Without evidence of benefit, an intervention should not be presumed to be beneficial or safe.

- Rogue Medic

Needless Scan Reflex


This week the Normal Sinus Rhythm blog is doing our un-themed theme. I again apologize for being late in posting my contribution.

Dr. Shadowfax at Movin’ Meat writes an excellent post about defensive medicine practitioners. It is called Running Scared. Needless to say, with such a topic this received a lot of comments on both sides.

There has been quite a bit of writing about defensive medicine lately, but this made some points that seemed different from the other posts. If there are any posts that address this from a legal standpoint, not “What if you get sued?” but posts by someone with a legal background. Something that provides a discussion of the actual risks a competent doctor faces in testing and treating according to accepted medical practices (what a concept), rather than spending as much of everyone else’s money to protect themselves from tort OCD, please let me know.

What is reasonable to protect the patient and the doctor?

How much risk should a doctor be allowed to inflict on a patient, especially without informed consent?

Are these doctors explaining that there is no medical benefit to the patient other than the one in a whateverillion chance, and that the doctor is not doing this to protect the patient?

Are these doctors explaining that the extra cost to you, if you have health insurance, is to protect the doctor’s income? That the extra cost, if you pay taxes, is to protect the doctor’s income? That the extra cost to the people who pay for your medical care, if no money comes out of your pocket, is to protect the doctor’s income, not to get one over on The Man?

In one of the comments, igloodoc states:

In the great “learned helplessness” environment of the ER, the theory goes that you develop behaviors to help you cope with a situation which you cannot control.

Your coworker is just exhibiting the major side effect of learned helplessness… he is running the algorithms. He is attempting to exert control in the one area he can…

I guess this makes these doctors the biggest welfare queens around. Is the behavior of the person who chronically goes to the ED to insist on constant attention and the million dollar workup any different? They are all attempting to control life, but failing miserably. They are worshiping whatever superstition appeals to them at the moment.

Since everyone seems to be afraid of lawyers, the lawyer is the big threat that is used by the powerless to grab at power. Likewise, the doctor, who is uncomfortable using clinical judgment becomes an overpaid automaton, ordering tests based on remote possibility, rather than clinical judgment. If we are to be saddled with algorithm reciting drones, we should at least avoid having to put up with the superior attitude.

How often does a good workup, but short of the million dollar workup, result in an adverse legal outcome?

Is there any statistical basis for this?

Why are the defense lawyers not able to convince juries of the wisdom of the clinical judgement of the doctor?

Isn’t there anyone left in this country who understands statistics and the harm of “You can’t be too safe?”

In a later comment igloodoc writes:

Everyone will agree not to do the CT until the visit where the CT needs to be done. Figuring that out is why we get the “big” bucks. You will never be rewarded for the money and radiation saved, but will be penalized for the one CT you didn’t do. You may call this running scared, but as I suggested above (rather poorly perhaps) that the behaviors are a product of what your coworker has learned. Not necessarily fear.

Maybe igloodoc has an important point – the medical reform we need is that we need to punish the doctors for this bad patient care.

So much for the often quoted Hippocratic Oath. When it suits the purposes of the doctor to cite it no problem. “We don’t do that. It would be unethical. Behold the almighty Hippocratic Oath.” When it comes to not increasing the costs to the patient – out of no legitimate concern for the patient’s health, but for the doctor’s pocketbook – then where is this oath? When it comes to not increasing the risks to the patient – out of no legitimate concern for the patient’s health, but for the doctor’s pocketbook – then where is this oath?

“Oh, that is just a medical anachronism.”

“It isn’t a binding oath.”

“You misunderstand the purpose of the oath.”

“Pay no attention to that man behind the curtain.”

What can be done to get doctors to practice medicine as an art that is for the benefit of the patient?

“What if . . . ?” does not have an ICD-9 code, does it?

How can doctors really complain about snake oil salesmen, homeopaths, and other anti-science groups in one breath and order a useless, expensive, test with the potential of harm to the patient in the next breath?

Well, I’m not a doctor, so I don’t have any place giving anyone any suggestions about how to be a doctor. This is what I often hear from those who appear to limit their medical decisions to admitting everyone who cannot be tested to death, or to calling someone for a second opinion.

Then, on the other hand, I am getting free legal advice from someone who isn’t a lawyer; someone who would be apoplectic at the suggestion that a lawyer might give medical advice – regardless of cost; so this legal advice is worth what?

The best suggestion in my non-doctor, non-lawyer opinion is the one proposed by Common Good. Medical courts that are handled by medical professionals (I would hope limited to the small fraction of doctors who do understand statistical relevance), not the impressionable innumerate wealth redistributing members of the medical illiterati. Of course those awarding these huge amounts of money, even when the doctor did not do anything wrong, are only exhibiting signs of “learned helplessness.” They are keeping alive the dream of the lawsuit lottery.

And in EMS these same doctors, who are terrified of not testing for Zebra Syndrome ignore dangerous medics, allowing them to do whatever they do to unsuspecting patients. Not that EMS is special, how many doctors will do anything to prevent a dangerous doctor from harming patients. Why do something to protect patients, when there are theoretical lawsuits to to be obsessed over.

Maybe I exaggerate too much. Maybe I just don’t have a clue, but the lawyers I do know have told me that the best way to avoid a lawsuit is to act in the patient’s best interests. I suppose it would be silly to rely on the advice of real lawyers, when there are doctors just thrilled to provide me with legal advice, as if that were to justify their DSM-IV behaviors. Some do not seem to order lunch without an expensive, to somebody else, test. My apologies to the rest – this is not about you. We need to improve critical judgment in all areas of medicine, not abandon it to computerized algorithms.

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Comments

  1. In the spirit of Fermat, let me say that I have a great and eloquent response to this post but it simply wont fit in the comment box here ;-)Seriously though, the big problem is obviously the “lawsuit lottery” mindset that our citizenry seem infected with. I will leave it to LD and others to take that ball and run with it; perhaps it is symptomatic of an overall decline in our “collective values”.The biggest stumbling block is of course the method by which the courts “evaluate” what is “appropriate care”. The test is generally “would another similarly trained physician have done the same” a clumsy way of comparing suspected errant treatment(or lack of treatment) with The Standard of Care. Anyone paying attention realizes that this is written on an Etch-A-Sketch. Sadly, it isn’t anything closely resembling evidence based medicine that turns over and shakes away the scribbling. The more that physicians practice reflexive, defensive medicine the more that practice is perpetuated, not only in the psychology of “monkey see [one monkey do one, monkey teach one] monkey do, but it becomes the “standard” against all other clinical decisions are measured against- when Mr and Mrs Sixpack consult Dewy, Cheatham, and Howe; Attorneys-at-Law.The only viable solution, shy of aerosolizing Responsibilital™ over the entire nation, has to be radical tort reform.This message brought to you by the Future Physicians of America 😉

  2. Your ’emotional plague’ runs deep. Any first year psychology student would recognize that you have massive feelings of inadequacy, and an insatiable need for validation. The constant denigration of physicians, and the assertion that ‘all would be right in medicine if they would only listen to the lowly paramedic’ is a definite red flag. I suggest that you print out your blog archives and bring them to an analyst ASAP. Your thesis, that ‘We need to improve critical judgment in all areas of medicine, not abandon it to computerized algorithms. ‘, is patently absurd. If you had even the slightest appreciation of history and science you would understand that it took medicine hundreds of years to evolve to the point where there is some (scientifically based) standardization in clinical practice. The algorithms, which you are so quick to malign, are developed by medical researchers on the basis of clinical trials. Would you rather see cardiac arrests treated according to the ‘critical judgment’ of individual providers? Might it be worthwhile for each technician in an aircraft assembly plant to exercise his ‘critical judgment’ on how to install different components of the plane? ‘Critical judgment’ is a guess based on what you know at the time. Algorithms are patterns of activity that have proven themselves to be effective in certain situations. The reason that ‘defensive medicine ‘ is more commonplace is because our society has come to embrace ‘science’ as its guiding paradigm. As long as the ‘algorithms’ are the product of unadulterated science, I will take them every time over the best guess of an individual clinician. Treatment plans should be driven by the metrics when a clear-cut solution exists. In those cases where the course of action is ambiguous, all viable options should be presented to the patient / legal guardian in laymen’s terms, and he should be allowed to choose. In the scientific arena, judgments are driven by data, the more data the ‘better’ the judgment. Would science be better served by replacing data with ‘critical judgment’? Sometimes the acquisition of data can be harmful / problematic. In those cases full disclosure must be made to the responsible parties and a consensus much be reached. Our species is composed of 99% dullards and 1% geniuses. Great men create the plans of action and the rest of us follow. The medical professions are staffed with the highest functioning dullards, but they are just dullards. We are all better off when we allow the geniuses to guide our activity.

  3. Vince said…”big problem is obviously the ‘lawsuit lottery’ mindset that our citizenry seem infected with. I will leave it to LD and others to take that ball and run with it; perhaps it is symptomatic of an overall decline in our ‘collective values’.”Well, ld didn’t seem to have any problem with it.”The biggest stumbling block is of course the method by which the courts ‘evaluate’ what is ‘appropriate care’.” This is where medical courts, if allowed, would be able to eliminate the problem of laymen determining what is good medical care. “The only viable solution, shy of aerosolizing Responsibilital™ over the entire nation, has to be radical tort reform.”Some sort of tort reform is needed.

  4. Most (73%) settled malpractice claims involve medical error. A 2006 study published in the New England Journal of Medicine concluded that claims without evidence of error “are not uncommon, but most [72%] are denied compensation. The vast majority of expenditures [54%] go toward litigation over errors and payment of them. The overhead costs of malpractice litigation are exorbitant.” Physicians examined the records of 1452 closed malpractice claims. Ninety-seven percent were associated with injury; of them, 73% got compensation. Three percent of the claims were not associated with injuries; of them, 16% got compensation. 63% were associated with errors; of them, 73% got compensation (average $521,560). Thirty-seven percent were not associated with errors; of them, 28% got compensation (average $313,205). Claims not associated with errors accounted for 13 to 16% percent of the total costs. For every dollar spent on compensation, 54 cents went to administrative expenses (including lawyers, experts, and courts). Claims involving errors accounted for 78 percent of administrative costs.[16][17]Tort reform as ‘the answer’ — NO! The legal system, while clearly imperfect, is designed to protect the population against quacks. According to the Rogue —‘And in EMS these same doctors, who are terrified of not testing for Zebra Syndrome ignore dangerous medics, allowing them to do whatever they do to unsuspecting patients. Not that EMS is special, how many doctors will do anything to prevent a dangerous doctor from harming patients. Why do something to protect patients, when there are theoretical lawsuits to to be obsessed over.’Remove the legal safeguards and who / what will serve as the watchdog against quackery / greed ?? How will we be able to compel compliance w/ ‘the standards’? Without the legal system medicine would devolve into the wild west — everyone would do his own thing.

  5. ld said…”Your ’emotional plague’ runs deep.” You keep using that term. What do you mean by it?Then you rant about imagined psychological inadequacies, but that is your schtick.”Your thesis, that ‘We need to improve critical judgment in all areas of medicine, not abandon it to computerized algorithms. ‘, is patently absurd.” You go on to defend algorithms used to appropriately treat patients, not the unscientific mindless autoscan approach of defensive medicine.”The algorithms, which you are so quick to malign, are developed by medical researchers on the basis of clinical trials.”Really? Then why are some physicians opposing the scan everything to death approach?Where is the science supporting defensive medicine? “The reason that ‘defensive medicine ‘ is more commonplace is because our society has come to embrace ‘science’ as its guiding paradigm.” Society is clueless about science. We have a very poor understanding of science in this country people don’t know the difference between the scientific definition of a theory and the liberal arts definition used by people when not referring to science. When it comes to controlling for variables, those performing research often demonstrate their prejudices, rather than an understanding of science.”As long as the ‘algorithms’ are the product of unadulterated science, I will take them every time over the best guess of an individual clinician.”Show me some science that supports defensive medicine. As far as I can tell it is just a herd mentality in response to something scary.”Treatment plans should be driven by the metrics when a clear-cut solution exists. In those cases where the course of action is ambiguous, all viable options should be presented to the patient / legal guardian in laymen’s terms, and he should be allowed to choose.”Wow, you seem to agree. “In the scientific arena, judgments are driven by data, the more data the ‘better’ the judgment.”No! Quantity does not equal quality. You have to discriminate among the data. Bad data leads to bad decisions. Part of the scientific process is maximizing the acquisition of high quality data, analyzing it appropriately, and coming to rational conclusions from valid data. Defensive medicine violates this. Homeopathy violates this. Pseudoscience is one big boondoggle that thrives due to our poor understanding of what good science is.

  6. ld said…I left out the actual long quote, here.You cite evidence that the settled cases are for actual damages. That is good, but how does that relate to defensive medicine? You seem to be making the case that all of the unnecessary medicine is the waste that I portrayed.”Tort reform as ‘the answer’ — NO!””Remove the legal safeguards and who / what will serve as the watchdog against quackery / greed ?? How will we be able to compel compliance w/ ‘the standards’? Without the legal system medicine would devolve into the wild west — everyone would do his own thing.”I guess I missed the memo when they changed the definition of “reform” to “abolish.”

  7. ’emotional plague’ is a term that was coined by one of the greatest psychoanalysts of the 20th century – Wilhelm Reich. How do you define ‘needless scan’? If a scan uncovers a previously unidentified problem can it be described as needless? It seems to me to be difficult to label any (relevant) scan as ‘needless’ before you know the result. If you want to gamble go to Vegas. If your kid sustains a borderline closed head trauma — well, I’ll bet that ‘needless’ will take on a whole new meaning for you.

  8. ld said…”How do you define ‘needless scan’? If a scan uncovers a previously unidentified problem can it be described as needless? It seems to me to be difficult to label any (relevant) scan as ‘needless’ before you know the result.”If you scan for everything because it might tell you something, no matter how remote the possibility, or how relevant the positive result might be, then you are having others pay for your lack of critical judgment and your inability to understand evidence based medicine.We could scan everybody, for everything, because you can’t be too safe. Fortunately, I have not heard of any recognized medical body taking that position. There are some people who feel that you can’t be too safe. We will cripple the country with this attitude. I wrote about how dangerous this is in Safety über alles! “If you want to gamble go to Vegas. If your kid sustains a borderline closed head trauma — well, I’ll bet that ‘needless’ will take on a whole new meaning for you.”I never hit my kid on the borderline, the message would be too ambiguous. Is there a legitimate reason for the scan? If so do it.If it is being done because “You can’t be too safe,” then don’t do it.I guess, when it comes to medicine, you buy into the liberal agenda of “You can’t be too safe.”

  9. I am curious ….. what are the acceptable losses in the ‘RM’ system? How do you arrive at your cut-offs? Should providers make decisions on the basis of defined standards / algorithms, or should they just go with their gut?The standard of care is determined by research scientists, and the rank and file providers apply that knowledge in their clinical practice. Modern (American) medicine is so effective because ‘the group’ benefits from the strides made by the academics —- every swinging dick does not have to reinvent the wheel !!!

  10. ld said… “I am curious ….. what are the acceptable losses in the ‘RM’ system? How do you arrive at your cut-offs?” I have no problem with recognized standards, but what does defensive medicine have to do with recognized standards? “Should providers make decisions on the basis of defined standards / algorithms, or should they just go with their gut?””Go with their gut?” – as in defensive medicine? I am glad to see that you are recognizing the problem of defensive medicine. Algorithms made up on a whim, with no scientific basis.

  11. ‘I have no problem with recognized standards, but what does defensive medicine have to do with recognized standards?’If you have to ask —- you clearly don’t understand the subject matter.

  12. ld,It is a rhetorical question. That means that the answer is within the question. There is no connection.You might provide some evidence that overtesting, testing beyond what is indicated by patient presentation, but only for some bizarre possibility, is recommended by reputable organizations.

  13. A couple of points:LD- 1. I disagree with your assessment of our legal system being in place to protect us against quacks. Medical boards who issue licenses and impose sanctions/disciplinary actions are there to protect the populous. The legal system is a means to recoup damages AFTER THE FACT. If your argument is that out of fear of being sued better care will be delivered, then A) I don’t think we are talking about “quacks”- they generally wouldn’t know good care it it bit them on their Chakras, and B)at what point do you draw that line in the sand?True, that if you argue that from the point of the patient: any and all tests to rule out everything,regardless of how remote the chances, would afford that patient (technically speaking) the best possible care.But would you call a provider who did anything less than order EVERY test he could imagine “negligent”? At some point doesn’t this obviate the need for any initial screening by a physician? Shouldn’t patients just have a complete battery of tests- to investigate every possibility and just have a physician interpret the results?This thinking is absurd of course.2. Yes there are medical misadventures and physicians make mistakes like everyone else. The niche market for medical malpractice has exploded because of a lack of tort limits and the the pervasiveness of the attitude that whatever is wrong with me is someone else’s fault and more importantly, they gots to pay!A little risk/reward analysis: Since those med-mal sharks will work on the ‘zero money down’ principle and customarily take around 40% of any award recouped, people risk ABSOLUTELY NOTHING to file claims with the potential payoff somewhere around astronomical dollars and ridiculous cents. This is also why people play the lottery.Lawyers operate on a second principle of “throw enough shit against the wall and something will stick”. Insurance companies are well aware of the law of large numbers. Couple- a never-ending torrent of claims, with the possibility of unlimited awards, and this motivates them to settle cases to dispose of the potential financial liability.Settling costs money. In the end it costs us all. This is a huge burden on our health care system. Providers are paying more for malpractice insurance because insurance companies are paying more out to get rid of claims. Furthermore, in a misguided effort to reduce their liability physicians are ignoring sound clinical judgment and ordering seemingly unwarranted and very expensive tests. I agree if a test reveals a previously occult condition you would call it justified. But we unfortunately do not live in a vacuum and there are not unlimited resources. Some restraint must be used and that restraint comes from sound clinical judgment- and this judgment come from scientifically gathered statistical data. There are no hard and fast absolute rules in medicine, as you know. But what is the purpose of knowing that, say this constellation of symptoms point toward X as a diagnosis 98% of the time, when you will ALWAYS conduct a battery of time consuming, expensive tests to rule out the 2%?Enter judgment. Unfortunately with the motivation to bring suit being very high and financial liability approaching infinity, judgment takes a back seat to fear. This causes the practicing of defensive medicine that perpetuates the vicious cycle in that no one wants to be the guy that doesn’t order the “million dollar workup” on something that it really isn’t indicated for. Because at the end of the day in court, the lawyer will point to “x% of physicians in this jurisdiction ALL ordered this workup as a matter of routine, why didn’t you?” I would support tort reform that among other things, would place reasonable limits on pain and suffering awards and thereby remove some of the financial motivation to file claims. Interestingly enough the Federal courts have just such limits in place.Defensive medicine cannot sustain itself. Eventually the standard of care will approach Full-on, balls to the wall, Presidential style battery of tests with every presentation of the sniffles. This is when the wheels fly off the bus!Frankly I’d rather spray with Responsibilital™, but that’s just me!

  14. ‘1. I disagree with your assessment of our legal system being in place to protect us against quacks. Medical boards who issue licenses and impose sanctions/disciplinary actions are there to protect the populous. The legal system is a means to recoup damages AFTER THE FACT.’MMMMMM …… not so much. The ‘boards’ don’t have the authority or the resources to adequately protect the consumers. Why not charge the KKK to investigate all claims of racial discrimination? ‘True, that if you argue that from the point of the patient: any and all tests to rule out everything,regardless of how remote the chances, would afford that patient (technically speaking) the best possible care.’Any and all RELEVANT tests – not every possible test. There is no need to get an x-ray of the right foot to rule out arthritis in an ER patient who presents with closed head trauma. ‘But would you call a provider who did anything less than order EVERY test he could imagine “negligent”? ‘If the provider failed to order a relevant test AND the patient had a bad outcome then HELL YES !!!!!’At some point doesn’t this obviate the need for any initial screening by a physician? Shouldn’t patients just have a complete battery of tests- to investigate every possibility and just have a physician interpret the results?’No. The physician must select the relevant studies. I do not advocate doing every test on every patient, just the relevant exams on every patient. My position is that we should leverage our science / technology to the patients’ best advantage. ‘There are no hard and fast absolute rules in medicine, as you know. But what is the purpose of knowing that, say this constellation of symptoms point toward X as a diagnosis 98% of the time, when you will ALWAYS conduct a battery of time consuming, expensive tests to rule out the 2%?’Its easy to take that position when you use figures like 2% …… what happens when you replace 2% with names like Kathy or John? Assume that you get your wish —- tort reform — what happens to the 2% folks — will the medical boards provide for them ?’Enter judgment.’Decisions that are informed by more (relevant) data are better decisions. Its all academic now ….. the first time that you are in charge and you don’t order that CT for a kid w/ closed head trauma …. and that kid dies …… you’ll tell yourself that he was a 2%er — an acceptable loss …. but the reality is a little different.

  15. The ‘boards’ don’t have the authority or the resources to adequately protect the consumers. Why not charge the KKK to investigate all claims of racial discrimination?The boards ISSUE the licenses and allow the providers to practice. The boards giveth and the boards can taketh away. How is this not authority?If the provider failed to order a relevant test AND the patient had a bad outcome then HELL YES !!!!!…….The physician must select the relevant studies. I do not advocate doing every test on every patient, just the relevant exams on every patient. My position is that we should leverage our science / technology to the patients’ best advantage.The key word you use here is RELEVANT. This is my argument exactly. The very definition of what is relevant in medicine is in great part established by the Standard of Care- which is being skewed every day! If most of the providers scan every head that has any type of impact imaginable in the absence of realistic possibilities for serious injury or clinically relevant signs that would raise the index of suspicion then scanning every head regardless NOW BECOMES THE STANDARD OF CARE! Not every investigation is benign or without side effects i.e. radiation etc. Its easy to take that position when you use figures like 2% …… what happens when you replace 2% with names like Kathy or John? By no means am I being cavalier. I agree with you that we should use science to leverage the best outcomes possible for our patients. Defensive medicine isn’t based on science. Fearing you will be sued over not getting that scan doesn’t magically increase the likelihood of an occult injury! Assume that you get your wish —- tort reform — what happens to the 2% folks — will the medical boards provide for them ?You are beginning to sound like a liberal…are you channeling Ted Kennedy? 😉

  16. ‘The boards ISSUE the licenses and allow the providers to practice. The boards giveth and the boards can taketh away. How is this not authority?’1. Lets take a large state for example — California — do you have any idea what the size of the medical board is? Any idea how many cases it handles ? 2. I guess you have no problem with doctors policing themselves ??? 3. The medical boards do not have the authority to pursue civil / criminal complaints, nor do they have the authority to curtail practice in other states. BOARD ENFORCEMENT QUICKLY AND PERSISTENTLY COMES UNDER FIRE The Medical Board has struggled to live up to its necessary responsibilities. Just five years after the “deal,” the quality of the Board’s enforcement program was already being widely criticized. Throughout the 1980s, the Auditor General, Assembly Office of Research, Little Hoover Commission, and the Legislative Analyst all found serious faults with the Board’s enforcement performance. (Report, pp. 22-26) These serious and ongoing failures were fully documented in 1989, when the Center for Public Interest Law authored a report entitled Physician Discipline in California: A Code Blue Emergency. That report examined the history of the Board’s many problems and further documented even greater failings in the Board’s enforcement program. The use of the medical term for emergency – “code blue” — in the title was not an overstatement. The following year, its dire concerns were illustrated in a series of events that sustained the report’s core criticisms: o The public was shocked when Dr. Milos Klvana was sentenced to 53 years in prison for 47 felony counts, including nine counts of the second degree murder of infants. The Board had a history of discipline against Klvana dating back over a decade, but the Board continued to permit him to practice. In 1990, a judge publicly criticized the Board for its failure to discipline Klvana more severely, and asserted that the Board’s lax discipline opened the way for the physician to cause the deaths of the nine infants; o The Legislature discovered the Board had a backlog of almost 900 uninvestigated cases. In response, the Legislature withheld half of the Board’s budget until it addressed this unheard of bottleneck, which was preventing the Board from accomplishing its core legislative priority of physician discipline; and o A national report ranked the Board 42nd among all the states in the number of serious disciplinary actions taken against physicians. Five years later, in 1994, the Los Angeles Daily News published a series of articles on physician negligence that revealed yet more problems with the Board’s physician discipline function. The articles included ones titled: o “Anatomy of Malpractice Doctors. Insurers Settled $483 Million In Claims From 1990-92. Unknown To Public”; and o “Are The Public’s Interests Served? Doctor’s Multiple Settlements Not Disclosed In Medical Board’s Records.” These articles focused on a then little-known problem – $483 million was the amount insurers spent to settle 2,002 medical negligence claims from 1990-1992, without the public ever being able to learn whether their own physician had settled such a claim. The Daily News apparently obtained this information by filing a Public Records Act request with the California Highway Patrol, which had been called in to investigate allegations that the Board was improperly destroying documents. ‘The very definition of what is relevant in medicine is in great part established by the Standard of Care- which is being skewed every day!’No, not so much. Science, studies, and metrics determine the standard of care —- not every idiot with a license. Most people are stupid, but they can at least muster enough cortical function to ask why. The fact that X number of people do Y is not a justification to do Y. In order for any activity to be considered ‘the standard of care’ there must some science that supports it. ‘You are beginning to sound like a liberal…are you channeling Ted Kennedy? ;-)’I am so far right ….. I actually approach the left, BUT when it comes to education and healthcare I have to part company w/ my brethren.

  17. ‘Defensive medicine isn’t based on science. Fearing you will be sued over not getting that scan doesn’t magically increase the likelihood of an occult injury!’Defensive medicine …. lets analyze that term …… defend against what? ….. legal action ….. why would you be worried about legal action? …. perhaps because you didn’t meet the standard of care ….. if you can demonstrate that the preponderance of scientific evidence supports your treatment plan then ….. no worries. So to my way of thinking —- the fear of litigation keeps the slackers, under achievers, rogues, and greedy bastards in line. Self preservation is by far the strongest drive.

  18. ld writes,”Any and all RELEVANT tests – not every possible test.”Which is exactly the problem of defensive medicine. Taking the possibly relevant to an extreme. Of course, not the absurd that ld describes as extreme.”There is no need to get an x-ray of the right foot to rule out arthritis in an ER patient who presents with closed head trauma.”The problem is that the defensive medicine doctors are not responding to any standard of care. The standard of care is determined by a jury on an individual basis, case by case.Claiming that they are following the standard of care, when each jury will determine this differently, is only what they think they are doing. You still have not come up with anything to support this reckless, irresponsible, and dangerous practice of defensive medicine.”Defensive medicine …. lets analyze that term …… defend against what? ….. legal action ….. why would you be worried about legal action? …. perhaps because you didn’t meet the standard of care ….. if you can demonstrate that the preponderance of scientific evidence supports your treatment plan then ….. no worries.”They cannot demonstrate that “the preponderance of scientific evidence supports” their treatment plan. That is the whole point. It is a fraud.Or do you have an itsy bitsy teeny weenie iota of scientific evidence to support this paranoia?

  19. who would have thunk it ….. I am, arguing for science, and you seem to advocate feelings/beliefs/opinions/gut instinct/individual judgment/etc.its like season 5 of the X-files …. Scully and Mulder switched roles …… only … with all due respect …. you aint nearly as cute as Scully 😉

  20. ‘Claiming that they are following the standard of care, when each jury will determine this differently, is only what they think they are doing.”The standard of care’. The ‘the’ means that there is only one ‘standard’ ….. that’s the whole idea ….. standardization in clinical practice …… leveraging science (research) to the patients’ best advantage.I advocate good medicine not defensive medicine. It takes a great deal of effort to continually meet the standard of care — the provider must perpetually immerse himself in the most recent literature from leading scientific institutions and professional organizations (ex: ACEP). Most professionals don’t do this …… that’s where the fear comes from ……. they don’t know the current standards …… so they do everything to avoid getting caught …….. idiots !!! Is it clear yet ?

  21. ld said…”who would have thunk it ….. I am, arguing for science, and you seem to advocate feelings/beliefs/opinions/gut instinct/individual judgment/etc.”Please provide some science.You are using the feelings argument – “What if little Johnny really has that condition that happens more often on soap operas than in real patients? How would you feel if that were your little Johnny?”I am stating that the scientific evidence does not support ordering every remotely related test – remote as in far fetched. I do suggest that the physician should assess and determine the relevance of test. Where are the recognized guidelines/algorithms that support your statement that overtesting is reasonable?Please provide some of the scientific evidence you keep claiming supports your position and stop singing Feelings. “its like season 5 of the X-files …. Scully and Mulder switched roles …… only … with all due respect …. you aint nearly as cute as Scully ;)”More likely the episodes where Mulder switched bodies with David St. Hubbins. The stuff they did for laughs was good, the rest, not so much. I’m much more like Michael McKean and resent being the woman in this relationship you have planned for us. I wouldn’t even comfortable with you as the woman. You probably snore. 🙂

  22. “I advocate good medicine not defensive medicine. It takes a great deal of effort to continually meet the standard of care — the provider must perpetually immerse himself in the most recent literature from leading scientific institutions and professional organizations (ex: ACEP). Most professionals don’t do this …… that’s where the fear comes from ……. they don’t know the current standards …… so they do everything to avoid getting caught …….. idiots !!! Is it clear yet ?”If you agree with me, then why the big commotion?

  23. ‘If you agree with me, then why the big commotion?’1. I believe that there is only one ‘standard of care’ at any point in time —– you feel that it is fluid and determined by juries rather than scientists. 2. I believe that if a particular test is only worthwhile for 2% of a population (a specific illness / injury) then it should be administered to everyone in that population in order to help those in the 2%. (Unless the test itself has a greater likelihood of causing a problem than identifying one — (Ex: 2% chance you will find a head bleed w/ a CT and a 0.003% chance you will cause cancer w/ the CT — you go with the CT).

  24. The X-files comment was obviously not meant for you …… even on her worst day …… Scully was infinitely more insightful than you !

  25. ld wrote,”1. I believe that there is only one ‘standard of care’ at any point in time —– you feel that it is fluid and determined by juries rather than scientists.”In a court room, the standard of care is determined by the jury. We are talking about legal paranoia producing defensive medicine. The legal aspect of it is what happens in a court room.The difference between doing what is right for the patient and doing what is believe to scare away trial lawyers is the difference between good medicine and defensive medicine.”2. I believe that if a particular test is only worthwhile for 2% of a population”OK, where do you get the 2% from?Vince mentions 2%, probably making it up on the spot just to have something to work with, but now it is a recognized incidence of “something.” If you don’t do this test 2% of the patients will have “something,” and that is bad. We could end up in court for an unrecognized “something.”Where is the evidence that they are testing for anything as common as 2 in 100? Why are you working with a made up number, as if it is real? Where is there any science to support defensive medicine? I apologize for the broken record effect, but how many times do I have to ask? Are you just playing hard to get?

  26. ld said…”its like season 5 of the X-files …. Scully and Mulder switched roles …… only … with all due respect …. you aint nearly as cute as Scully ;)””The X-files comment was obviously not meant for you …… even on her worst day …… Scully was infinitely more insightful than you !”Obviously, you were addressing someone else. My insight must have failed me there. Or is that not meant for me either? So hard to tell with you changing your approach to things so frequently. Are you still Mulder, or was that not what you meant, either?

  27. ‘In a court room, the standard of care is determined by the jury. ‘Scientists / professional organizations (EX: ACEP) establish the standard of care, and juries determine whether the standard of care was met. The only thing that we have in common —- a number —– your weight and my IQ.

  28. ld said…”‘In a court room, the standard of care is determined by the jury. ‘Scientists / professional organizations (EX: ACEP) establish the standard of care, and juries determine whether the standard of care was met.”I was quoting a lawyer. I’ll tell him you disagree.On to the standard of care.Where is defensive medicine the standard of care? Where is the evidence to support defensive medicine?”The only thing that we have in common —- a number —– your weight and my IQ.”Oh boy, you really are smart!

  29. ‘”The only thing that we have in common —- a number —– your weight and my IQ.”Oh boy, you really are smart!’I was going out on a limb there …. you could have lost a lot of weight ;)I think that terms need to be defined.The standard of care = management that is consistent with the results of research / experimentation.Defensive practice = management designed to minimize legal vulnerability.Comprehensive care = providing all beneficial interventions to all patients.Defensive clinicians order irrelevant studies because: they don’t bother to keep themselves up to date on the current standards, they profit from extra studies, or they are just extra obtuse. My position includes the following points:1. Standards of care are determined by professional organizations and researchers. Science drives the development of the standards, not the activity of risk adverse clinicians.2. Provide the standard of care and you will not be successfully sued. ‘The standard of care’ is the legal measure of acceptable practice. 3. The standard of care is not good enough. The US has ample wealth to provide all beneficial interventions to all of its citizens. Greed (rationing) is responsible for a certain percentage (x%) of bad outcomes. Cheney / Obama / Clinton all receive every possible medical advantage —- the average ER patient does not —- that’s my beef.

  30. Since I am stupid enough to actually BE in medical school I am sorry I missed all the fun exchanges here today but allow me to jump back in here…Lou, you said:Scientists / professional organizations (EX: ACEP) establish the standard of care, and juries determine whether the standard of care was met.”You could not be more wrong! Don’t worry I have Ripley’s on the other line and he is doing some research but this could be the one ;-))The standard of care is a living breathing fluid thing that varies not only temporally but geographically. In court you as a physician are judged against what other similarly trained physicians in the same situation have done/would do. I hope you can see that if defensive medicine is allowed to continue unchecked, then the standard of care evolves into a “just work up everything no matter how obscure the possibility”. This, I hope we agree, cannot go unchecked.You state the the standard is set by scientists, professional organizations such as the ACEP. OK and just who do you think these bastards are if not doctors??You seem to put your faith in physicians to ESTABLISH the standard just not “policing themselves” ? [my bullshit alarm is screaming at 130 dB!]Defensive medicine is not just practiced by the obtuse, lazy, or uninformed clinician. On the contrary, it has been my experience that many providers order tests that they know there is no reasonable indication for solely based on the “this one is for the lawyers” principle. I will never support anything that allows mediocrity to fester, and am an avid proponent on keeping up with new information to constantly readjust your treatment modalities BASED ON EVIDENCE!So far there is no evidence whatso-friggin-ever that supports the assertion that ordering low probability, expensive, and potentially harmful investigations actually improves patient outcomes. This is the only yardstick the astute clinician should base his practice on. Evidence. Period. I see you have said that you do not indeed support this ass-clownery (defensive medicine). I am happy to see that. What, pray tell, do you see as the solution to this growing and serious problem if not tort reform?????

  31. ld wrote,”Defensive clinicians order irrelevant studies because: they don’t bother to keep themselves up to date on the current standards, they profit from extra studies, or they are just extra obtuse.”We agree on that. That was my point in the post. If the doctors are ordering tests that are not indicated, rather than evaluating the patients, making informed clinical decisions, and ordering appropriate studies, that is defensive medicine. These doctors could be replaced by automatons following a protocol, that spits out testing orders, without any evaluation of the appropriateness.Testing for the remotely possible as if it were probable. Testing for things that ACEP, et al. do not recommend be tested for on every patient.”My position includes the following points:””1. Standards of care are determined by professional organizations and researchers. Science drives the development of the standards, not the activity of risk adverse clinicians.”This is one area where medical courts would improve the fairness of the outcome. A group of reputable doctors making decisions about the quality of care, the appropriateness of care, whether standards were followed, . . . .Having a bunch of medically naive people make these decisions does not improve care. Having these same decisions sealed, does nothing to bring about changes. There is plenty of room for tort reform that is in the interest of improving patient.”2. Provide the standard of care and you will not be successfully sued. ‘The standard of care’ is the legal measure of acceptable practice.”Unfortunately, that does not appear to be the case. Some provide horrible care, but are very nice to patients, and do not end up in court. Some provide excellent care, but their bedside manner is pathetic, and they end up in court over hurt feelings – not a hurt patient. A medically naive jury hears about the mean old doctor who left a scar, while saving the patient’s life, and they see deep pockets and an opportunity for redistribution of wealth. “3. The standard of care is not good enough. The US has ample wealth to provide all beneficial interventions to all of its citizens. Greed (rationing) is responsible for a certain percentage (x%) of bad outcomes. Cheney / Obama / Clinton all receive every possible medical advantage —- the average ER patient does not —- that’s my beef.”I disagree about the unlimited medical resources in the US. Part of the problem is how the resources are used. The JCAHO screening questions are about to go from obscene to very dangerous when the SBIRT (Screening and Brief Intervention with Referral to Treatment) for every patient who presents to the ED takes effect. We will have nurses spending more time on screening questions, that should not be the job of the nurse to begin with, than the time they have available to spend on patient care.Yes, VIPs are treated differently. Often this leads to worse care. I have not been able to find it for several years, but I read a review of “executive medicine” or “VIP care” by a flight surgeon(?) who was pointing out the many ways VIPs interfere with their care. This leads to inferior care, not better care. Of the presidents who have been shot, 3 probably had their death hastened by the most senior, but least current, doctor providing care. Reagan was smart enough to tell everyone to just treat him as they would anyone else. Then he did not ask for any special treatment, such as skipping a standard, but undignified treatment. Maybe it would not have mattered on his case, but he is unusual in taking this approach to medical care.

  32. ‘The standard of care is a living breathing fluid thing that varies not only temporally but geographically. In court you as a physician are judged against what other similarly trained physicians in the same situation have done/would do.’I did not imply that the standards are static. As everything changes with time — this is not news. Lets chicken / egg this puppy. Physicians (good ones) practice on the basis of what science / research tells them — they should not guide their practice according to what the 5 hick bastards around the corner are doing (unless those 5 mutants are using science as their guide). Science sets the pace — science establishes the standards — not the mob. We threw out God for this mofo (science) —- our society is not going to abandon it so quickly. ‘You seem to put your faith in physicians to ESTABLISH the standard just not “policing themselves” ? [my bullshit alarm is screaming at 130 dB!]’ Just curious —- why do we have 3 co-equal branches of government? The legislature makes the laws — why not let them interpret / enforce them as well ?? Why do we have an independent counsel statute? That’s why the docs can’t do it all — the whole absolute power thing. Docs / scientists create the standards, but they cannot be charged with policing their brethren. FBI / State police investigate local agencies — Justice Dept special prosecutors investigate the FBI — yada yada yada.’Defensive medicine is not just practiced by the obtuse, lazy, or uninformed clinician. On the contrary, it has been my experience that many providers order tests that they know there is no reasonable indication for solely based on the “this one is for the lawyers” principle.’Ok …. I should have added: spina-non-gotta … ball-less … cocksuckers ! Happy now ?’This is the only yardstick the astute clinician should base his practice on. Evidence. Period. ‘That’s my line …. practice should be based on science — not what the mob does.’What, pray tell, do you see as the solution to this growing and serious problem if not tort reform?????’I’ve got the answer …… let’s just say that more than a few special interest groups would take offense at my solution. Don’t just look outward for the cure …… this one is going to require a little mirror gazing. Medicine isn’t what it used to be …. it doesn’t attract the caliber of people it used to …. the focus is on productivity not quality …… yeah, lawyers are rat bastards …. yeah, the legal system needs tweaking …… but one of the reasons for the increased amount of litigation is that there are more fuck-ups than ever in the health-professions …. and fuck-ups fuck-up … a lot !!! Just ask the Rogue —- he hasn’t met a medical commander worth a damn since the fall of Saigon !!!

  33. I think we have come to about as much agreement as we’re likely to. Although that may be a very optimistic statement. :-)As far as medical directors, there are a bunch I respect and admire. Unfortunately, I do not know of a lot of them. I think that many medical directors do not know much about how EMS works. Even those who come from EMS often do not know how to improve things, but only continue things in the way that they were done when that medical director was a lowly medic.I see a lot of room for improvement. There are places that do a good job of this. These should be the examples we use to judge other places. The individual cases of egregiously bad care are usually, in my opinion, a sign of a failure of oversight. Oversight that should have anticipated and prevented these problems.If the medical director is going to delegate oversight to a non-physician, the medical director had better make sure that the oversight is focused on the right things. If you want to discuss depriving patients of quality care, then providing dangerous medics to those not able to exercise any choice over their care (those calling 911) is an important example.

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