How Defensive Medicine Changes the Practice of Medicine.

Emergency physicians are well known in the medical profession to be paranoid about litigation. And well they should be. Emergency medicine docs are among such litigation high risk specialties as obstetricians and neurosurgeons. There is every reason to believe (and some evidence) that this paranoia alters how these physicians practice medicine and not necessarily for the better.I was called by a local ER physician for a possible admission. The patient was elderly and by elderly I mean that she was entering her child bearing years when the US was entering World War I. She had been brought by her family to the ER because of chest pain which had since resolved. The ER physician revealed that the family and patient only wanted medical options (like pain relief) and did not want any invasive procedures. Both the ER physician and I agreed with this considering the patient’s advanced age, any invasive/intensive treatment attempts would likely cause more harm than good. The first rule is “Do no harm”. Right?The patient’s EKG was normal. Her first set of cardiac enzymes were all normal. She had no further chest pain or any other symptoms and she didn’t want to be resuscitated in the event that she had cardiopulmonary arrest (DNR). Satisfied, I didn’t seen anything more that we should do and I recommended discharging the patient home on nitrates, aspirin, clopidogrel, and pain medications, and have her follow up in the office within a few days. Then the ER physician threw me a curve ball.ER Doc: “I was going to admit her to telemetry for observation”.Me: “To observe for what? We aren’t going to do anything more than we are doing now.”ER Doc: “Well, to rule her out. Make sure she didn’t have a heart attack.”Me: “But even if she has had a heart attack it won’t change our treatment! We’re not going to do a cardiac catheterization or cardiac bypass on her. She won’t agree to it and her risk of dying from those procedures alone would be unacceptably high.”ER Doc: “What if she has more chest pain?”Me: “Then she can take her home medication or come back to the ER for treatment in the event that she has severe refractory pain. She might have more chest pain tonight. She might have severe chest pain 2 weeks from now. I can’t admit a patient just for convenience!”ER Doc: “But we’ve only gotten one set of cardiac enzymes on her. We need to get at least one more set to make sure that she didn’t have a heart attack.”Me: “Does she want to consider invasive testing or treatment if her enzyme levels are elevated?”ER Doc: “No, the family and the patient just want medical treatment regardless.”Me: “Is the family or the patient insisting on being admitted to the hospital?”ER Doc: “No, they are fine with whatever we recommend.”Me: *Banging my head on the table* “All right. It’s been several hours since her chest pain resolved and several since her first cardiac enzyme levels were drawn. You can get a second set now and if this set is normal then you can send her home.”The ER physician agreed to this, the second set of cardiac enzymes were normal, and the patient went home.The practice of emergency medicine (among other high risk specialties) has become so regimented and infused with defensive medicine tactics that many ER docs are not even aware of how this has changed the way they think. It seemed as if this ER physician could not fathom the concept that we would send home a patient who could easily have just had a heart attack despite the fact that we were going to do absolutely nothing different for her then if she went home. Even though the possibility of litigation in this case was remote it was the constant and overall threat of litigation that has fundamentally changed the thinking of physicians and how they practice medicine.This change in thinking has had significant consequences. Ever wonder why we spend so much on medical care? Part of the answer lies in this example. This ER doc was about to turn an $800 ER visit into a $4,000 hospital admission. Now imagine this happening all over the country in multiple variations and degrees of absurdity tens of thousands of times EVERY DAY.Medical malpractice attorneys are not directly at fault for this mess. But I don’t see this problem correcting itself as long as physicians feel that the current tort system is a disincentive to changing from a mostly CYA (Cover Your Ass) system to one which couples good medical care to proper resource utilization. However, tort lawyers tend to oppose every single reform attempt and so in my book, if they are not part of the solution, then they are part of the problem.