My wife is a family doctor working in a small rural practice owned by a regional hospital. While she has not yet been sued for malpractice she knows many doctors who have, and while the vast majority of these suits never reach court they still inflicted many sleepless nights and higher malpractice premiums on the innocent doctors. She recognizes that everything she does may have to be justified someday so that if she is forced to testify she can explain the rationale of her treatment. This is the essence of defensive medicine.
The American Board of Internal Medicine Foundation in partnership with Consumer Reports has announced Choose Wisely, an educational initiative recommending physicians avoid 45 unnecessary tests and procedures the group believes are performed unnecessarily. These include routine EKGs and Stress Tests as well as prescribing antibiotics for minor ailments such as mild sinusitis. Oncologists are also encouraged not to perform cancer screens on breast cancer and prostate cancer patients diagnosed with non-metastatic forms of these cancers.
But as the New York Times article states, these recommendations are controversial and there is fear among some patients and doctors that they will be applied too broadly. The newspaper quotes Dr. Eric Topol, chief academic officer of Scripps Health who says, “These all sound reasonable, but don’t forget that every person you’re looking after is unique…This kind of one-size-fits-all approach can be a real detriment to good care.”
As a resident of the great state that raised John Edwards to the heights of power on the backs of doctors he sued for malpractice, I’m skeptical over this recommendation for a number of reasons. Dr. Topol makes an excellent point. Those who aren’t health care practitioners may fail to understand that patients often do not present with clear cut symptoms. There is a finite number or reasons your car won’t start in the morning such as the battery is dead, the tank is empty or the ECM needs replacement. But the human body is infinitely more complex. What may present as back pain from too much Pilates can turn out to be bone cancer that had metastasized from the esophagus, as happened to my father-in-law. The chronic tickle in the back of the throat that drove my mother-in-law crazy for months, turned out to be an atypical and rare form of breast cancer. Both were dead within months of their initial complaints both were misdiagnosed by their primary care physicians, though it is unlikely in either case the proper diagnosis would have mattered much. But both cases of cancer could have been treated had they been detected early. Obviously doctors cannot perform these tests on everyone because it would take too much time and cost too much, but this decision should be left to the judgment of the doctor and not interfered with by the government, an insurance company or a non-elected body such as the American Board of Internal Medicine Foundation.
These recommendations will no doubt be cheered by insurance companies and the government (since Medicare, Medicaid and Obamacare make the government a de facto insurance company I’ll lump it together with the likes of Kaiser Permanente and Blue Cross for the rest of the article.) Insurance companies can now refuse to pay for these tests or at the least requiring doctors jump through time-consuming and money-losing hoops such as requiring pre-authorization to do them. The article claims that as much as 1/3 of the $2 trillion spent on health care in the USA is unnecessary, so imagine the savings to their bottom lines these companies will enjoy by cutting nearly $700 million from their payments. The problem with this figure is that it’s like the old saying about half of marketing dollars being wasted, but no one knows which half. Because it is impossible to accurately determine which person needs a test and which doesn’t it will be impossible to reap the savings hinted at in these recommendations.
Doctors are taught the cliche, “When you hear hoofbeats, think horses, not zebras.” The problem is in the real world zebras aren’t limited to the Serengeti, they are mixed in with the horses here. And doctors are blind. The practice of medicine remains an art where such non-quantifiable processes as “intuition” still play an important role. A doctor might be presented with a healthy young man in his prime with no signs of heart problems, but something might trigger his intuition to call for an EKG. While rare, young people do make the headlines when they drop dead of cardiac arrest caused by a previously undiagnosed heart condition. The physician suspecting he might have a patient with an undiagnosed heart problem will have to fight to get the insurance company to pay for the EKG, skip the EKG and console himself that the young man is healthy, or do the test for free.
Imagine the doctor finds himself in the dock, facing an attorney hired by the family of his patient. “Why didn’t you do the test, doctor? It’s a simple test you could have performed in your office that would have saved the life of my client’s son. Yet you didn’t. Why?” The American Board of Internal Medicine Foundation will not be on the stand, the doctor will, and parroting off the American Board of Internal Medicine Foundation’s recommendations will not play very well to the jury.
So to avoid that possibility, the doctor will either have to fight the insurance company to pay for the test or will have to perform it gratis. Either way the physician is the one left bearing the responsibility for these recommendations. And 99% of the time the doctor will find that the patient’s heart is fine, in which case outside groups like Consumer Reports will wail about unnecessary tests. But the doctor knows that without tort reform she must do everything to protect herself including ordering tests which may seem considered medically unnecessary but will protect her in court. The tests might be medically unnecessary but until there is tort reform they will be legally necessary and will continue to be performed.