Lemon Drop wrote:
This thread needs davester or Ted king. I think it was one or maybe both of those guys who provided research in a much earlier thread showing that the claims that malpractice claims are a major cause of problems and expense in the health care system are bunk. It's a partisan talking point that caught fire and continues to be exploited by groups who want to limit physician and hospital accountability and liability for mistakes.
I can tell you as a physician, CYA (defined below) is being done routinely. The trouble is that when you do not order the test, the trial attorneys point to your lack of testing as a source of malpractice. Even when there's no clear evidence that the test would do anything, that is a point which comes up. No jury in a low income county would find such a physician action as acceptable. As was stated recently, standards of medical practice is now defined by the juries and not by doctors. The intricacies of clinical decision making are fraught with uncertainty. It astounds me that we have a legal system which expects a jury of 'peers' to decide upon medical wrongdoing when groups of highly educated physicians cannot reach consensus in many such cases. No wonder why Harvard Law school found what they did--the tort system for healthcare does not make sense.
CYA Defined:
I will turn the question around, if you were a physician, and you had a patient who you were 95% sure of not having a devastating disease. Would you order a test to determine if the patient has the disease? Would you order the test if you were 10% certain that the patient has the disease? What about 15%? A lot of these pre-diagnostic decision making is not based in science, as History and Physicals are not sensitive or specific enough to make a clear judgment. In fact, as we have more electronic medical records, physician researchers are delving into the science of H&P's and realizing that our classical descriptions of many diseases are quite inaccurate.
To continue the question, what if the test costs $10,000? What if that test only has an 80% chance of detecting the disease? I hope everyone here realizes that very few tests in our medical arsenal is 100% sensitive (i.e. is always able to detect disease when disease is present) and none are 100% specific (is always able to say that a person has a disease when disease is present). Most tests fall into the 70-80% sensitivity and 70-80% specificity ranges. Good tests are in the 90% for both...but they are relatively rare.
Of course, each test carries a risk. CAT Scans with intravenous contrast, for instance, carries an approximate risk of 2% for developing renal failure. However, if you have diabetes, or are older in age, have anemia, and a lot of other medical issues, your risks could be as high as 30%. If your doctor orders this test for you and you are of high risk, and you develop contrast induced nephropathy and go on to developing complete renal failure (which means you are permanently a renal dialysis patient), do you sue your doctor for malpractice? Do you sue your doctor because he didn't weigh the risks of CIN versus the risks of not doing the test for that catastrophic illness?
Or, if your doctor did not order the test, then you die or are permanently injured as a result of that catastrophic illness, do you (or your survivors) sue the doctor for malpractice? How do you weigh the risks?
In the end, many, many physicians choose to order the test because at least in the eyes of the jury, it appears that the doctor was 'competent' and caring enough to order the test. Each test we order when we are fairly certain that the patient doesn't have an illness is an example of CYA.
To be fair, even when we know that a person has an illness (i.e. pneumonia), we order tests because if we didn't, the patients would likely call that physician a 'quack' and never return. It's a strange, strange business...
