Inside Medicine: When playing it safe isn't better for you
By Dr. Michael Wilkes -
Published 12:00 am PDT Sunday, May 25, 2008
An appendectomy is usually a relatively simple and quick surgical procedure. For Paul, 42, a healthy commercial pilot, the operation was planned after a CT scan and blood tests suggested a high likelihood of infection. By the time the surgeon saw Paul, his doctor had already ordered the pre-op tests including blood coagulation studies, an EKG and a chest X-ray.
When the surgeon arrived, he examined Paul and looked at the CT scan. He also noticed that the doctor ordered hundreds of dollars worth of other tests. Most of the tests the doctor ordered – including the EKG, the coagulation studies and the chest X-ray – were unnecessary given Paul's excellent health. In an otherwise healthy 42-year-old, who has no prior history of heart or lung disease, the chance that an EKG or chest X-ray will detect anything serious is incredibly small – so small that the risk of radiation exposure and the cost of the tests have lead experts to recommend against the routine ordering of these tests before an operation.
When the surgeon saw Paul's doctor, he mentioned that most of the tests ordered were unnecessary. The doctor admitted that ordering the tests were long shots – in other words, very unlikely to provide any useful information and not likely to benefit the patient. But he explained that the tests might help the doctor if he was ever sued. The doctor admitted he didn't follow expert guidelines.
There are several reasons doctors don't follow guidelines. Sometimes they don't agree with the experts and feel their own experience is of greater value. Other times the patient doesn't really match the people in the research studies – the patient may be too old or have other illnesses that need to be factored into the clinical decision. Other times they choose not to do what the guidelines suggest.
In this case, however, the doctor rejected good scientific research based on his long-standing habits and a fear of a malpractice suit at some point in the future. His thinking went like this: Should the patient have a chest problem, an abnormal heart rhythm, or a problem with blood clotting, the tests would allow him to detect and manage the problem prior to surgery. While this is correct, let's say the chance of detecting one of these conditions (in a man with absolutely no history of illness or bleeding problems) is 1 in 10,000. This means that the doctor would order 9,999 chest X-rays on healthy middle-age men to detect one chest problem that might (in theory) make a difference during surgery. This is indeed a long shot.
At the very least, Paul should be asked whether he wants these low-yield, expensive tests. In my opinion, these tests should not have been considered for Paul. When a test has almost no benefit for the patient and all the benefit is to protect the doctor against a potential malpractice claim, we have a major "systems problem." The incentives for the doctor to do what is in the patient's best interest are out of alignment.
For Paul's doctor, no amount of discussion or review of the evidence was going to change his perceived need to order lots of tests. He was convinced that someday he would be sued and lots of tests would help his defense team. In fact, the opposite is true: Evidence suggests that doctors are more likely to be sued when they deviate from accepted expert guidelines. Still we spend at least $15 billion a year on unnecessary pre-operative tests that are ordered only as a protection against some theoretical, future lawsuit; they provide no benefit to the patient.
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