-
We’re currently investigating an issue related to the forum theme and styling that is impacting page layout and visual formatting. The problem has been identified, and we are actively working on a resolution. There is no impact to user data or functionality, this is strictly a front-end display issue. We’ll post an update once the fix has been deployed. Thanks for your patience while we get this sorted.
Defensive medicine?
- Thread starter AFB
- Start date
BaliBabyDoc
Lifer
Sadly the politicians like Bush have no clue what they are talking about. There is a "small" amount of excess utilization that occurs b/c a healthcare provider is trying to avoid future liability. The overwelming majority of "defensive medicine" is basically what you do when you don't know what's going on.
Every good medical school teaches students to NEVER order a test unless you are looking for something. A competent history and physical examination should drive differential diagnosis . . . the differential should drive testing . . . and the final diagnosis (in concert with history/physical exam and prior testing) should determine treatment.
I guarantee you that elite teaching hospitals (Hopkins, Mass General, UCSF) have A LOT of defensive medicine b/c they are largely staffed by residents . . . learning how to practice medicine. It's part of the reason that Medicare gives BILLIONS each year to teaching hospitals.
A nonteaching hospital will rarely incur such expenses . . . except of course when they hire incompetent doctors.
Far greater expense comes from the uncertain nature of medical science. It costs mad money to staff and utilize a cardiac triage unit (basically to assess and watch people that come in with "suggestive" symptoms of a heart attack). These units save lives but they are quite expensive.
Virtually all of the people with "suggestive" symptoms come in through the ER . . . usually by EMS. The gold standard for testing has been a moving target for decades which means people get a lot of tests . . . cardiac enzymes, EKG, etc. Standard MONA therapy (morphine, oxygen, nitro, and aspirin) is relatively cheap but if it truly is an MI then the cost of care rises dramatically. My point is that if we knew EXACTLY what was going on there would be a lot fewer tests and a lot fewer procedures. When we miss it . . . we get sued. But hell it's been a relatively recent update that physicians started to acknowledge that women may present with DIFFERENT symptoms than men during a myocardial infarction. Ignorance is often not bliss in medicine . . . it's expensive (excess tests/treatment) and deadly. But it's not quite that simple . . . sometimes ignorance is actually better.
Cancer is quite similar. The feds are currently planning to spend several hundred million dollars (I think) on a lung cancer screening study. There are several problems with this initiative:
1) We have NO good treatments for lung cancer. Granted, if you catch it early enough you can remove the lung disease before the disease spreads.
2) It is highly unlikely that the chosen modality (helical CT scans) will catch the majority number of lung cancers before they spread.
3) The primary cause of lung cancer is smoking. Stop people from smoking and lung cancer would become a nusance instead of the #1 cause of cancer mortality in America.
4) If the study is a "success", the standard of care may become the periodic screening of all smokers.
Number 4 is particularly pertinent. In essence, if medical "science" says it has a useful method of detecting early lung cancer then it would be malpractice to deny a smoker their annual, biannual, or whatever CT scan. But MOST people that smoke will NEVER get lung cancer. They will definitely get COPD, bronchitis, emphysema, erectile dysfunction, and damage their heart . . . but they probably will not get cancer. But if you want to screen for lung cancer you would have to screen smokers. Further, smokers would likely insist upon it . . . at least some.
This phenomenon is happening right now with breast cancer. If you want to screen for breast cancer you have to screen everyone with boobies (with special attention for older women and women with family history of certain cancers). We go back and forth about monthly breast self-exam. We got back and forth about annual physician breast exam. And we vacillate as well on how frequently and a what age do women need mammograms.
A cohort of physicians and some politicians lump all of this into "defensive medicine". At best they are just misguided . . . at worst they are liars.
Every good medical school teaches students to NEVER order a test unless you are looking for something. A competent history and physical examination should drive differential diagnosis . . . the differential should drive testing . . . and the final diagnosis (in concert with history/physical exam and prior testing) should determine treatment.
I guarantee you that elite teaching hospitals (Hopkins, Mass General, UCSF) have A LOT of defensive medicine b/c they are largely staffed by residents . . . learning how to practice medicine. It's part of the reason that Medicare gives BILLIONS each year to teaching hospitals.
A nonteaching hospital will rarely incur such expenses . . . except of course when they hire incompetent doctors.
Far greater expense comes from the uncertain nature of medical science. It costs mad money to staff and utilize a cardiac triage unit (basically to assess and watch people that come in with "suggestive" symptoms of a heart attack). These units save lives but they are quite expensive.
Virtually all of the people with "suggestive" symptoms come in through the ER . . . usually by EMS. The gold standard for testing has been a moving target for decades which means people get a lot of tests . . . cardiac enzymes, EKG, etc. Standard MONA therapy (morphine, oxygen, nitro, and aspirin) is relatively cheap but if it truly is an MI then the cost of care rises dramatically. My point is that if we knew EXACTLY what was going on there would be a lot fewer tests and a lot fewer procedures. When we miss it . . . we get sued. But hell it's been a relatively recent update that physicians started to acknowledge that women may present with DIFFERENT symptoms than men during a myocardial infarction. Ignorance is often not bliss in medicine . . . it's expensive (excess tests/treatment) and deadly. But it's not quite that simple . . . sometimes ignorance is actually better.
Cancer is quite similar. The feds are currently planning to spend several hundred million dollars (I think) on a lung cancer screening study. There are several problems with this initiative:
1) We have NO good treatments for lung cancer. Granted, if you catch it early enough you can remove the lung disease before the disease spreads.
2) It is highly unlikely that the chosen modality (helical CT scans) will catch the majority number of lung cancers before they spread.
3) The primary cause of lung cancer is smoking. Stop people from smoking and lung cancer would become a nusance instead of the #1 cause of cancer mortality in America.
4) If the study is a "success", the standard of care may become the periodic screening of all smokers.
Number 4 is particularly pertinent. In essence, if medical "science" says it has a useful method of detecting early lung cancer then it would be malpractice to deny a smoker their annual, biannual, or whatever CT scan. But MOST people that smoke will NEVER get lung cancer. They will definitely get COPD, bronchitis, emphysema, erectile dysfunction, and damage their heart . . . but they probably will not get cancer. But if you want to screen for lung cancer you would have to screen smokers. Further, smokers would likely insist upon it . . . at least some.
This phenomenon is happening right now with breast cancer. If you want to screen for breast cancer you have to screen everyone with boobies (with special attention for older women and women with family history of certain cancers). We go back and forth about monthly breast self-exam. We got back and forth about annual physician breast exam. And we vacillate as well on how frequently and a what age do women need mammograms.
A cohort of physicians and some politicians lump all of this into "defensive medicine". At best they are just misguided . . . at worst they are liars.
Pliablemoose
Lifer
I work in a teaching hospital, it's defensive medicine all the way.
It's truly insane, we spend more time covering our asses than we do in actual patient care.
It's truly insane, we spend more time covering our asses than we do in actual patient care.
Pliablemoose
Lifer
Instead of a focused approach related to symptoms, a "shotgun array" of labwork is initially ordered for virtually every patient.
Using symptoms & initial labwork to work with, the worst possible diagnosis is assumed, and further work is done to narrow down the diagnosis from that point.
It'd be like going into a mechanic for an oil change and the mechanic tears down the engine instead:disgust:
Also, there is a significant amount of time spent documenting all the labs, tests, etc, and then interpreting the same labs & tests, justifying the diagnosis/treatment.
Compound that with overpriced drugs that patients are trained by TV ads to ask for, and you have a hellaciously expensive system of health care.
IMHO, I'd like there to be some legislation to limit the amount & type of care delivered @ the end of someone's life.
100 years ago, with a terminal diagnosis, a patient would die @ home among family & friends. Nowdays, patients & families are instead opting for a weeks to months long incredibly expensive ICU stay where the outcome is quite predictable.
The end of life ICU stays do no one any good, hospitals generally loose $ on them, and the patient & insurance companies are out loads of cash in an attempt to thwart the inevetable...
The bottom line is everybody dies
Problem is when you get into a discussion about health care, everyone feels they are entitled to the best health care money can buy, damn the expense.
Is it worth it to give an alcoholic with cirrhosis a new liver on the taxpayer's dime? IMHO No.
Is it worth it to spend $100K on end of life care that could be done @ home with the help of Home Hospice? IMHO No.
Is it worth it to give a man a kidney transplant on the public's $ even though he ignored his hypertension & diabetes for years & eventually destroyed his kidneys? IMHO No.
Is it worth it to give a 50 year old man or woman a coronary artery bypass & extend their lives by 15-20 years? Yes...
On a personal level: My father died @ home 5 years ago, after he was diagnosed with a terminal brain tumor, he was with the people he loved, instead of an antiseptic environment surrounded by strangers.
We simply will not be able to continue to provide the level of care our parents/grandparents are recieving, and no-one wants to admit it.
Using symptoms & initial labwork to work with, the worst possible diagnosis is assumed, and further work is done to narrow down the diagnosis from that point.
It'd be like going into a mechanic for an oil change and the mechanic tears down the engine instead:disgust:
Also, there is a significant amount of time spent documenting all the labs, tests, etc, and then interpreting the same labs & tests, justifying the diagnosis/treatment.
Compound that with overpriced drugs that patients are trained by TV ads to ask for, and you have a hellaciously expensive system of health care.
IMHO, I'd like there to be some legislation to limit the amount & type of care delivered @ the end of someone's life.
100 years ago, with a terminal diagnosis, a patient would die @ home among family & friends. Nowdays, patients & families are instead opting for a weeks to months long incredibly expensive ICU stay where the outcome is quite predictable.
The end of life ICU stays do no one any good, hospitals generally loose $ on them, and the patient & insurance companies are out loads of cash in an attempt to thwart the inevetable...
The bottom line is everybody dies
Problem is when you get into a discussion about health care, everyone feels they are entitled to the best health care money can buy, damn the expense.
Is it worth it to give an alcoholic with cirrhosis a new liver on the taxpayer's dime? IMHO No.
Is it worth it to spend $100K on end of life care that could be done @ home with the help of Home Hospice? IMHO No.
Is it worth it to give a man a kidney transplant on the public's $ even though he ignored his hypertension & diabetes for years & eventually destroyed his kidneys? IMHO No.
Is it worth it to give a 50 year old man or woman a coronary artery bypass & extend their lives by 15-20 years? Yes...
On a personal level: My father died @ home 5 years ago, after he was diagnosed with a terminal brain tumor, he was with the people he loved, instead of an antiseptic environment surrounded by strangers.
We simply will not be able to continue to provide the level of care our parents/grandparents are recieving, and no-one wants to admit it.
I'd agree with all of those except the alcoholic example because like smokers I believe in the addiction model.
Otherwise, you are right on the money.
On the Second Wind list a lot of kids with Cystic Fibrosis are waiting for lungs and they are competing with people who smoked for 30 years! The kids with CF, of course, think smokers should fusk off. 🙂 The smokers of course say they were hoodwinked as kids and became addicted. Got to admit I feel much more compassion for some kid with CF who never had a chance at a decent life than I do for the smokers who "BLEW AWAY" their chance. Regardless, if a smoker otherwise meets the transplant criteria I wouldn't remove them from the list, but that sure is tough to accept.
Ditto for alchoholics, of course.
I just hope when I'm ready to go I can do it myself or go like a doctor friend of mine who died at the 9th tee of a local golf course of a massive heart attack. He knew he had a bad ticker, so when he stood up to take a swing, he grabbed his heart and all he said was: "Oh, shi*"! 44 years old, too. 🙁
-Robert
Otherwise, you are right on the money.
On the Second Wind list a lot of kids with Cystic Fibrosis are waiting for lungs and they are competing with people who smoked for 30 years! The kids with CF, of course, think smokers should fusk off. 🙂 The smokers of course say they were hoodwinked as kids and became addicted. Got to admit I feel much more compassion for some kid with CF who never had a chance at a decent life than I do for the smokers who "BLEW AWAY" their chance. Regardless, if a smoker otherwise meets the transplant criteria I wouldn't remove them from the list, but that sure is tough to accept.
Ditto for alchoholics, of course.
I just hope when I'm ready to go I can do it myself or go like a doctor friend of mine who died at the 9th tee of a local golf course of a massive heart attack. He knew he had a bad ticker, so when he stood up to take a swing, he grabbed his heart and all he said was: "Oh, shi*"! 44 years old, too. 🙁
-Robert
Pliablemoose
Lifer
PSA...
When you're shopping for a doctor, ask them if they'd prescribe you a lethal dose of pain killers if you were diagnosed with pancreatic cancer.
If they say no, look for another doctor.
When you're shopping for a doctor, ask them if they'd prescribe you a lethal dose of pain killers if you were diagnosed with pancreatic cancer.
If they say no, look for another doctor.
CADsortaGUY
Lifer
Why? Please expand on this. Or is Pancreatic cancer THAT bad that you would want to die before it got "bad"? 😕
CsG
Pliablemoose
Lifer
The management of pain for patients with pancreatic cancer is one of the most important aspects of their care.
Yes, it's one of the most painful ways to die, and typically terminal.
Pliablemoose
Lifer
Those concerns are valid & a symptom of an overworked medical system.
Shooting for 85% capacity in manufacturing is typically the break even point between production & a quality product, but in health care, particularly in county/public hospitals, they're >100% capacity.
Mistakes in health care aren't pretty.
BaliBabyDoc
Lifer
What pliablemoose describes is the broad use of the term "defensive medicine".
If a resident orders a bunch of tests the most likely reason is that they don't know what they are doing (and are poorly supervised). But it's part of the learning process . . . to the tune of billions of dollars.
All of my colleagues that came through UNC had to endure Dr. Kizer in Internal Medicine. He's totally old school ie he predates a lot of our testing. Accordingly, he GRILLS it home that tests FINE tune the diagnosis. He has a great exercise where he gives a history and physical exam scenario and then asks what tests/procedures should be ordered. It's given in a group setting (20+ students) and you will get a mighty beatdown if you cannot explain EVERY thing you do. A variation is where he forces you to pick a VERY limited number of tests. Both drive home the point of being intelligent and judicious instead of ordering a huge battery just because you can.
Pliablemoose also strays into the minefield of "heroic medicine" and end of life care. IMHO, the "hero model" is easily one of the most prominent factors in our expensive healthcare system. Obviously, if the life flight helicopter, a trauma surgical team, and 10 units of O- blood saves your life after a car accident . . . you may think it's worth it. But after a month in the surgical ICU, another month or so on the ward, and then a couple of years of PT/OT . . . life is the gift that keeps on giving(or taking) . . . depending on who is paying. Myself and many other doctors are unwilling to put a price on that. It's a question that society has to answer or we will continue with the model of doing everything at our disposal to save life without much thought to the consequences.
When I was in medical school I met a classmate that had a double lung transplant (cystic fibrosis). His twin sisters had died a few years earlier . . . I believe one or both had previous transplants. Anyway, he's about as nice a person as you will ever meet. And I believe he would have been a very good doctor . . . not necessarily the intellect side but he had the empathy part down like a champ (plus he was a diligent student). He died during our 3rd year. Was the millions of dollars of healthcare consumed by him and his sisters a waste? How about his taxpayer subsidized education?
IMHO, it wasn't because everyone deserves opportunity. But we cannot ignore the very real costs of our "morality."
Sadly, these very complicated yet important issues fall by the wayside as we rant about tort reform, MSAs, and other BS that are really at the margins of our healthcare morasse.
If a resident orders a bunch of tests the most likely reason is that they don't know what they are doing (and are poorly supervised). But it's part of the learning process . . . to the tune of billions of dollars.
All of my colleagues that came through UNC had to endure Dr. Kizer in Internal Medicine. He's totally old school ie he predates a lot of our testing. Accordingly, he GRILLS it home that tests FINE tune the diagnosis. He has a great exercise where he gives a history and physical exam scenario and then asks what tests/procedures should be ordered. It's given in a group setting (20+ students) and you will get a mighty beatdown if you cannot explain EVERY thing you do. A variation is where he forces you to pick a VERY limited number of tests. Both drive home the point of being intelligent and judicious instead of ordering a huge battery just because you can.
Pliablemoose also strays into the minefield of "heroic medicine" and end of life care. IMHO, the "hero model" is easily one of the most prominent factors in our expensive healthcare system. Obviously, if the life flight helicopter, a trauma surgical team, and 10 units of O- blood saves your life after a car accident . . . you may think it's worth it. But after a month in the surgical ICU, another month or so on the ward, and then a couple of years of PT/OT . . . life is the gift that keeps on giving(or taking) . . . depending on who is paying. Myself and many other doctors are unwilling to put a price on that. It's a question that society has to answer or we will continue with the model of doing everything at our disposal to save life without much thought to the consequences.
When I was in medical school I met a classmate that had a double lung transplant (cystic fibrosis). His twin sisters had died a few years earlier . . . I believe one or both had previous transplants. Anyway, he's about as nice a person as you will ever meet. And I believe he would have been a very good doctor . . . not necessarily the intellect side but he had the empathy part down like a champ (plus he was a diligent student). He died during our 3rd year. Was the millions of dollars of healthcare consumed by him and his sisters a waste? How about his taxpayer subsidized education?
IMHO, it wasn't because everyone deserves opportunity. But we cannot ignore the very real costs of our "morality."
Sadly, these very complicated yet important issues fall by the wayside as we rant about tort reform, MSAs, and other BS that are really at the margins of our healthcare morasse.
Pliablemoose
Lifer
You're pretty good:thumbsup:
Society isn't even being asked, there are so many ethical/legal & moral issues involved, I fear the heroics will never end🙁
What we end up with instead is a type of self imposed rationing or stratification of health care, the system is too complicated & unforgiving for those elderly or too uneducated to ask the right questions @ the right time.
Those without insurance end up in ER waiting rooms, clogging up the system with clinic level issues.
Here in the DFW area we provide free care to illegal immigrants to, liver transplants, heart bypasses, you name it...
Pliablemoose
Lifer
Nope, tween Waxahachie & Mansfield😀
I really don't know about how the caps on punative damages have impacted health care prices.
BBD would have a better idea than me I suspect. I'm just a small cog in the health care machine, and my hospital doesn't require insurance.
BBD:
I hear you about the CF transplants. One of the girls on the Second Wind list died after complications. But almost everyone who has a lung transplant has serious complications. The five year survival rate is not very high. This area is probably one of the difficult areas. The VA does lung transplants and it takes a good chunk out of their budget. Most of those guys smoked too. I don't have any answers either, but when I see a 20 year old dying of CF it takes my breath away-literally and figuratively.....
-Robert
I hear you about the CF transplants. One of the girls on the Second Wind list died after complications. But almost everyone who has a lung transplant has serious complications. The five year survival rate is not very high. This area is probably one of the difficult areas. The VA does lung transplants and it takes a good chunk out of their budget. Most of those guys smoked too. I don't have any answers either, but when I see a 20 year old dying of CF it takes my breath away-literally and figuratively.....
-Robert
Well, the only problem with lawsuit reform is that people that are truly hurt get fucked. It is amazing how slim the tort reform bill passed by in Texas. 51-49
http://www.overlawyered.com/archives/000325.html
BaliBabyDoc
Lifer
Well wonderful North Carolina . . . home to Darth Vader himself, John Edwards . . . does not have a limit on punitive damages at all . . . obviously. North Carolina was very recently added to the list of "crisis states". Medmal rates aren't as bad as places like FL, PA, or WV but everybody is taking notice. A group of doctors have been airing an hour long infomercial every Sunday for several months. It's typical alarmist BS. BUT . . . nobody likes pay cuts . . . even when the monthly take home pay is more than many people make in a year.
But for the typical OB (obstetrician) many are quitting b/c they are being squeezed from two directions. Big providers (HMOs, PPIs) give crappy reimbursements . . . it's basically capitated for many. The insurance company gives the physician a set amount of money to provide ALL care from the first prenatal visit through delivery . . . the leftovers is the MDs take. Then on the other side MDs are paying skyrocketing rates for medmal insurance.
Our state legislature had a decent plan 250k on non-economic damages and no cap on compensatory and basically a ban on punitive damages. I don't recall why it failed. But for quite a few years we've had rules that generally keep frivolous lawsuits out of the courts.
The primary reason awards climbed dramatically during the 80s and 90s is due to the fact that healthcare costs climbed dramatically during that period. If an MD is responsible for life altering adverse event . . . then the "award" has to cover the cost of lifelong care. But here's the kicker . . . punitive damages climbed in concert. Big profits for drug companies and big profits at (for-profit) hospitals are the targets. When a good trial lawyer says that punitive damages should punish and discourage "malapropos" behavior . . . deep pockets lead to big awards.
TRENDING THREADS
-
Discussion Zen 5 Speculation (EPYC Turin and Strix Point/Granite Ridge - Ryzen 9000)- Started by DisEnchantment
- Replies: 25K
-
Discussion Intel Meteor, Arrow, Lunar & Panther Lakes + WCL Discussion Threads
- Started by Tigerick
- Replies: 25K
-
Discussion Intel current and future Lakes & Rapids thread- Started by TheF34RChannel
- Replies: 24K
-
-
