surprised by some of the tests I have been asked to perform for arguably inappropriate indications. For example, in the initial (read: naive) months of my fellowship, while on a nuclear imaging rotation, I was asked to perform a stress test on a gentleman with no risk factors other than age whose nonexertional pleuritic chest pain (which he only experienced after paroxysms of coughing and was reproducible to palpation) was clearly due to his resolving bronchitis. After performing my own focused history and physical, I approached the ordering physician to discuss the case because I believed this patient did not need further work-up of his chest pain and did not want to expose him to unnecessary radiation (or the risk of a false-positive result). The response was not a medical justification of the test; instead, I received a lecture on the exceedingly low risk tolerance of the American public and this physician’s own desire to avoid a lawsuit at all costs.

This example is perhaps extreme, but I have heard many of my fellow colleagues describe similar situations, and I am concerned that the practice of defensive medicine is overriding the implementation of appropriate use to the detriment not only of economics and patient care, but also of medical education. If we learn that it is completely acceptable to look the other way when we know tests or procedures are not indicated, we will only perpetuate this cycle of inappropriate use. There is no doubt that we need a huge overhaul of medical litigation in this country (starting with a rule that a losing plaintiff must pay for the entirety of an exonerated defendant’s legal costs in order to discourage frivolous lawsuits), but at the same time, we as physicians have an obligation to uphold the standards of appropriate use. We owe it to our economy, to our patients, and to our trainees.

2 Responses to “Appropriate Use or Defensive Medicine?”

  1. Joseph Soler, MD says:

    I fully agree that we need a large overhaul of the medical litigation process, and we will NEVER solve the healthcare cost problems until the litigation process of massively reformed.

    You should be aware that a large medical malpractice insurance company in Florida, after a detailed study, concluded that the number of frivolous lawsuits was very small. The problem is not the attorneys because in Florida a medical malpractice suit can not be initiated without a medical professional attesting that malpractice has occurred.

    In other words, we have a “medical expert witness crisis” and not a frivolous lawsuits crisis. We, as physicians, are our own enemies, and we have failed to regulate the lucrative medical expert trade.” It is a shame.

  2. Tort reform is an immovable object. The Obama administration and policymakers know this is not winnable, and although part of the preamble of the ACA, has not been pursued because it is not winnable. A liberal legislature tandem to a coincident state and federal court environment will not limit access to the courts to “citizens”, particularly, when the preponderance of legislators who construct statutes are attorneys. The attorneys protect their own- knowing that the med-mal specialty is an industry of their own which -what did we hear about ourselves ? – “they will not self regulate or self monitor”.

    And, Dr. Soler is correct- until we stop preying on our own( as the attorneys have occultly, surreptitiously pledged not to do to themselves)the magnitude(volume of pursued cases- settled or litigated) will not change. For instance, in my personal experience why did an “expert” need be imported from New Mexico to apply a community standard in Florida?

    As to appropriate use, with due reference to us as knowledgeable physicians who should understand the comparative effectiveness of a recommended test or treatment, there needs to be applied informed patient preference- concept of shared decision making – with some attempt at quantitation, where feasible, of value(inclusive of risk/benefit and cost- cost to each of society and patient)