Ordering More Tests DOES Reduce Your Risk Of Being Sued. You're Being Lied To

[Birdstrike]

---

Members don't see this ad.

Ordering more tests absolutely DOES reduce your risk of being sued. You suspect it. You know it. It makes sense. Your gut tells you its true. It is true. Yes, you absolutely are being lied to; for monetary, social and political reasons.


"Abstract
Study question Is a higher use of resources by physicians associated with a reduced risk of malpractice claims?

Methods Using data on nearly all admissions to acute care hospitals in Florida during 2000-09 linked to malpractice history of the attending physician, this study investigated whether physicians in seven specialties with higher average hospital charges in a year were less likely to face an allegation of malpractice in the following year, adjusting for patient characteristics, comorbidities, and diagnosis. To provide clinical context, the study focused on obstetrics, where the choice of caesarean deliveries are suggested to be influenced by defensive medicine, and whether obstetricians with higher adjusted caesarean rates in a year had fewer alleged malpractice incidents the following year.

Study answer and limitations The data included 24 637 physicians, 154 725 physician years, and 18 352 391 hospital admissions; 4342 malpractice claims were made against physicians (2.8% per physician year). Across specialties, greater average spending by physicians was associated with reduced risk of incurring a malpractice claim. For example, among internists, the probability of experiencing an alleged malpractice incident in the following year ranged from 1.5% (95% confidence interval 1.2% to 1.7%) in the bottom spending fifth ($19 725 (£12 800; €17 400) per hospital admission) to 0.3% (0.2% to 0.5%) in the top fifth ($39 379 per hospital admission). In six of the specialties, a greater use of resources was associated with statistically significantly lower subsequent rates of alleged malpractice incidents. A principal limitation of this study is that information on illness severity was lacking. It is also uncertain whether higher spending is defensively motivated.

What this study adds Within specialty and after adjustment for patient characteristics, higher resource use by physicians is associated with fewer malpractice claims.

Funding, competing interests, data sharing This study was supported by the Office of the Director, National Institutes of Health (grant 1DP5OD017897-01 to ABJ) and National Institute of Aging (R37 AG036791 to JB). The authors have no competing interests or additional data to share."

Full text: http://www.bmj.com/content/351/bmj.h5516-0

 

[em1234]

a consistent 500% reduction across all specialties studied, between the lowest and highest utilization.
If you've ever sat through a deposition, every question centers around why you didn't order test X, or consult Dr. Y, or admit them for further work up.
I have no personal misgivings about ordering an extra test to make people prove their wellness.
Is it great resource utilization? No.
Do I sleep better? Yes.
Is there now reasonable data that supports what intuitively has always been assumed to be true? Hell yeah.

 

[DeadCactus]

What's the reduction for not practicing medicine in a medmal ****hole like Florida?

 

[RustedFox]

What's the reduction for not practicing medicine in a medmal ****hole like Florida?

Florida isn't the worst. We've moved up on the ACEP report card. I think we're in the mid 20-ranks.

I think you meant new England. All of it. Including PA.

 

[EMIM2011]

What is really interesting is the lack of media echo on this study....when there is a study that seems to find that those who order less tests etc are not higher risk, you hear about it much more...

 

[TrumpetDoc]

What is really interesting is the lack of media echo on this study....when there is a study that seems to find that those who order less tests etc are not higher risk, you hear about it much more...

Doubt we will see any play from ACEP/AMA for sure.

 

[deleted77919]

…

 

[coachB]

Ordering more tests absolutely DOES reduce your risk of being sued.

1.Actually, that is not at all the appropriate conclusion to draw from this study. Go back to basic principles of epidemiology if you must.

2. Emergency physicians were not included.

 

[GeneralVeers]

So we know that more testing harms patients, but reduces risk of getting sued? That's certainly quite the catch-22. Society incentivizes us to harm the patients we are supposed to be helping.

 

[Psai]

So we know that more testing harms patients, but reduces risk of getting sued? That's certainly quite the catch-22. Society incentivizes us to harm the patients we are supposed to be helping.

Bowel preps for headaches man. The privates have to make money by holding hands and ordering tests

 

[Birdstrike]

1.Actually, that is not at all the appropriate conclusion to draw from this study. Go back to basic principles of epidemiology if you must.

2. Emergency physicians were not included.

All I can say is, Whatever, whatever, whatever.

Order less tests. Drink the cool aid. It's your career.

 

[coachB]

All I can say is, Whatever, whatever, whatever.

Order less tests. Drink the cool aid. It's your career.

Never mind, no reason to even get in to this with you here. It's not about drinking cool aid, it's about doing what's right for patients.

 

[WilcoWorld]

1.Actually, that is not at all the appropriate conclusion to draw from this study. Go back to basic principles of epidemiology if you must.

2. Emergency physicians were not included.

Can you explain what conclusion you think is appropriate to draw from this study?

 

[HooliganSnail]

Never mind, no reason to even get in to this with you here. It's not about drinking cool aid, it's about doing what's right for patients.

We all practice defensive medicine.

The thing is that defensive medicine is often times decent medicine in the EM world. Our job is to rule out badness

That is why we spent all those hours learning about cardiac patients in med school, but in real life they're just so easy. 52 M with chest pain......Observation.....Next patient

The thing is, 52 M with chest pain have a decent probability of coronary artery disease. Defensive? Maybe.

 

[GeneralVeers]

We all practice defensive medicine.

The thing is that defensive medicine is often times decent medicine in the EM world. Our job is to rule out badness

That is why we spent all those hours learning about cardiac patients in med school, but in real life they're just so easy. 52 M with chest pain......Observation.....Next patient

The thing is, 52 M with chest pain have a decent probability of coronary artery disease. Defensive? Maybe.

Not so easy. What if their chest pain started > 8 hours ago? What if it's reproducible on exam? Both of these things are strong negative predictors of AMI. Are you going to admit them for a "stress test" which we all agree is complete garbage as far as diagnosis or predictive value?

 

[Apollyon]

Can you explain what conclusion you think is appropriate to draw from this study?

Yeah, I'm kinda dumb. I hope that the coach lets us know what he believes to be the appropriate conclusion, for it is not obvious to me.

 

[doctalaughs]

Yeah, I'm kinda dumb. I hope that the coach lets us know what he believes to be the appropriate conclusion, for it is not obvious to me.

Only an idiot (or healthcare economist,lawyer or other person not involved in patient care) can think that defensive medicine is not a huge driver or heathcare costs across all specialties.

I'm a dermatologist. If a patient comes to me concerned about a mole and I look at it, and I can tell that 99.9% chance its benign what do I do? I probably remove it in this system. Low risk procedure but disaster for me if I'm wrong that 0.1% of the time (which would happen after a few years). Of course that means I cost the system 1,000 moles x 200 bucks for path and procedure for very little benefit but it's worth it to not get sued.

We've trained a whole generation of physicians to practice super-defensive medicine so its not going away anytime soon (even if the system changed it would take decades).

 

[doctalaughs]

D

 

[Tiger26]

Only an idiot (or healthcare economist,lawyer or other person not involved in patient care) can think that defensive medicine is not a huge driver or heathcare costs across all specialties.

I'm a dermatologist. If a patient comes to me concerned about a mole and I look at it, and I can tell that 99.9% chance its benign what do I do? I probably remove it in this system. Low risk procedure but disaster for me if I'm wrong that 0.1% of the time (which would happen after a few years). Of course that means I cost the system 1,000 moles x 200 bucks for path and procedure for very little benefit but it's worth it to not get sued.

We've trained a whole generation of physicians to practice super-defensive medicine so its not going away anytime soon (even if the system changed it would take decades).

Doctalaughs nailed it--I generally think on the patient and population scale in terms of limiting my miss rate over a month, year, lifetime, etc to limit my exposure to adverse outcomes

 

[Hair Police]

Not so easy. What if their chest pain started > 8 hours ago? What if it's reproducible on exam? Both of these things are strong negative predictors of AMI. Are you going to admit them for a "stress test" which we all agree is complete garbage as far as diagnosis or predictive value?

I agree. Folks should read this.

 

[goodoldalky]

So we know that more testing harms patients, but reduces risk of getting sued? That's certainly quite the catch-22. Society incentivizes us to harm the patients we are supposed to be helping.

I think the point of this study is that we are disincentivized from missing a diagnosis to an extreme standard that is only achievable through a ridiculous amount of testing.

I am not otherwise incentivized to order tests, admit patients, or order scans as that has no bearing on me financially for all intents and purposes.

Now to be fair I practice in a state with strong tort reform, but I think the point is the system punishes a miss so heavily that you have to avoid it at all costs.

What I should be able to do is say, yeah sir, your chest pain is probably nothing, small chance it's some tiny subsegmental PE that your body is filtering out and your pleurisy will go away in a few days and you'll never have a problem. Go home. Come back if problems. But nope. The expectation now is that you catch that tiny PE with a $5K workup and put them on some life saving anticoagulant that's more likely to kill them than the clot. And if you don't and they get diagnosed two days from now at another hospital, you'll hear about it, probably from a lawyer.

Tort reform, more aggressive than what we have now, everywhere, is the answer.

 

[HooliganSnail]

Not so easy. What if their chest pain started > 8 hours ago? What if it's reproducible on exam? Both of these things are strong negative predictors of AMI. Are you going to admit them for a "stress test" which we all agree is complete garbage as far as diagnosis or predictive value?

Sorry dude, I already put him in Obs and moved onto the next patient.

Not going to be my ass. Never go down alone, let a cardiologists name get on that chart too.

When they design a system where I can't lose all of my personal wealth, house, savings, because of some stupid jury decision, then I will gladly send that guy home.

Admin is always yapping about "clinical decision rules" and blah blah blah. Here's the kicker, they want us to take all the liability.

 

[emergentmd]

I work in probably the best Med Mal practice. I order more tests for the following reasons in order or importance

1. Lets me sleep better at night. Who wants to go home wondering if that young SOB lady with some concerning hx had a PE? Just CT.
.
.
.
.
.


2. Pt requests or anxiety for more testing. No reason to fight the battle. Do it. They are happy. Your sats go up. They won't come back b/c they just home and googled that I should have ordered more testing

.
.
.
.
3. Chart buffing/medmal. That young guy with chest pain always get a EKG/CXR although you know its nothing. Hard IMO to not do both for anyone complaining of chest pain.

 

[NinerNiner999]

I wonder if it would even be possible to design a study for Emergency Medicine, since we pretty much scan, lab, radiate, and re-order on just about everyone who walks in the door. Our differential for life threatening illness almost requires this depth of testing to practice our specialty. Personally, with the current throughput initiatives and expectation for quality and standard of care, I'm surprised we haven't created a conveyor belt that goes from triage and through a CT scanner before we see the patient...

 

[WilcoWorld]

Yesterday I was talking to the triage nurse when a middle aged man in no apparent distress came up to the window and said "When I cough I get a sharp pain right here" as he pointed to a specific spot on his chest. I really wanted to walk around to his side of the desk and whisper "Leave now, as fast as you can! I can already tell you that you're almost certainly fine, but if you check in, you're going to get a huge work up."

Instead I said nothing.

It was the end of my shift, and I didn't take care of him. I'd bet dollars to dimes that he got an ECG, a CXR and a troponin (+/- dimer/CT/Obs). And you know what? I wouldn't fault a doc who did just that.

 

[deleted547339]

I wonder if it would even be possible to design a study for Emergency Medicine, since we pretty much scan, lab, radiate, and re-order on just about everyone who walks in the door. Our differential for life threatening illness almost requires this depth of testing to practice our specialty. Personally, with the current throughput initiatives and expectation for quality and standard of care, I'm surprised we haven't created a conveyor belt that goes from triage and through a CT scanner before we see the patient...

We have. It's called the trauma system.

 

[NinerNiner999]

lol touche. First trauma, next every elderly patient with abdominal pain...

 

[RustedFox]

lol touche. First trauma, next every elderly patient with abdominal pain...

Oh, maaan. Everyone over 55 with abd.pain = CT abd/pelvis, alllll daaay looong.

Welcome to Florida. People come to Sarasota to retire, and their parents live just south in Venice.

 

[Spinach Dip]

Within a couple decades, the standard treatment for "CC: ankle pain" will be a full-body CT and a suite of every blood test available (if only to rule out the possibility of lupus-induced joint degeneration).

 

[deuist]

Within a couple decades, the standard treatment for "CC: ankle pain" will be a full-body CT and a suite of every blood test available (if only to rule out the possibility of lupus-induced joint degeneration).

You joke, but I already have a partner who is like this. Once a 20-year-old female came in for sore throat. The next thing I know, the patient got a pelvic exam and a CT of the chest to rule out pulmonary embolism.

 

[bravotwozero]

Not so easy. What if their chest pain started > 8 hours ago? What if it's reproducible on exam? Both of these things are strong negative predictors of AMI. Are you going to admit them for a "stress test" which we all agree is complete garbage as far as diagnosis or predictive value?

Doesn't tintinalli say 30% of patients with MI have reproducible chest pain on exam?

 

[GeneralVeers]

I'll preface this link by saying that nothing ever rules out anything. Even a patient with a negative coronary angiogram can go on to have an MI. That being said here's the link:
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2233977/

"Based on this meta-analysis it was not possible to define an important role for signs and symptoms in the diagnosis of acute myocardial infarction or acute coronary syndrome. Only chest-wall tenderness on palpation largely ruled out acute myocardial infarction or acute coronary syndrome in low-prevalence settings."

Again "largely". You have to use chest wall tenderness in the correct setting. With a normal, unchanged EKG, and negative troponin you've very likely ruled out AMI as the cause. Bear in mind for me, the chest wall tenderness has to EXACTLY match where they say the pain is.

 

[RustedFox]

I'll preface this link by saying that nothing ever rules out anything. Even a patient with a negative coronary angiogram can go on to have an MI. That being said here's the link:
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2233977/

"Based on this meta-analysis it was not possible to define an important role for signs and symptoms in the diagnosis of acute myocardial infarction or acute coronary syndrome. Only chest-wall tenderness on palpation largely ruled out acute myocardial infarction or acute coronary syndrome in low-prevalence settings."

Again "largely". You have to use chest wall tenderness in the correct setting. With a normal, unchanged EKG, and negative troponin you've very likely ruled out AMI as the cause. Bear in mind for me, the chest wall tenderness has to EXACTLY match where they say the pain is.

I write this in my charts all the time; "The lateral/inferior border of the p.major muscle is remarkably tender on the right-side, at the anterior axillary line (for example). The patient identifies this as the site and source of pain."

 

[Hair Police]

This article is an interesting read:

http://www.ncbi.nlm.nih.gov/m/pubmed/7979843/

6% of ED Chest pain patients with rheumatology-diagnosed chostochondritis also had MIs.

 

[Birdstrike]

The next patient you have with a definite MI, do a little experiment. Push on them where their pain is. Ask them if that hurts. You may be surprised at what you find. Many will say, "Yes." Then ask yourself, if reproducible tenderness has any negative predictive value, whatsoever.

 

[deleted77919]

…

 

[GeneralVeers]

Our cardiologists do this all the time, drives me nuts. Come down to see the patient. Basically punch them in the chest or perform chest compressions on them. When the patient says ouch decide that it is reproducible and want to discharge the patient.

It may be useful in the appropriate context, but please don't force it.

It's useful to document as it's certainly defensible as an evidence-based way to make liklihood of MI less likely. If you press lightly on their chest/skin and they say ouch, that's reproducible. If I have to press on them hard enough to almost break ribs, then it's not.

If you're still worried about them after a negative EKG, negative troponin, and physical exam, then by all means admit them.

 

[cbrons]

Doesn't tintinalli say 30% of patients with MI have reproducible chest pain on exam?

Physical examination findings most strongly associated with acute myocardial infarction in patients presenting with acute chest pain are hypotension, S3 gallop, and diaphoresis, although the frequency, interrater reliability, and added diagnostic value are limited. Reproducible chest wall tenderness is suggestive of a musculoskeletal etiology but is reported in up to 15% of patients with confirmed acute myocardial infarction and cannot alone exclude the diagnosis of acute coronary syndrome.

Simon A. Chest Pain. In: Tintinalli JE, Stapczynski J, Ma O, Yealy DM, Meckler GD, Cline DM. eds. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 8e. New York, NY: McGraw-Hill; 2016.

 

[GeneralVeers]

Physical examination findings most strongly associated with acute myocardial infarction in patients presenting with acute chest pain are hypotension, S3 gallop, and diaphoresis, although the frequency, interrater reliability, and added diagnostic value are limited. Reproducible chest wall tenderness is suggestive of a musculoskeletal etiology but is reported in up to 15% of patients with confirmed acute myocardial infarction and cannot alone exclude the diagnosis of acute coronary syndrome.

Simon A. Chest Pain. In: Tintinalli JE, Stapczynski J, Ma O, Yealy DM, Meckler GD, Cline DM. eds. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 8e. New York, NY: McGraw-Hill; 2016.

15% is a good number. That means 85% don't have it. The question is, what percentage of those 15% had a normal/unchanged EKG, normal VS, AND negative troponin. If I can reduce the chance that someone is having an MI by 85% just by a physical exam finding, that has clinical utility for me. I would never use chest wall pain all by itself as inclusion/exclusion criteria for MI.

 

[Lord Humongus]

What about the transition to bundled payments? Could we end up with a situation where ED docs are unable to order all the tests that they consider to be necessary, but still be liable for missed diagnoses resulting from not conducting those tests that they were prohibited from ordering? Sounds completely loony, but then again you guys are already forced to see everyone under penalty of law while being unable to charge anyone for it and being legally liable for these compulsory free services. Nothing would surprise me at this point, frankly.

Edit: Now that I think about it, I suppose the execution of the above idea wouldn't take the form of being "barred" from conducting tests under certain scenarios but rather being financially disincentivised. So perhaps you'd still be paid a base of $200/hr but there would be some kind of blended calculation to subtract from this base amount for "aggressive" testing. Then it would be up to each individual physician to sweat about where to strike the balance between taking on legal liability versus ordering enough tests and being docked pay for it.

On the bright side, I think bundled payments in the ED would severely undermine midlevel encroachment. If the hospital has to choose between losing money on midlevels spam ordering tests vs taking on huge legal liabilities for letting midlevels exercise their "clinical discretion" they will probably just go with the good 'ol ED doc.