« Upgrading | Main | In which I demonstrate the conflicts in paying for health care »

February 10, 2006

Comments

shadowfax

First of all, I agree with the general idea that military (and VA) docs should bear some accountability for the quality of their care. For a long time, there was the notion inside the medical community that these institutions were havens for incompetent docs because of this immunity. I have no experience whether that was based on fact or myth, but certainly one can see the risk.

I would like to take issue with the statement that "Doctors are not driven by defensive medicine." As a doctor, I can tell you that defensive medicine is endemic -- especially in the ER, where I work. For example, the "Standard of care" in ruling out an aneurysm in someone with the worst headache of their life is a CT scan and a lumbar puncture (spinal tap). This is something every ER doctor will agree on to near-unanimity. However, with modern high-resolution CT scans, the negative predictive value of a CT scan is something like 99.8% -- yet every single ER doctor will still do that LP, because if you don't and you are unlucky enough to have that one person in 500 who had the false-negative CT any ER doc will testify that you messed up. That's defensive medicine. What's the cost? Well, a spinal tap costs maybe $300-$500, and you are doing 499 unnecessary spinal taps for each aneurysm you diagnose by the tap -- that adds up (in dollars as well as pain inflicted on patients who didn't need the LP). There are examples of this kind of defensive practice for most any presenting complaint in the ER.

If you would like some data which documents the defensive practice by ER doctors:

So please don't accept at face value the statement that doctors aren't motivated by fear of lawsuits -- we are. Now if you want to claim that the overall fraction of healthcare dollars spent on defensive practice is low -- 1-2% of all spending -- I might agree with that. You can look at it two ways -- that the fraction is low so the potential cost saving is low so it shouldn't be a central item in healthcare reform, or that even though the fraction is low the expense is still in the billions so it is a major public-policy issue.

shadowfax

Hmm. Clearly I shouldn't be allowed to use html. Apologies for the broken link and weirdness. Here's the link and the truncated bit of the comment:

Emergency Physicians' Fear of Malpractice in Evaluating Patients With Possible Acute Cardiac Ischemia, Annals of Emergency Medicine, 46,6, 525-533 (abstract only)

Which documents that the more fearful a doc is of malpractice the more likely s/he is to admit a patient with chest pain, and the more likely s/he is to order extra tests or admit the patient to the ICU. And, as imporantly the diagnostic yield of the extra admissions/tests was nil. For those of us who work in the pits, we call this "proving the inherently obvious."

So please don't accept at face value the statement that doctors aren't motivated by fear of lawsuits -- we are. Now if you want to claim that the overall fraction of healthcare dollars spent on defensive practice is low -- 1-2% of all spending -- I might agree with that. You can look at it two ways -- that the fraction is low so the potential cost saving is low so it shouldn't be a central item in healthcare reform, or that even though the fraction is low the expense is still in the billions so it is a major public-policy issue.

The comments to this entry are closed.