Jay Woody, MD, FACEP
Physicians tend to agree that the practice of defensive medicine is widespread, especially in oncology where much more is at stake than in the general practitioner’s office. But whereas ordering a few extra tests can provide a sense of security for both patient and doctor, things can go drastically wrong when a benign “blip” leads to more testing and potential complications. Just ask Jay Woody, MD, FACEP, cofounder and chief medical officer of Legacy ER & Urgent Care, a Texas-based healthcare facility.
Woody recalls a time about 15 years ago when full body CT scans were becoming popular following an early cancer detection “that had saved somebody’s life.” People didn’t realize, however, that the results of these tests could also be misleading.
“I cared for a patient who had one of them done,” he recalls. “They found this spot, and so they went in and did this biopsy and it turns out it was just some calcium, which is totally normal. But in doing the biopsy, they punctured the lung, and then when they were fixing the punctured lung, an artery got damaged. And so this healthy guy who had no cancer growing in him had to spend half-a-year in the hospital from complications due to that full body scan he got.” Woody acknowledges the case is an extreme example, but he says that once you start doing more testing, you might find more “noise,” and the more noise you have, the more testing you do, and it becomes a vicious circle that could hurt a patient by prompting a test or procedure that didn’t necessarily need to be done.
Various studies estimate that the practice of defensive medicine costs upward of $46 billion a year in the United States. A Cleveland Clinic study published in JAMA Internal Medicine
, in 2014, examined the cost of defensive medicine at three different hospitals in Massachusetts, hypothesizing that “physicians who were concerned about being targeted by litigation would practice more defensively and have higher overall costs.”1
The study, which asked physicians to evaluate their own motives for ordering tests and other forms of care, found that 28% of orders and 13% of costs were “at least” partially defensive. The mean cost was $1695 per patient (95% CI, $1566-$1824), of which $226 was defensive.
Defensive Medicine Takes Various Forms
Common definitions of defensive medicine include not only the ordering of additional tests or hospital stays, but also the avoidance of patients and procedures that doctors fear may lead them down paths of litigation. Often, the fear of missing something in a diagnosis leading to malpractice lawsuits is sufficient impetus for physicians to overprescribe tests and procedures. That fear is magnified among oncologists.
“You’re dealing with the life and death of the patient,” explains Larry Altshuler, MD, a board-certified internist and director of oncology intake at Cancer Treatment Centers of America in Tulsa, Oklahoma. “With primary care providers, their concerns are more [about] the diagnostic misses. For specialists, a mistake can be deadly.”
Indeed, errors in diagnosis are, by far, the most common generic cause of malpractice suits against radiologists, with breast cancer being the most frequently missed diagnosis, according to a 2012 study by Rutgers New Jersey Medical School.2
“The specter of malpractice actions is a matter of continuous concern for radiologists. There is justification for this anxiety because suits against them are not rare, nor are they declining in frequency,” the authors wrote. Of 8401 radiologists enrolled in the study, 31% had at least one claim against them during their career. The study found that failure to diagnose was the most common reason for the initiation of a lawsuit, with a rate of 14.83 (95% CI, 14.19-15.51) suits per 1000 person-years. Procedural complications ranked a distant second, with a rate of 1.76 (95% CI, 1.58-1.96) suits per 1000 person-years. Failure to recommend additional testing was among the rarest of reasons for a malpractice suit (0.41 claim per 1000 person-years [95% CI, 0.34-0.50]).
“We know, for a fact, that one of the leading causes of malpractice in the United States is a delay of diagnosis of breast cancer,” says Judy Smith, MD, chief of the Spectrum Health Cancer Center in Grand Rapids, Michigan, adding that oncologists on the front lines may be under the most pressure to seek the extra security that more testing can provide. “I think there is a high degree of defensive medicine, in terms of avoiding any delay in diagnosis of cancer, especially by those who are doing the initial evaluation of patients who may or may not be at risk.”