From the Physician’s Point of View
By William Jacott, M.D. Physicians practicing defensive medicine is not a new issue; it dates back to the post–World War II era where malpractice had its real beginnings. For many years, all the evidence was anecdotal and there were not many studies that documented the practice. In fact, the early estimates that defensive medicine raised the cost of health care by 25% were not based on data but were simple guesses. In the past few years, the medical literature has published legitimate defensive medicine studies such as the June 1, 2005 article in the JAMA or the July 13, 2005 article in Annals of Emergency Medicine. The data in these publications confirm that defensive medicine is widespread. They also confirm that over-ordering of diagnostic tests, unnecessary referrals, and avoidance of high-risk patients are the most common forms. It is unfortunate that physicians are painted into the corner of ordering a test, making a referral, or not wanting to see a patient for fear of getting into a malpractice situation. How many times have we ordered cervical spine X-rays for a whiplash or a CT scan for a headache when we know the results will be normal? It’s costly, wasteful, sometimes invasive, and often painful. There are no easy solutions and this practice may be increasing. However, some helpful solutions are offered in the recent Joint Commission public policy initiative Health Care at the Crossroads: Strategies for Improving the Medical Liability System and Preventing Patient Injury (http://www.jcaho.org/about+us/public+policy+initiatives/tort_resolution.htm).These recommendations include, but are not limited to, the following: - Encourage appropriate adherence to clinical guidelines, which are physician-developed and evidence-based. Thus, if the guideline says no X-rays are necessary for a certain condition, the physician can choose not to order that test with some confidence. Many guidelines are now available in software that can be downloaded to a personal digital assistant.
- Support teamwork development through team training. Having multiple health care professionals involved in a patient’s care can reinforce a decision not to order a test or procedure.
- Promote open communication between patients and physicians. Patients should be invited to be active members of the health care team. Leaders should also encourage open communication between physicians and patients or families when an adverse event occurs.
These suggested solutions will not eliminate defensive medicine; as long as there are professional liability issues, these situations will occur. We can bring some changes to the behavior when there is adequate professional liability reform, appropriate patient safety measures in place, and a confidence in using medical guidelines for the care of our patients. William Jacott,M.D., is a Special Advisor for Professional Relations at the Joint Commission. |