Defensive medicine is misunderstood

To the editor:

The article on defensive medicine published Nov. 5 was interesting but failed to address some important points that are routinely neglected in this discussion. Namely, it neglects to mention one of the most important motivators physicians have for ordering unnecessary tests. Furthermore, it does not point out that, though medical errors can be reduced, poor medical outcomes cannot be eliminated altogether. The current approach to this problem, which focuses on assigning blame, mitigates the open analysis of human error and hinders the implementation of safety measures to avoid repeating similar mistakes.

An important, but hardly discussed, reason physicians have for ordering tests is a lack of confidence in their diagnostic abilities. Arriving at the correct diagnosis is the most important, and challenging aspect of the practice of medicine. Traditionally this was achieved by obtaining information through a medical history and a good physical exam. As the great professor of medicine Dr. Herbert Fred lamented in a paper by the name of “Hyposkillia,” a large number of practicing physicians lack the clinical skills to do this effectively. Other providers lack the time because they routinely overbook their schedule. These doctors rely instead on technology, sometimes in a shotgun approach doctors refer to as a “fishing expedition,” in the hopes of stumbling onto a diagnosis. Ironically, many patients are reassured by this approach, confusing physician ineptitude with thoroughness.

Studies have shown that the likelihood that a physician will get sued is more often a function of interpersonal skills. Patients that like their doctor and feel that their concerns were addressed in a conscientious manner are less likely to sue when there is an unfavorable outcome. Arrogant physicians are more likely to be sued. Yet, I’ve never heard a colleague say, I’m going to spend more time with this family and answer all their questions so I don’t get sued.

If we truly hope to remedy this situation, three things must happen. The current system of litigation must be replaced with a more just system of medical review that fairly compensates victims of malpractice, identifies problematic physicians and improves processes to reduce future errors. Secondly, physicians must stop ordering tests (sometimes before even seeing the patient) that are not likely to yield useful information. Finally, patients must become better informed, realizing that all tests have the potential to lead to unnecessary and potentially harmful treatments.

Peter Palmieri, M.D., M.B.A., F.A.A.P.
Mission