I have had several experiences with physicians who preferred to take a “wait and see” approach to disease instead of prescribing medications. I have also witnessed physicians order every test available, even expensive and seemingly unnecessary tests. Both sets of physicians were practicing defensive medicine. I recently read an article which quoted a doctor saying that physicians who practice defensive medicine do so “to save your behind in the unlikely event of a 1:1000 outcome.”
As a young doctor preparing for the next step in my medical career, this is something that I have thought about a lot. When is the line drawn between trying to be the physician hero and careful caregiver? Having shadowed aggressive and conservative physicians, I understand why they make these decisions. Physicians have become frustrated that even for seemingly straight-forward infections, they are forced to use the “big gun” antibiotics with bad side-effect profiles. Lack of conservatism with respect to antibiotic usage in certain infections commonly caused by viruses led to the development of multi-drug-resistant bacteria and ineffective antibiotics.
On the other hand, sometimes it is necessary to be aggressive. If a 50-year old Caucasian male presents with epigastric pain after eating a large fatty meal, he most likely has a gastrointestinal problem. However, the consequences of missing an MI are so grave that the ER must do all tests to rule out serious cardiac disease. No doctor wants to be the one asked in court “How could you miss this finding? Or “Why didn’t you do this test?”
The fear of malpractice suits drives most defensive medicine, but patients themselves can be a major driving force for defensive medicine. In the information age, patients have at their fingertips potential solutions to any of their illnesses. Armed with this knowledge, many patients will have a preconceived plan of action and insist that their doctors “do every test,” even if it is expensive or unreasonable, simply because they read about it on the internet or saw it on TV.
Does defensive medicine harm or help the patient? If each additional test causes the patient discomfort, are we “doing no harm”? If each additional test drives the patient further into bankruptcy, have we helped them? Alternatively, if doctors are wary of performing risky tests or treatments because of the potential for lawsuits in a bad outcome, have we helped them? As long as our culture remains as litigious as it is, these questions will be a constant ethical battle for both new and seasoned physicians. The ability to make the right judgment call will come with experience, and I hope that when we are faced with these difficult situations, we will be comfortable enough to make the decision.
by Alberto Marcelin, Class of 2011