Defensive Medicine...How do you deal with working with these attendings??

[deleted480308]

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It's a problem with our socialized system of cost that takes the decision out of the patients hands. If the patient is paying, we would be able to say "there's a 95% this is nothing and it costs $800 to figure out that last 5%...do want the test or do you want to go home?" Then we've given all the information and the patient made the call using their own autonomy and the decision was theirs.

But our stupid system has the government/insurance trying to shame us for ordering tests to cover that 5% while waiting to nail us to the wall for not being omniscient if we comply with their pressure and the patient gets burned...i'm not going down in the name of resource allocation

 

[VA Hopeful Dr]

Completely agree. I don't even get mad about this anymore. I only get mad when patients are promised something they should not get. If you want to send me some BS head injury so I can share some liability, I'll take it. Just don't tell the patient that they "need" a CT. The same goes for admits - I'll admit the low-but-not-no-risk chest pain, but I don't tell them that they "need" a catheterization.

Slightly off topic, but this hits on the most valuable thing I've learned from my years on SDN - understanding other specialties and what I can do to make their lives easier/make them less mad at me.

I never tell the patient what the other doctor needs or is going to do. Its always "I think ortho/cards/whoever will likely do this, but I could easily be wrong"

I've taken to apologizing profusely for obvious ED dumps, even admitting I know that I'm just dumping the patient on them.

Stuff like that.

 

[Zebra Hunter]

It's a problem with our socialized system of cost that takes the decision out of the patients hands. If the patient is paying, we would be able to say "there's a 95% this is nothing and it costs $800 to figure out that last 5%...do want the test or do you want to go home?" Then we've given all the information and the patient made the call using their own autonomy and the decision was theirs.

But our stupid system has the government/insurance trying to shame us for ordering tests to cover that 5% while waiting to nail us to the wall for not being omniscient if we comply with their pressure and the patient gets burned...i'm not going down in the name of resource allocation

We don't have a socialized system. What you are talking about is a lack of end-user sensitivity.

 

[deleted480308]

We don't have a socialized system. What you are talking about is a lack of end-user sensitivity.

30% of the country is on medicare/medicaid/military care...those are socialized programs and those are the programs that push the concept of not doing tests on us. It is absolutely the socialized aspect of care doing this to us as they are the only ones with the ability to require the medical establishment to deal with them.

end user sensitivity also applies to everyone with insurance but the medical community isn't changing because bcbs wants it to...it's being forced by the government

 

[Zebra Hunter]

30% of the country is on medicare/medicaid/military care...those are socialized programs and those are the programs that push the concept of not doing tests on us. It is absolutely the socialized aspect of care doing this to us as they are the only ones with the ability to require the medical establishment to deal with them.

end user sensitivity also applies to everyone with insurance but the medical community isn't changing because bcbs wants it to...it's being forced by the government

Insurance companies also push this same concept, the issues you are decrying are not specific to socialized medicine.

 

[deleted480308]

Insurance companies also push this same concept, the issues you are decrying are not specific to socialized medicine.

but the hospital isn't required to take BCBS, they can tell them to jump off a cliff and charge full cash price to the patient.....they can't do that to the government

 

[Doctor Bob]

It's a problem with our socialized system of cost that takes the decision out of the patients hands. If the patient is paying, we would be able to say "there's a 95% this is nothing and it costs $800 to figure out that last 5%...do want the test or do you want to go home?" Then we've given all the information and the patient made the call using their own autonomy and the decision was theirs.

I take a different view on this (mind you, neither view is wrong)

I don't give patients the choice. If I think the test is warranted, I order it. If I don't think it's warranted, I don't order it. I don't expect patients (with no medical education other than webMD) to have as good of a medical decision making ability as I do, and to put the onus on them doesn't defend me in any way. When the price tag comes into play it's almost coercion.

"Well your honor, he told me the test was $1000, and I got to thinking about my upcoming power bill and I didn't have the money for that so I didn't get the test and then my aorta ruptured."

Sure, my approach is somewhat paternalistic (or very). But when I have a diagnostic plan, I tell the patient what it is going to be ahead of time. At that point they can decline a test, at which point I have a discussion as to why I think it's necessary. If they still decline, then it's all documented.

Maybe I'm just over-emphasizing a small semantic difference.

 

[deleted480308]

I take a different view on this (mind you, neither view is wrong)

I don't give patients the choice. If I think the test is warranted, I order it. If I don't think it's warranted, I don't order it. I don't expect patients (with no medical education other than webMD) to have as good of a medical decision making ability as I do, and to put the onus on them doesn't defend me in any way. When the price tag comes into play it's almost coercion.

"Well your honor, he told me the test was $1000, and I got to thinking about my upcoming power bill and I didn't have the money for that so I didn't get the test and then my aorta ruptured."

Sure, my approach is somewhat paternalistic (or very). But when I have a diagnostic plan, I tell the patient what it is going to be ahead of time. At that point they can decline a test, at which point I have a discussion as to why I think it's necessary. If they still decline, then it's all documented.

Maybe I'm just over-emphasizing a small semantic difference.

You're fine, it's much bigger than semantics...my suggestion for patient autonomy is also predicated on the concept that the patient should be responsible for their own expenses. The end game of that is that at some point in life almost all of us would end up declining some care/test due to cost.....and that this downward pressure on demand would actually decrease costs overall

 

[GeneralVeers]

To say that price is "coercive" is ludicrous. We offer a service, and we (and the hospital) provide consumable goods. Our time is worth something, and the goods/medications/equipment we provide cost money. At some point all of those things cost money to develop, produce, store, and distribute. Is it more realistic to shift costs to the government/taxpayers who will generally spend wastefully and create perverse incentives? We've all seen how government mandates, and "cost controls" have done over the past 30 years

 

[Old_Mil]

i'm not going down in the name of resource allocation

What you're saying is that you're not going to increase your liability to save someone else money. That's a perfectly legitimate case to make, and a good motto for every emergency physician.

 

[Birdstrike]

To say that price is "coercive" is ludicrous. We offer a service, and we (and the hospital) provide consumable goods. Our time is worth something, and the goods/medications/equipment we provide cost money. At some point all of those things cost money to develop, produce, store, and distribute. Is it more realistic to shift costs to the government/taxpayers who will generally spend wastefully and create perverse incentives? We've all seen how government mandates, and "cost controls" have done over the past 30 years

...and by flooding the market with federal support for subsidies for people to buy insurance in the exchanges and to expand Medicaid, costs will sore even higher further inflating the cost of healthcare. The ACA puts more dollars on the market chasing the same goods and services but offers no price controls. Gruber even admitted that in his moments of brutal honesty that no price controls were placed in Obamacare because it would be too painful and might threaten bill passage.