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Sunday
Jan162011

Patient Advocates on How to Defend Oneself from Defensive Medicine

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Defensive medicine is not limited to obstetrics. I asked two well-known patient advocates and authors if they would contribute to the conversation about how to defend oneself from defensive medicine.

 

By Trisha Torrey  

Sometimes it’s difficult to know whether your doctor wants you to undergo a test or procedure for your benefit, or for his or hers.

In this day and age, doctors know that the more patients they see, the more money they make.  Further, they can increase their profits by performing tests and procedures. And, they are highly fearful of lawsuits. For those reasons, some doctors will order extras even if the patient may not necessarily need them.

Sometimes, if those extras are invasive (an unnecessary biopsy, or radiation from the CT scan for example), or if they are expensive (whether or not they are covered by insurance), there may even be a detriment to the patient.

Smart patients know to ask two questions for each test or procedure the doctor recommends:

1. What is this test for? 

2. What do you expect to find (or hope you won’t find)?

Your doctor’s response will help you determine whether you really need that extra or not. Listen carefully to the answers to make sure they address an aspect of your care you feel is important.  For example, a baseline blood test early in your pregnancy might be important, but drawing blood week after week may not, depending on how healthy your pregnancy has been to that point.  If your doctor’s answers seem excessive to you, then ask more questions to clarify.

An important clue is your doctor’s demeanor.  A defensive reaction to your questions, hesitation, avoiding your eyes - these may be additional clues that will help you decide whether the recommended test or procedure is for your benefit or your baby’s.  Without a clear benefit to you, the doctor will have a more difficult time giving you a decisive and direct answer.

Remember, you get the last word. If you don’t want a test or procedure, and you are confident that decision is based on what is best for you and your baby, then you have a right to say no.

Finally, don’t forget – for any appointment, test or procedure, ask your doctor for a copy of the medical record that results.  Review it to be sure it’s accurate, correct any errors you may find, and keep it with your other medical history information.

 

 

 

By e-Patient Dave deBronkart

As I’ve begun learning about Shared Decision Making (SDM) through FIMDM.org, I’ve come to realize something that in my opinion closely parallels protecting ourselves against defensive medicine: protecting ourselves against surgery we don’t need in the first place, even if the doctor thinks we do. (Or says we do.)

My friend Elyse was urged (due to severe perimenopausal cramps) to have a hysterectomy, stat. She trusted her docs at the university, but she’d recently been widowed by a car crash and as sole provider for her son needed to minimize recovery time, so she researched. Well, turns out she didn’t need surgery at all, much less did she have a 4 inch tumor that required open surgery asap. (And as she questioned the university docs, they eventually stopped returning her calls.)  

And I think defensive medicine is a subset of a larger issue: practice variation.

Very large parts of healthcare are delivered inconsistently from area to area. Yes, the care you get depends on where you live. The same patient in a different local area might or might not get a prescription for treatment. Very often. Which one is right? Is one overtreated, or is the other undertreated?

This isn’t a matter of economics: it’s a matter of local medical practice. It cuts across all economic levels. (That’s why it’s not called discrimination; it’s called practice variation.) And the killer (sometimes literally) is that the people involved – the doctors – mostly don’t know they’re doing it.

I emphasize that this isn’t some evil scheme; it’s an unrealized pattern that has resisted change for decades. It was first discovered (accidentally) in the 1970s by researchers who were looking for something else. It’s not specific to the US, either. For example, residents of Oxford, UK, are 16 times more likely to get a particular procedure than residents of London, and it’s documented as far back as 1938 in this paper from the UK on variations in tonsillectomy rates. 

What every patient (or family caregiver) needs to realize is that you don’t just need a second opinion; you may want an opinion from a different part of the country, because often the decision “cut this person” or “scan this person” has a very different threshold elsewhere, and most doctors don’t realize it. 

And aside from cost there is danger: the treatment can accidentally be worse than the condition. The 1938 UK paper pointed out that tonsillitis had caused 60 deaths in one year, while tonsillectomies had caused over 500 - most of them children.

Surgery today is safer than it was then but we still face the reality that over 500 patients a day are accidentally killed in hospitals. 

 

 

 

Trisha Torrey can be found online at Every Patient’s Advocate (everypatientsadvocate.com) and author of You Bet Your Life! The 10 Mistakes Every Patient Makes (How to Fix Them to Get the Health Care You Deserve).

Dave deBronkart, also known as e-Patient Dave (epatientdave.com), is a leading spokesperson for the e-Patient movement and author of the book Laugh, Sing and Eat Like a Pig.

 

 

 

 

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Reader Comments (6)

THANK YOU for this piece. It is my sincerest conviction that health care and profit motivation are two diametrically opposed forces; they simply cannot co-exist. Until this country makes massive systemic changes (and gets over its hysteria over the S-word), we health care consumers will have to look out for ourselves.

The physician catch phrases that make me cock an eyebrow are "just in case" and "to be on the safe side." Whose safe side exactly? I've allowed these words to convince me to do ridiculous tests and procedures that amounted to little or nothing. Having learned the hard way, I now know the importance of NOT accepting these vagueries and instead pinning down more concrete information. "Dr., statistically speaking, what are my chances of X or Y?" When the fear-mongering begins, I widen my eyes and say, "Wow! That sounds scary! Do you have references to any studies about this?"

And above all, unless I'm seriously convinced of an immediate and life-threatening emergency, I never make "impulse buys." It seems that in 90-95% of cases, there's time to go investigate your options and call your doctor later.

By the way, I finally started questioning my OB's "authority" when she did a biopsy on a fibroid and, on the day of the test (read: before the sample was even submitted to the lab!), was trying to talk me into a hysterectomy. Mind you, this was before I had my two children. Oh, and don't hold your breath. The test results were negative. The fibroids have never bothered me. They may still be there...

January 16, 2011 | Unregistered CommenterWendyS

I have chronic health issues and a recent move from Oregon to Iowa really drove home how bizarely different the 'standard of care' can be! It has really been strange (and in some ways frightening, vexing, frustrating, and overwelming) to adjust to the difference.

January 16, 2011 | Unregistered Commenterjespren

This can also be seen when speaking with doulas who work in different hospitals in a locale. The variations in practice can be seen from hospital to hospital, and from practitioner to practitioner. It speaks to the need to interview doctors and get different opinions, because there is often a choice to be made between treatment options and the choices vary from doctor to doctor and between places of care.

January 16, 2011 | Unregistered CommenterZejmom

I don't know, WendyS. It's a lot easier to say no to extra tests if YOU have to pay for them. When they're covered by "the S-word," or any 3rd party (whether insurance or government), you have no economic reason to refuse. Not saying we don't need massive systemic changes, but I think they need to go in the opposite direction of what (I think) you're suggesting.

There is an economic principle that says you will spend your own money more carefully than you will spend someone else's. In the medical market, paying out of pocket makes you more aware of costs, risks, and benefits, and more likely to ask lots of questions before agreeing to any procedure. I don't know if you've ever experienced this phenomenon for yourself (chose to live without insurance for a time), but for me it was the first time I questioned a doctor's recommendations, because it was costing me $90 a hit to see him, and all he was saying was, "see me again in a month." I asked, "well, is there anything wrong?" He replied, "No, but we just want to make sure nothing changes." When he got really uncomfortable, I realized he didn't even EXPECT anything to change. I kept my $90 and stayed home rather than make that recommended follow-up appointment. Had I been insured at the time, I probably would have continued seeing him anyway.

January 16, 2011 | Unregistered CommenterHeather

Heather, I don't want to derail, but I see this argument come up all the time and I know it attracts many people because it appeals to our idea that individual effort and virtue yields rewards. But sadly, that's not the case with disease. Cancer and heart disease don't care how hard you work, or how good a person you are.

A typical cancer patient can neither shop around nor save the thousands of dollars it would take to treat their disease. In fact, paying out of pocket for most healthcare is simply not workable--and has the even worse knock-on effect of reducing preventative care. People skipping inoculations and flu shots and prenatal care to save money cost *much more* to the society as a whole than they save; epidemics are extremely expensive in lives, emergency care, and lost productivity to the whole country.

Health care is not a luxury, any more than having an active military or police force or passable roads is a luxury. It's a necessity to having a stable population, to avoiding massive upheaval and high mortality, and in keeping society functioning as a whole. Sick people don't work; families devastated by the death of loved ones add to the level of poverty, crime, and homelessness. Emergency rooms overloaded with critically ill people who could have been treated much more cheaply earlier are less effective. The nation as a whole becomes weaker and more vulnerable.

The good health many of us enjoy now is a *direct* result of many decades of public funds spent on health care--on inoculations for every child, on good sanitation, on food safety, on food programs, on screening programs at schools and workplaces, on some forms of medicine and surgery available free or subsidized to the poor and retired people on fixed incomes, on school lunches that provide some nutrition, even if not the best. And every dollar spent on those programs yields many more dollars in the productivity of healthy citizens. No investment on Wall Street yields the dividends that making sure pregnant women get prental care does. Not even close.

Rising healthcare costs are a concern, but at least some of what we spend is because of a fragmented and inefficient employment-based system, our inability to create a functional electronic patient records system, and lack of coordination of healthcare across different actors as a whole. A national system could at least in theory insist on more evidence-based care, and more helpfully, compare types of treatment across different locations and for different conditions. It could expand preventative care to all citizens, saving even more money and lives in the process. It could encourage and support the education of more doctors and other practitioners by medical schools and produce some really good and helpful research and treatments. It has tremendous possibilities.

Whereas, getting rid of all insurance or government support will simply put American health and advancement back about 150 years, which doesn't seem like much of a bargain to me.

January 16, 2011 | Unregistered Commenteremjaybee

I would say that a third question needs to be asked, in addition to the two suggested. "Would anything you find by doing this test change your treatment recomendations?" I think the best example of using this to combat unnecessary tests is to ask it about routine vaginal exams at 36 weeks. Does it matter if I am dilating? Not really, it is normal if I do, and just as normal if I don't. The only reasonable explanation for doing one would be to establish ripeness for an early induction, but if you are planning a spontanious labor, why do the checks?

January 17, 2011 | Unregistered CommenterDianna
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