During a busy Emergency Department shift, I received a referral from a GP about a patient with pain and discharge from his ear (or otalgia and otorrhea in layman medical terms), that needed to be seen urgently in the ED. Now there are very few ENT emergencies, although they tend to be serious, so of course it piqued my interest…
I call Patient X.
‘No I don’t have discharge or pain it’s just a blocked ear.’
Hmmm, did the GP mishear the patient? Or was this just good old defensive medicine rearing its head again? We’ve all been there, perhaps even done it ourselves. Make that unnecessary referral, request some routine medical consult, embellish symptoms or order an MRI brain for a headache. Because we are unwilling to accept the minute risk that something more sinister may be happening.
What is defensive medicine really?
Defensive medicine, taken from the very reliable Wikipedia (facts), is the practice of recommending a diagnostic test or medical treatment that is not necessarily the best option for the patient, but an option that mainly serves the function to protect the physician against the patient as potential plaintiff. Basically, it is making decisions about what a patient does or does not need based on the potential for a lawsuit against you, if something goes wrong.
It appears the practice of defensive medicine is quite common. In a study of 204 doctors in the UK, 78% reported practicing one form of defensive medicine. In the form of ordering unnecessary tests, requesting unnecessary referrals to other specialties and avoiding high risk patients or procedures. That’s right! Some doctors avoid performing procedures or seeing patients that they think are likely to sue them.
How it all began…
As society has become more accountable and patients can readily access information, the paternalistic all-knowing doctor has become extinct. Armed with “Dr Google”, patients can challenge Doctor’s decisions, oftentimes without the ability to put information into context. The growth of the medical malpractice, combined with the need to find someone to blame for negative outcomes has led to an ever increasing fear of litigation. The key words here are fear and litigation. Defensive medicine arises when we replace what is best for the patient with the fear of being sued or criticised and when we see patients as potential adversaries.
It is a subconscious automatism that is subtly drilled into us right from medical school. We hear the stories of lawsuits against consultants, we cringe at the scandals in the media and we hear people talk about ‘covering your a*s’. You’re a primed defensive stalwart ready to take on the Lionel Messis of medicine before you know it.
Unrealistic patient expectations and a growing intolerance for poor outcomes only worsens the plague. Pressure from colleagues, including requests from allied healthcare professionals, nurses, physios and pharmacists can also influence physicians to do what would not necessarily benefit patients.
It is widely practiced…
Unfortunately, this mindset affects everything and everyone. If you think you are exempt, consider the unnecessary consults you’ve been called to when on call. A nurse once called me to review a patient whose charger fell on his face. After eventually yielding, I arrived to find the patient asleep. The nurse wanted me to document that they were okay so she would be ‘covered’.
I once saw a patient on plastic surgery who’s GP referred him with concerns about melanoma. The spot on his shoulder couldn’t have been more than a freckle. You must have noticed the increasingly lengthy medical notes containing largely irrelevant information which only serves the purpose of drowning out the main things. Perhaps you feel obliged to write down a million negative findings, just in case someone is going to be snooping around later… routine CT scans requests, FBC, U+E, CRP, oh yeah, throw in LFTs, just in case. The list is endless, but so are the consequences.
What is the impact on patient care?
The problem with defensive medicine is that it distracts from what is important. It follows that if you do things to tick boxes, you are likely to miss things. So in reality what we think is helping, might in fact be doing the opposite. The practice of defensive medicine also places excessive demands on limited healthcare resources, artificially prolongs waiting lists and restricts access to those who need it most. Defensive medicine is also one of the causes of skyrocketing healthcare costs.
It exposes patients to unnecessary risks, such as radiation exposure, general anaesthesia, antibiotic resistance. Not to mention anxiety and a false idea of the source of their symptoms. The practice of defensive medicine also contributes to physician dissatisfaction and burnout. All this, not really to treat the patient, but to cure your fear.
So what’s the solution?
More support for trainees
Firstly, it is important to note that studies have shown a reduction in DM amongst doctors of more senior grades. So there is obviously some reassurance provided by a higher position. This perhaps means that the more involved consultants and senior trainees are involved in decisions, the less likely a patient is to be treated defensively. It also means more support is needed for junior staff who take proactive decisions. As opposed to throwing them to the dogs if things go wrong. If a trainee does not have their superior’s support, he/she is likely to want to ‘cover his/her a*s).
Managing patient’s expectations
Managing unrealistic patient expectations is something doctors need to work on. It is something that quite frankly, is poorly taught to trainees. Often patients underestimate the risk of failure or complications that come with medical interventions. We need to do a better job at correcting false ideas that set people up for disappointment. If we counsel patients frankly, they are less likely to seek litigation if things go wrong.
A culture change
Lastly, there needs to be a shift in culture away from wanting to sue doctors. The culture should be, how can we support doctors to act in patient’s best interest? The medical malpractice business is big money and this culture also needs to change. Medical governing bodies must provide more protection for doctors who are taking reasonable decisions. One study showed that within specialties, the highest billers had the least malpractice cases against them. This is after adjusting for cost of procedures. Whichever way you look at it, the current system rewards defensive medicine and that is not good enough.
At the end of the day we have to ask ourselves, am I doing this because I am afraid or does the patient really need this? It all comes down to what is right for the patient.
