Cover Your . . . The Idea Of Defensive Medicine
By: The Musing Medic (@TheMusingMedic)
Let me preface this article with a disclaimer: I am not a physician nor do I claim to be one. The thoughts in this article are based on anecdotes and experience. My current education and training do not qualify me to do anymore than make observations. Hopefully this article will spur some discussion on the topic.
So What’s The Topic? Defensive Medicine, a.k.a CYA Medicine.
After almost four years in a busy suburban ED, I have been witness to multiple instances of physicians practicing defensive medicine. Let me tell you, it doesn’t take a physician to witness what constitutes defensive medicine. But it may take a physician to know when defensive medicine is justified.
My Question Is: “When Is Defensive Medicine Justified?”
I always thought the gold standard was to be evidence based medicine (EBM). After doing a little research, the actual percentage of EBM utilization hovers between 15-30%. That means more than 70% of clinical decision making is not evidence based. Why is this? Is it due to the litigious nature of modern Medicine? Is it the fear of missing a diagnosis resulting in a poor outcome?
These are questions that many of the ancillary staff ask ourselves, amongst ourselves. We discuss them in hushed tones, though some may be more willing to ask the physician “why’d you do that?” But, in my experience, many physicians view this as questioning their decision making or clinical prowess. That isn’t the idea behind the question though. Medicine is a complex amalgam of science, psychology, business, and customer satisfaction. Those of us without the medical school education and residency training are not privy to this information but we still want to know why. I think communicating these thoughts and ideas are beneficial to all involved.
Let Me Provide An Example From A Recent Case…
(If you don’t speak Medicine for some reason, ask a friend to translate.)
63 y/o F presents with left sided rib pain and left shoulder pain that worsens with movement x 24 hrs. States she fell while playing with grandchildren, landing on left side. PMHX of HTN, hyperlipidemia, and COPD.
Attending MD orders workup for r/o MI with admission to chest pain unit. Admission is out in prior to any testing.
Testing was within normal limits. ECG was NSR with no ST changes from previous ECG. Enzymes were all normal. CXR was that of a COPD patient. No rib or shoulder injury noted on films.
Never once did I get the impression this patient’s complaints were cardiac related. My thought was the patient suffered a MSK injury due to the fall. The onset of pain coincided with the fall. The pain worsened with movement and was localized to a very particular area. The patient had no other symptoms such as nausea, diaphoresis, etc.
When I asked the attending why the patient was being admitted to the hospital for r/o ACS, he stated “I have no way to tell if this pain is from the fall or not”.
…Actually, you do. The puzzle pieces add up. Like I mentioned before, think horses when you hear hoofbeats not zebras. There were a hundred pieces that fit together. But he went another route and I am still asking myself why? What did he see or think that I didn’t?
But if I had to guess, he was practicing defensive medicine. Maybe that was the safe choice. I can’t answer that. But would’ve practicing EBM here resulted in a different disposition. I think it would.
This is a topic with no black or white answers. But discussion is possible. Feel free to leave some comments and provide your own thoughts, stories, or criticisms.
Till next time,
The Musing Medic