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How should physicians handle patients requesting unnecessary tests?

By Richard E. Anderson MD, CEO and Chairman of The Doctors Company, the nation’s largest physician-owned medical malpractice insurer to Defensive Medicine


The State of Defensive Medicine

Our guest on Healthcare Matters is Richard E. Anderson MD, CEO and Chairman of The Doctors Company, the nation’s largest physician-owned medical malpractice insurer. In part 2 of our State of Defensive Medicine series, we asked Dr. Anderson how physicians should deal with patients requesting unnecessary medical tests. We asked Dr. Anderson questions on many different topics:
  1. Defining “Defensive Medicine” and why it’s a violation of the doctor/patient relationship.
  2. How should physicians handle patients requesting unnecessary tests?
  3. The BMJ study: Physician spending and subsequent risk of malpractice claims: observational study
  4. Alternative dispute resolution systems.
  5. MICRA’s most effective provisions.
  6. Is further tort reform necessary?
  7. The current state of the medical liability insurance landscape.
  8. Watch the full interview with Dr. Anderson.
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Mike: Well, the patient is generally a lay person. And discussing defensive medicine with other lay people, I often get the response that if there is a chance that I have a specific condition or ailment, I want to get tested for it. If there is any benefit, I want it. Better safe than sorry. How would respond to that patient who wants to make sure every avenue has been covered?

Dr. Anderson: That is, again, that is another very good question. It is easy to understand the sentiment that I don’t want any stone left unturned, and I wouldn’t want anything not appropriately investigated or treated if it was for me or my family or my loved ones. Very understandable sentiment. But obviously, taken to its logical extension, you can see that it actually doesn’t make any sense. Nobody wants everything done. In other words, nobody goes to the hospital and saying, “Give me your 10 best operations.”

And no one goes to info MRI and says, “I’d like to have an MRI of everything.” And so we understand that intuitively the best medicine is not everything. The best medicine has to be the medicine that is appropriate for the condition. And beyond that aside from the waste of time and resources both of which is significant because it takes a lot of the patients time and, of course, it takes a lot of society’s resources to do almost anything in medicine today so we understand the significance of that ways. But it’s well beyond that. The cost of defensive medicine is well beyond that because there are risks to any medical procedure.

We say that, for example, an imaging study whether it is a chest x-ray, or a bone scan, or a CAT scan, or an MRI, the actual risk is quite low, but it’s not zero. But even if you chose to ignore the relatively small risks of the procedure itself, the problem is when you order a test that isn’t indicated, you may get the answer to a question that you didn’t ask. For example, you order an unnecessary CAT scan of the chest or you ordered a millions of CAT scans of the chest in the hope of finding something sometime, you will end up finding hundreds if not thousands of small, questionable abnormalities that once discovered, require further investigation. And so the patient will now start down the road of having investigation of a tiny nodule of uncertain consequence whose presence was not known, which was not symptomatic, which we shouldn’t have been looking in the first place. And yet, patients will end up having biopsies, anxiety, cost, additional studies, sometimes even surgery for a nodule that, in fact, has no clinical significance whatsoever.

Mike: So what you are saying is, it is actually has the opposite effect. Defensive medicine, rather than reducing risk, actually increases risk.

Dr. Anderson: Right because no matter good or how risk free or how much risk reduction we do in medicine, there is virtually nothing that we can do that has zero risks. And so the more tests we order, the more therapies we give, the more medications we take even if they are inherently good medications when prescribed or given appropriately, they all have an inherent risks. And when we’re dealing with our own health and our own future, then taking unnecessary risks is a very dangerous thing to do particularly when we’re really talking about lottery sized numbers. In other words, on any given test, the odds of a major reaction are relatively small regardless of what the test is, or even an operation, relatively small.

But we are not talking about should society order extra CAT scans for example. We are saying, would it be a problem if we ordered a million extra CAT scans this yea? Or if we ordered a 100 million extra blood studies and it turns out that only .01% of those had false positives. Well .01% times a big number is a big number. And those false positives are dangerous. Or those one in a million allergic reactions, as soon as we order a million tests, somebody is virtually sure to have an allergic reaction. Again, it’s impossible to have a risk free diagnosis and treatment in today’s world.