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A common rule in the ER. Every headache gets a CT scan, every normal CT scan gets a MRI.

Rangel points out something that is often missed in the debates about whether defensive medicine even exists. Certainly those who suggest it doesn’t don’t pass the straight face test (do corporations make silly decisions based on potential liability?). However, defining it is problematic because of what Rangel points out – it is insidious. The ER doc didn’t see that it was unnecessary to admit the patient because defensive tactics had drifted to the “standard of care.” This is almost as dangerous a trend for medicine as a John Edwards candidacy. When we are unable to recognize our CYA behavior we will be unable to advocate for logical reforms in medicine or law.

I might add a little here. In my experience the ER staff are very ignorant of standard medical care. Their ability to read EKG’s and other important test is very much subpar. Now that is my experience. They will almost always defer a decision. Constantly desiring more testing than is necessary and always pulling in a consultant or two (who ultimately make the decisions). What really gets you mad is that many insurance companies are single pay. Only one doctor gets the fee for everything. If you had to admit this patient after spending all night with here and the family, the ER doctor will usually have beat you to the insurance company and already filed. They thus pay him and not you.

But the basic premise of defensive medicine is alive and well. Consider what would happen if a young person called me with a headache. I could count on the fact that the probable diagnosis would be tension or muscular, but there are a very small number who could have more significant pathology. So instead of telling them to take an aspirin and see me if the symptoms persist, I have to send them to the ER. With the combination of scan and x-rays and consults the final bill will be well into the thousands. So that is the real cost of medicine.

Having practiced as a board certified emergency physician (EP) for 17 years (BTW, reading my own EKGs with never a significant mis-read), I think ignorance does play a role; however, I’m seeing some very disturbing trends. Self-insured EP groups issuing “practice guidelines” (all prompted by bad outcomes or recent litigation) that are linked to physician reimbursement. A push for more “pre-evaluation” (pre-emptive) testing — that is testing ordered at triage based on a cursory physician evaluation, cursory mid-level evaluation, or nursing protocols. The rational is to decrease LWBS (left-without-being seen) and LOS (length-of-stay) national metrics of hospital performance. Many hospital CEOs and upper management have pay incentives linked to decreasing LWBS and LOS — whence a downward pressure to test quickly without precision in the ER. In a similar manner the “satisfaction cult” (e.g., Press Ganey) drives testing and admissions to improve the satisfaction scores. This may also be linked to physician and hospital management reimbursements. There is a very ugly side to P4P (pay-for-performance). We throw antibiotics into the waiting room based upon a cursory assessment that someone might possibly have pneumonia and might get the first does greater than 4 hours after arrival in the ER (we are not treating patients, we are treating a statistic).

A very common twist to defensive medicine that I see all the time is where the primary care doctor or advice nurse fields a patient’s call and gives a worse-case list of possible diagnoses to go to the ER with. It is almost impossible to stop that train when it arrives in the ER and the patient or family are demanding expensive testing and imaging studies based upon telephonic advice. It places us in potential opposition (and potentially adversarial if there is a bad outcome) to their primary care doctor when we suggest anything less then the workup they were sent to the ER for. In this scenario, the primary care doctor reaps what was sown.

If you practice in a highly capitated area (as I do) there is also the problem with insufficient primary care to handle the captitated workload. This drives many chronic and poorly managed patient into the ER for the most expensive forms of chronic care AND sending them to the one specialty least likely, by training and disposition, to be able to handle chronic primary care.

With regards to every headache gets a CT scan, I’ll refer you this blog posting. I don’t disagree. When I started emergency medicine pulse oximetry became the entrenched fifth vital sign (I’ve never understood why a pulse ox is done on an ankle sprain). Today, unfortunately, I know and work with colleagues that use CT as the sixth vital sign. Every belly gets an appendicitis workup and every headache…

I think defensive medicine is a symptom of something much more evil than just lawsuits gone wild. It’s a symptom of our “single standard of care” philosophy.

Some people might reasonably like to choose a lower standard of care and pay less. It’s certainly a better solution than being unable to afford any insurance at all.