Defensive Medicine: Cautious Or Costly?

When Doctors Cover Bases By Ordering Extra Tests, It Can Cost Patients Big

(CBS)  It started as a simple stomach ache, but Alexandra Varipapa, a sophomore at the University of Richmond, decided to go to the emergency room.

There, doctors ordered a full CT scan, a radiation imaging test, which found a harmless ovarian cyst. She never questioned the CT scan, CBS News correspondent Wyatt Andrews reports.

But her father did - when he got the $8,500 bill, $6,500 of which was that CT scan.

“I was pretty flabbergasted,” said Robert Varipapa, himself a physician.

Varipapa says his daughter's pain could have been diagnosed far more easily and cheaply with a $1,400 ultrasound.

“A history, a pelvic examination and probably an ultrasound,” he said. And he would have started with the ultrasound.

But the hospital defends the CT scan, saying an ultrasound might have missed something more serious.

“It would not have ruled out appendicitis obviously, it would not have ruled, necessarily, out a kidney stone,” said Dr. Bob Powell, ER medical director of Bon Secours St. Mary’s Hospital.

Varipapa agrees, but asks why not start simple - and do the CT scan only if necessary?

“Well it's my opinion this is defensive medicine,” Varipapa said.

Defensive medicine is what happens when doctors order too many tests because they are afraid of missing a diagnosis and later losing a multi-million dollar lawsuit for malpractice. Defensive medicine these days is so pervasive, some estimate its yearly cost at more than $100 billion.

Dr. Kevin Pho runs the popular medical blog, Kevin M.D., where doctors routinely confess exactly how they run up costs by practicing defensive medicine.

“Defensive medicine is bad medicine,” Pho said.

In a post, one ER doctor says he's just admitted two patients to the hospital - when he was sure "neither was having cardiac (problems), but what am I to do?"

Another admits that in his practice, “every patient with a headache gets a (CT) scan.”

“It's much easier to defend the fact that you ordered a test than it is to not order the test at all,” Pho said.

And the costs of defensive medicine today are increasingly paid by patients, even those with insurance - because of rising deductibles and co-payments.

“There’s no doubt in my mind this is a significant driver in health care costs today,” Pho said.

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Couric & Co. Blog: Do I Need This Test?

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But there are ways the patient can sort out the necessary from the unnecessary tests.

Experts tell CBS News you should ask basic questions.

First: Why is this test needed? Ask about the cost and if there's a less expensive, alternate test. Ask if the test results might change your diagnosis - or treatment. And, "what is the risk if I don't have the test?"

“They didn't really talk to me about doing anything else,” Alexandra Varipapa said.

In Varipapa's case, the hospital insists her CT scan was medically required, given her symptoms.

But in the end, the hospital did present an $8,500 dollar bill - for a condition that went away on its own.

[cride1]

I don''t blame doctors practicing unnecessary defensive medicine. Why? Because there are so many frivolous lawsuits and the only way for the doctors to protect themselves really is to play it safe no matter the cost. Fortunately, this is a method to shift the cost onto the patient so that they will think twice before going for a frivolous lawsuit.

[why_not_nar]

dear rick kaplan,
whoa...hang on for a second. first there are a great number of conditions that can be treated if found early and treated quickly. cancer is at the top of that list. does anyone know what percentage of people having tightness in their chest make it alive to the hospital?? under 40%. the point is that pain is something to be understood, not ignored as you suggest. cats scan''s and mri are rarely used indiscriminately. they are both remarkable diagnostic tools.

[why_not_nar]

Here is the question though. the average cost of a cat scan is $1000-1,5000 dollars. i had one taken six months ago for $600 dollars. the equipment is expensive but it is amortized, the test itself is given by a technician, so my question is why $6,500 for a test that rarely takes more that 20 minutes. i would strongly challenge the hospital bill.
does medicine have excesses?? yes. too much cosmetic surgery, probably too much surgery in general, but cat scans??, of the problems we are facing this evening overuse of cat scans isn''t one of them. and to suggest that you should ignore pain, and then question each test before it is given, is just plain irresponsible.
i know that ms. couric, who was absent tonight would have led with ''a cat scan for a headache?''. turns out that a headache is often a precursor to a stroke. me..i am glad the technology is available. the lesson is to have long relationship wich doctors who can tell ''what is different'', and doctors that you know well and trust. in a college population of 10 or 15 thousand students, that just is not possible.

[grammawhamma]

cride1: You are exactly right. I worked at a small hospital as a RN. My husband''s doctor didn''t catch his cancer at a regular checkup and my husband died from the cancer which had spread to his brain five months later. Did I sue...no. The doctor apologized to me over and over but I didn''t and don''t blame him.

Patients have the right to refuse tests but doctors should get it in writing from the patient to prevent lawsuits.

[nerothedog]

What a disappointment on the part of CBS and this report. It would have been more informative to explain what drives ''Defensive Medicine'', rather than describe it as some shortcoming or fault on behalf of doctors and other providers. Defensive Medicine is alive and well in medicine thanks to the constant threat of malpractice lawsuits. A missed diagnosis is one of the most common reasons for medical malpractice litigation in this country. The costs incurred by Defensive Medicine for a patient pale in comparison to the awards associated with cases involving missed diagnoses. The litigation in these cases also results in tremendous stress upon the provider, not to mention a permanent mark on their record even if the case settled and was a baseless, frivolous lawsuit. This in turn usually results in higher malpractice insurance premiums, and the vicious cycle perpetuates. I''m disappointed that CBS provided such a myopic view of a much more pervasive and complicated problem in health care. I would hope that there would be a similar profile on trial lawyers and their role in the exorbitant costs of health care and access to it in this country.

[dr_noshots]

RES IPSA LOQUITUR (or Why I Wrote "terrO.R.").

If a person dies suddenly in a hotel room, the initial diagnosis is "heart attack."

If a person dies suddenly in an operating room, the initial diagnosis is "anesthetic death."

American citizens are innocent until proven guilty. In murder cases, it is up to the police and to the prosecutor to prove that the murderer is the killer.

AMERICAN PHYSICIANS ARE GUILTY UNTIL PROVEN INNOCENT.

Why ? Because of the RES IPSA LOQUITUR doctrine (a Latin phrase which means: "the thing speaks for itself"). In other words: the patient was alive before the medical services and dead after them . Could the good doctor prove his or her innocence?

But physicians are never invited to sit on a medical malpractice "jury of your peers" and, believe me, health care innocence is hard to prove in front of carefully selected non medical jurors. Raising "medical liability insurance" fees is simpler. Much simpler. The 2007 professional insurance for a Long Island neurosurgeon is $309,311 ! Would you encourage your child to become one ?


BUT PHYSICIANS ARE NOT ALWAYS GUILTY AND "terrO.R." IS HERE TO PROVE IT.

[dr_noshots]

For as long a medical liability jury is not a "jury of my peers" who understands medicine, the only way a physician like me can avoid the "doctor, why didn''t you order this test ?" question, is by ordering all possible tests under the sun.

[dr_noshots]

Re "RES IPSA LOQUITUR."
I forgot to emphasize a point: the family of a "cardiac arrest on the O.R. table" patient is allowed to sue the surgical team, even if they refuse, the only hope for a final diagnosis, AN AUTOPSY (for religious or other reasons), .

[labourboss]

MRI $1200, CAT SCAN $1,500, PEACE OF MIND PRICELESS!

[otdky07]

Unfortunately,CT scans are slowly becoming the standard of care. If a physician misses a case of appendicitis, some slick, scumbag lawyer will be salivating at the lips for a chance to sue. Why? Because this is America, where everyone wants to get rich by winning the lottery, only the odds of winning a medical malpractice case are much greater. The physician has to pay his defense, while the plaintiff''s attorney can work pro bono and keep a large chunk of the settlement if they win. Cover your *** is the standard of care in medicine today.

[sonotso]

'' ... maybe edible algae and mushroom knick knack artwork could store and possibly even lever or multiply water molecules and microbes ... maybe since we can turn acorns into atomic stars, we can turn acorns into atomic stomachs and forego all the consumption anyways ... ''

[alphaa10-2009]

Dr_Noshots said, "American citizens are innocent until proven guilty... AMERICAN PHYSICIANS ARE GUILTY UNTIL PROVEN INNOCENT."
---
There is another side to this, of course. The AMA and state medical groups have spent the better part of 50 years in opposition to patient litigation by trial attorneys-- all on the principle, apparently, that the doctor can do no wrong.

Or, if he can, at least that the good doctor should not take responsibility for his every mistake, even when somebody is harmed or dies as a result.

To this end, state and national medical lobbies have pushed for what they disingenuously term "tort reform". Tort reform, in practice, means badgering the state assembly until some bozo takes up the AMA cause. A little money usually helps, and presto! The bill is written to make the physician essentially bullet-proof.

That approach means a patient or his family is sharply limited by what can be recovered when they sue for damages. These damages once included not only pain and suffering, but economic loss, as well. Now, damages may be legally limited ("capped") and not compensate for even medical costs, much less pain and suffering, not to mention economic loss. A tidy bit of self-interest legislation by the medical community, there..

Damage to the patient''s interest, of course, is not the basis of the suit, but medical negligence. Every doctor wants to avoid litigation, but not all doctors try to avoid negligence. Even when someone else''s life depends on it.

[scoliosuxs]

The CYA policy is everywhere in medicine today. Not just with the physicians. Social Workers and nurses practice it everyday due to the fear of a lawsuit 5 yrs down the line. It is the first thing they teach the first day of school. Tort reform is desparately needed in this country. It is too easy for someone to sue when they don''t understand the underlying basis of medicine and hospital care. I agree a jury of one''s peers should be those who actually do the same work as you in the medical field. 4 yrs of medicine can''t be taught in a courtroom.

[emh1701]

I have to ask, if it was just a stomach ache, why didn''t anyone tell the kid to just take some OTC stuff and go home and see if it got better first? I don''t know about you folks, but most people can''t afford to go to the emergency room for stomach aches.

I think the media plays up the medical stuff so much that people are freaking out over the smallest things these days.

[alphaa10-2009]

Part 2-- Patients, Patient Families, Beware!
The attending physician or other managing professional is instructed to inform the patient''s family with a poor prognosis-- "I am sorry, but the outlook is not the best. We''ll do what we can, of course, but it appears all four wheels have fallen off. It will be difficult."

What a blow to an anxious family! What a failure of the oath to do no harm! At hearing such a report, family members have been known to become ill, as a result. But as the seminar tells medical professionals, it is all to the good. They are given the following explanation--

"If you promise the moon, but deliver coal and ashes, you probably will be sued by angry relatives, regardless of the effort you made and difficulty of the case. If you promise little or nothing-- yes, even advise of the worst-- but deliver something, anyway, and maybe even the sun and moon, combined, you will be hailed as a miracle worker. Your fees will be received with gratitude, not scrutiny."

[alphaa10-2009]

Patients and Patient Families, Beware!

The medical community for the last decade has been blitzed by little-publicized, traveling "legal seminars"-- these professing to help medical professionals avoid litigation.

As innocent as that sounds, some the methods taught by the seminars are anything but defensive. They cause needless pain and suffering, and are based upon manipulation of patient expectations.

Here is how the methods work. Suppose a patient and his family rush to the hospital for a critical procedure. They are beside themselves with anxiety, and need all the hope and reassurance possible. While emotional comfort sounds like an easy mission for staff, not so fast-- medical professionals are now told, this is "bad medicine".
(See Part 2, below)

[hissteps4u]

Unfortunately in a litigious society Defensive medicine is a requirement and safe guard even if it adds to the over all Bill better safe than sorry. Either that or TORT REFORM which seems unlikely in todays society.

[hissteps4u]

There is some truth that some procedures are needlessly ordered and often cash incentives are given to Physicians who keep things in House rather than out sourcing and second Opinions. HMO''s have done similar things for many years.

Medicine as practiced currently needs to be changed and MEDICINE and Particularly Pharmaceuticals with their Adds pushing Medicines hoping to claim a portion of the Money and all they can Grab.

REP Dinners, gifts, Incentives, they are totally out of control and Their Millions BUY allegiance from many physicians and even entire clinics who use their Money to expand and push prophets even further upward as costs continue to spiral.

[alphaa10-2009]

scoliosuxs said, "Tort reform is desparately needed in this country. It is too easy for someone to sue when they don''''t understand the underlying basis of medicine and hospital care..."
---
But a courtroom exists to establish that underlying basis. If it can be taught to you, it can be presented to others, as well. Should people no longer have the right to sue for justice in medical cases, simply because you fear they may not agree with you?

In any event, the tort reform you suggest has nothing to do with proper understanding of the merits of a case. Its sole purpose is to isolate and limit the ability of a jury to decide what is just. Tort reform is an effort to limit legal recourse.

Put another way, if only technical practicioners have the facts and know the truth, how could they be held accountable under law for their actions? Some medical professionals do not seem worried by that prospect.

Professional peers are already allowed in jury cases-- they are called expert witnesses. Medical professionals who are not satisfied with this approach seem to want a "tribunal", a closed-session adjudication similar, perhaps, to the disciplinary procedures of a medical associaton. In other words, "We''ll handle this in-house. The public need not inquire further."

This would place medical malpractice above the law.

[dr_noshots]

Suing and collecting from physicians who did nothing wrong, IS EASY:

http://www.americanauthorsassociation.com/Book%20Review-TerrO.R.%20-%20Neuschatz.htm

[dr_noshots]

alphaa10 said:

"Professional peers are already allowed in jury cases-- they are called expert witnesses. "

Expert witnesses are exactly that: WITNESSES. They don''t take part in the legal decision. And the carefully selected juries don''t always understand the pathological facts.

Do you want to be rejected from jury duty in a medical liability case ? Just tell them your spouse or your best friend is a physician. It happened to my wife.

[dr_noshots]

The Non-Hypocritic Oath

I swear:
To obey the law and practice medicine to the best of my knowledge and according to my local judges, medical malpractice lawyers, jury decisions, mandatory second opinions, liability insurance companies and HMO limitations.
If abortions remain legal, I will or I will not produce them, depending on my own personal beliefs, on the number of abortion clinics burned in my immediate vicinity, and on the number of anti-abortion people picketing the local hospitals.
I will give no deadly medicine to anyone if asked, nor suggest any such counsel. Unless, of course, a euthanasia law is finally passed and I will then make such desperate decisions case by case.
Whatever in connection with my professional practice, or not in connection with it, I see or hear, in the life of men or women which ought not to be spoken of here or abroad, I will not divulge, as reckoning that all such should be kept secret.
Unless of course, their charts are subpoenaed by medical liability attorneys, requested by Medicare or Medicaid, checked by the hospital peer review committees or investigated by the department of Health.
While I continue to keep this Oath unviolated, may it be granted to me to enjoy life and the practice of the Art of Defensive Medicine.

[bm6005]

Not only the expensive tests but afterwards you cannot get insurance when you retire due to a physician ordering exploratory tests previously!

[hippychicky-2009]

Dr_Noshots: Non-Hypocritic Oath

Thats pretty amusing, and sadly true. I think alot of MDs are gun shy of people who may sue them for malpractice. And then they tend to go over board in the assessments of their patients.
Defensive medicine..very cute. We just have to protect our license, right?

[mathewcs-2009]

If people did not treat the ER as their personal doctor, maybe healthcare prices would drop. I do CT scans and x-ray, and see defensive medecine all the time. Patients should get a personal Dr. Going to the ER for a cough, or abdomen pain that has gone on for weeks is not an "emergency". I''m tired of people complaining of the wait times in the "ER"/ clinic. They themselves are increasing wait times. It is the amount of patients the doctors must see, and having to get every patients full medical history in minutes or a couple of hours that forces them to get the best tests quickly to diagnose a ruptured appendix, so they can get to a patient with a rash that has been there for a month. We should change the name of the "Emergency" Department to 24 hr. clinic.

[radmdtx]

As a radiologist I benefit some from useless test being ordered from the ER. But I do not like the lack of skills of todays ER doctors. To the point that I am going to work in an outpatient center to get away from them. Today most of them order useless test because they are not confident in their assesments. Or they have not looked at the patient yet- which happens where I am at a lot. My state has tort reformed and it has helped a bunch but the ER refuses to practice hands on medicine. They say the same thing the doc on the report says "...but I could miss something..." Cry me a river!!! If you use sound judgement and EXAMINE the patient you have the whole medical community to back you up. Quit being triage nurses and be a physician!!!!!! I am tired of reading CAT scans on body parts that don''t even hurt!!!! That cost all of us $$$$

[dr_noshots]

FICTION ?
http://www.americanauthorsassociation.com/Book%20Review-TerrO.R.%20-%20Neuschatz.htm

[rf36]

My wife has been forced into the ER on several occasions because she cannot get seen in a timely manner at our base Medical Treatment Facility (new term for base clinic). She''ll try to get an appointment on the 5th of the month, be told there are no opening for the rest of that month and they can''t book into the next month. Call back on the first of next month. By that time, the condition has either resolved itself or gotten so much worse, the only option to releive the pain is to go to the ER. Some time ago, the Air Force''s HMO set up a "nurse advice line" for people to call in and get medical advice from an RN. We have used it several times and the advice has ALWAYS been "go to the ER." It''s our healthcare system that has turned the ER into a 24 hour clinic, not us. Oh, and just try forming a lasting relationship with a doctor when you (and the Drs) get moved every 3-4 years or less.

Now here is a "classic example" how the medical professionals look at a situation and figure out how to get the most money possible. A few competent doctors might have diagnose her correctly but when you can easily order such test for a bigger piece of the pie this is a no brainer for this money driven industry. Socialize medicine is the only way to straighten up this mess that is doing nothing bout getting worse.

[drivelphobe]

If there aren''t enough sick and injured people to treat, then promote over-testing and the great new disease, "preventive medicine".

This is one reason why our health insurance premiums are outrageous. Most doctors are probably competent to diagnose a condition within their specialty. The use of high priced testing equipment is not required on a routine basis. It''s revenue builder. Don''t let them do it to you. Just say "no"! Don''t go to the doctor for annnual physicals and routine visits urged by the physician. Go when you are sick or hurt.

[mathewcs-2009]

To avoice, instead of your Dr. sending you to the ER, and incur an additional $1000.00 minimum for the ER visit, He or she could have sent you to the hospital for an outpatient CT or Ultrasound. These are available 24 hrs. a day. All you need is a written order. You could have gotten the results from your Dr. via the radiologist within 30 minutes of your exam. But that would require your Dr. being able to take the call from the rad. after hours, instead of leaving your personal care up to an Er physician that just met you. Just because your Dr. sent you to the ER, it doesen''t mean the Er will order the test your dr wanted. Some doctors have x-ray equipment at their office, but I would never recommend anyone having an x-ray there. The "radiology" techs at most offices go thru a 6 week course to do limited exams. ARRT technologists go thru a minimum 2 year radiology program to learn proper equipment operation, positioning, and radiation safety. I have seen exams from doctors offices, and the quality is very poor, and the equipment usually is too. You can also have outpatient x-rays 24 hrs. a day. the wait time is much less than the ER. Ask if your tech is ARRT Registered......

[mathewcs-2009]

As for the price of the CT they showed on the segment, it seemed a bit high, about twice as much as I have seen at several facilities. You have the right to know the price of any procedure before it is done. As the patient, you have the right to deny any test that is ordered. Many facilities will negotiate the price with you if you talk before the exam is done, and often after. If you do not have insurance, and pay cash upfront, or work out a payment plan, you could get the test for half off. Go to a not for profit hospital and apply for charity care, they may pick up the tab. Easier to do when you are not tying up an ER bed.

[radmdtx]

Socialized medicine is the last thing we need. If you think you have to wait to see your doc now it will only worsen- see rf36. This country is already short of docs and socialized medicine will only worsen that- who the hell would want to be a doc for $100g/yr or less when there are a lot of other careers that pay much better with out all of the BS? I already would not recommend medicine to anyone as a career. Plus we will have to fill the need with yet more foreign doctors- see England (almost 50%) and some of them are want to kill christians. No, liberal boy, more government interference will drive more people out of medicine- we need less interference. (i.e. some agencies require a 6 hour class one how to put your finger in someone *** to get stool!!!!) And don''t go to the ER for stupid stuff. Half those people don''t need to be there, and the more free it is the more show up. I have had many people tell me they don''t care why they are there, It''s free!!! Which leads to my $5 co pay for all non emergencies. I don''t care how poor you are- you can cut out one pack of cigs if your going to the ER. When people pay for something, even if just a small token fee, they respect it more- see you kids. and will not abuse the system as much

[dr_noshots]

Defensive Medicine: A NON-HYPOCRITIC OATH.

I swear:
To obey the law and practice medicine to the best of my knowledge and according to my local judges, medical malpractice lawyers, jury decisions, mandatory second opinions, liability insurance companies and HMO limitations.
If abortions remain legal, I will or I will not produce them, depending on my own personal beliefs, on the number of abortion clinics burned in my immediate vicinity, and on the number of anti-abortion people picketing the local hospitals.
I will give no deadly medicine to anyone if asked, nor suggest any such counsel. Unless, of course, a euthanasia law is finally passed and I will then make such desperate decisions case by case.
Whatever in connection with my professional practice, or not in connection with it, I see or hear, in the life of men or women which ought not to be spoken of here or abroad, I will not divulge, as reckoning that all such should be kept secret.
Unless of course, their charts are subpoenaed by medical liability attorneys, requested by Medicare or Medicaid, checked by the hospital peer review committees or investigated by the department of Health.
While I continue to keep this Oath unviolated, may it be granted to me to enjoy life and the practice of the Art of Defensive Medicine.

(Sorry but....it had to be repeated !)

[dr_simmons]

I have found your series on Defensive Medicine interesting and informative. Two things strike me regarding it''s presentation however. Does anyone really think one can question one''s Doctor and get straight answers as to risks and decision alternatives? If you are right, the Doctor''s interest is the avoidance of such testimony. Second, and I admit here I have some proprietary research to guide this comment: the over - prescription of tests may have nothing to do with the patient- Doctor assessment process. Rather it may be due to the economics of medicine under current conditions. We are faced as a nation with a medical community ramped up to serve at a considerable cost which is experiencing a major drop in demand because of a rapidly declining base of insured patients to treat. The over-prescriptions, and perhaps over-recommendation of procedures, could be driven by the need for capacity utilization rather than concern for the patient. To test my point, see if you can find a frequent story of defensive medicine practiced on street people; else your hypothesis of what is going on may only be partially correlated with reality.

[dr_noshots]

As an allergic reaction to Defensive Medicine, I was thinking on becoming an Executioner. After all, in the post-electric chair era, who knows better than an anesthesiologist how to administer intravenous drugs ?

But, as all American doctors are, I am obsessed by the possible legal implications of such choice. What happens if "the patient" survives ?

DO I HAVE TO BUY EXECUTIONER MALPRACTICE INSURANCE ?