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I have completed bits of my EM training from India. Currently I am boarded with credentials from Christian Medical College, Vellore and also from the prestigious Royal College of Emergency Medicine, UK.  I am currently working in London as an A&E doctor, trying to appreciate the differences in the practise and culture of Emergency Medicine across different healthcare systems. I have always been an avid FOAMed supporter because FOAMed played an indispensable role during the days of my initial training. Through this blog, I aspire to disseminate knowledge and stay up to date with the EM literature. 

Monday, February 27, 2017

Nuisances of Defensive Medicine

Defensive Medicine, refers to the practice of recommending a test or treatment that is not necessarily the best option for the patient, but an option that mainly serves the function to protect the physician against a potential lawsuit. 



When medical students are nurtured into physicians, they are seldom taught this part of medicine but it gets imbibed into them when they begin practicing in high-risk environments and see their peers landing into lawsuits in mishaps, sometimes for petty and unimaginable reasons. Physicians from United States are at highest risk of being sued for missed diagnosis and even for a delayed diagnosis! Over years, this litigation culture has penetrated other healthcare systems as well. India is not left behind either. 

I vividly recall my freshman year in medical school, back in 2005 when we were taught that a solid history provides you over 50% of the diagnosis. Required laboratory investigations are then used to confirm your suspicion. Few years later it was reinforced again when I learned that killer pathologies such as “Acute Coronary Syndromes” are suspected based only on the history but followed by ECGs, Troponins and cardiac stress testing. This applies not only to ACS but also to most other diseases. History is the key to reach a diagnosis. 

As a trainee, I was always asked before ordering a test – Why do want this and how is this going to change your management? But things have changed now, I frequently see the blood reports first and then talk to the patient. 

Almost every physician (Emergency Medicine, Cardiology, Internists, Ortho etc.) is aware of this mantra of “solid history” but there are many who choose to do the other way around i.e. order tests/imaging to safeguard regardless of the history. In Emergency Departments across the globe, now blood tests are requested even before a patient encounters a physician. Indisputably, this saves time and averts overcrowding. But what about the non-specific positive tests that increase the length of stay exponentially and force us to order some more tests, some more imaging. Few classic examples are non-specific troponins and d-dimers and unnecessary Head CTs ordered on everyone who walks in with syncopy and has a normal CNS exam. 

Indian Healthcare is distributed between private and public sector and laypersons often believe that physicians always earn a significant share from the cost of blood tests! Investigations are also done as physicians now work with an instilled fear of litigation in their minds, at least in the private sector.


Issues with Defensive Medicine
  • Fuels Overcrowding: This is becoming a global concern because more patients are using Emergency Services and we are being too cautious due to fear or litigation. EDs are growing bigger in size but it is not helping. Too many labs equal false positives i.e. watch them for more hours/admit for invasive testing. Even if we interpret every test in context of history and physical, how many of us feel safe discharging a patient without performing a CTPA but with a label of non-cardiac chest pain and elevated d-dimer. From a physician’s standpoint, I don’t see anything wrong when we practice in a defensive manner. We learn this over years as we observe what our contemporaries go through during the process of handling a lawsuit. This is normal human behavior – no one wants to invite trouble.  So what would you do - Order a few more tests or handle a lawsuit that comes with months of stress and disrupts your life? Be mindful of the fact that a lawsuit can be extremely demoralizing and distressing; it has the potential to change the personality and mindset of a doctor. It can be shattering!

  • Time and Resources – A ton of time and resources can be saved if labs are ordered judiciously. For instance, Routine blood cultures for well appearing patients is becoming a norm.
  • Overtreatment – Overtreatment with unnecessary Antibiotics carry the risk of adverse reactions, sometimes life-threatening. Everything comes with pros and cons, even “normal saline” and “oxygen”. 

  • Risks to patients – Needless imaging such as CT scans expose to radiation. Pan CT in trauma can be disastrous if clinical background is not taken into consideration. For me, it never made any sense to do CT for trivial chest trauma who look well and are hemodynamicaly stable. And if you happen to do a scan, don’t scan their whole body just because they are on a CT table. I recall a patient with blunt torso trauma (GCS 15/15, no evidence of head trauma, Normal CNS exam) who was undergoing a CT Abdo/Chest when a doctor jumped in asked to add a Head CT. His reason was – Anyways he is on the CT table, let’s do it! Not acceptable.
  • Assurance/Avoidance behaviour: As described above, assurance behavior involves the charging of additional, unnecessary services in order to reduce adverse outcomes, deter patients from filing medical malpractice claims and provide documented evidence that the practitioner is practicing according to the standard of care so that if, in the future, legal action is initiated, liability can be pre-empted. Avoidance behavior occurs when providers refuse to participate in high-risk procedures or circumstances. A surgeon who was gutsy to take an unstable patient to operation theatre may not choose to operate high-risk cases in future if he gets sued due to a bad outcome. Every physicians behaviour gets shaped based on his past experiences and training environments.



Few Arguments against defensive medicine
  • Documentation: Now we are doing BNPs to document heart failure in previously known heart failure patients. Amylase and Lipase and sent for every abdominal pain (RIF/Suprapubic pain as well!). This is the argument that comes with defensive medicine – We need to document that it was not pancreatitis! We are all aware that, no test is perfect in Medicine – there can always be false positives and false negatives. Therefore, it is crucial for physicians to interpret test results keeping history and physical in the background. Conversely, it can be frustrating from patient’s perspective if you tell them it can still be your heart (after two negative troponins, normal ECGs and 6 hours of wait!) 


  • You never know! – I took care of this elderly gentleman lately from a nursing home. He was bed bound, aphasic, occasionally gets restless. On that day, he pulled out his urinary catheter. I thought of replacing the catheter and discharge him but ended up ordering CBC, Renal Function, LFT, Coags for him. The argument being we don’t know anything about him, he is aphasic, we do not have a history although he looks okay and hemodynamically stable. Let’s do this and make sure he is okay. This would sound like reasonable way to go for many. One of my mentors said something very interesting during a discussion about defensive medicine – Lakshay, this is what my patients want me to do and I think he was right to a great extent!
  • It improves patient care: Defensive medicine certainly leads to more in-hospital admissions, more referrals and more follow up visits but what is the impact of patient care? This is what I picture  - more blood tests, more false positives, more imaging and invasive procedures (Biopsies, Angiography), unnecessary treatments, more adverse reactions, of course extra cost and utilization of resources!

In hospital Violence
Practising Medicine in India also put you at high risk of facing violence. Therefore, physicians justify their standpoint by doing every possible test. Nobody likes a bad outcome after spending a fortune and with negative prejudice against the physicians based on anecdotes  Indians are no different. In India, patient relatives prefer to settle things on the spot by creating a havoc and damaging the hospital assets. Interestingly, I overhead this conversation between a patient's family and treating ICU physician. She was very candid with the family. 



Your wife is quite critical and despite our best efforts, she may not make it. For now, she needs dialysis to support her kidneys. This might help her to recover but nothing in medicine is 100%. The cost of dialysis will be 10,000INR per session and she will require a few sessions for sure. I want you to be very clear on this. There is no guarantee that we are going to get her back even after dialysis but this will certainly give her a better chance. If things go wrong, I do not want a mob coming her and creating a havoc. I hope you understand what I am trying to explain. Any questions?

This post does not intend to justify or refute defensive medicine. Indeed it is getting difficult to practise Evidence Based Medicine in high risk environments and convincing patients about a certain test or treatment can be challenging. For instance, many want a Head CT with trivial head trauma. Shared Decision Making in one way to combat this but are we absolutely safe if we do that? 

In 2004, the case of Dr. Daniel Merenstein triggered an intensive debate in scientific journals and media on defensive medicine. Following the guidelines of several well-respected national organizations, Merenstein had explained the pros and cons of prostate-specific antigen (PSA) testing to a patient, rather than simply ordering the test. He then documented the shared decision not to order the test. Later, the patient was diagnosed with incurable advanced prostate cancer, and Merenstein and his residency were sued for not ordering the test. Although Merenstein was acquitted, his residency was found liable for $1 million. Ever since this ordeal, he regards his patients as potential plaintiffs: ‘I order more tests now, am more nervous around patients: I am no longer the doctor I should be’.


References:
  • Kessler D, McClellan M. Do doctors practice defensive medicine?. The Quarterly Journal of Economics. 1996 May 1;111(2):353-90.
  • Tancredi LR, Barondess JA. The problem of defensive medicine. Science. 1978 May 26;200(4344):879-82.
  • Sekhar MS, Vyas N. Defensive medicine: A bane to healthcare. Annals of medical and health sciences research. 2013 Apr 1;3(2):295.
  • http://timesofindia.indiatimes.com/india/Over-75-of-doctors-have-faced-violence-at-work-study-finds/articleshow/47143806.cms
  • Hurwitz B (2004). "How does evidence based guidance influence determinations of medical negligence?". British Medical Journal. 329 (7473): 1024–1028. doi:10.1136/bmj.329.7473.1024.
  • Atkins, D., Siegel, J. & Slutsky, J. (2005) Making policy when the evidence is in dispute. Health Affairs, 24 (1), 102–113.
  • Merenstein D (2004). "Apiece of my mind. Winners and losers". JAMA. 291 (1): 15–16.
  • Lapp, T. (2005) Clinical guidelines in court: it’s a tug of war. American Academy of Family Physicians Report, 2005. Available at: http://www.aafp.org/x33422.xml
Author:

              
     Lakshay Chanana
     
     Speciality Doctor
     Northwick Park Hospital
     Department of Emergency Medicine
     England

     @EMDidactic



                    

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