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).