In one corner , we have Kate Steadman, arguing that defensive medicine doesn’t really exist in the statistics. In the other, we have Kevin Pho, who believes defensive medicine not only exists –it’s increasing.

Now, what could make two intelligent people, both well-versed in health care, have such different understandings? Well, as they say, the proof is in the pudding. Or, no, don’t cry over spilt milk. No no no. The devil’s in the details. That’s the one.

It really depends on what your definition of “defensive medicine” is. I think most doctors would define it as “excessive labs or tests or studies or procedures to rule out disease that is highly unlikely but performed anyway for fear of lawsuit.” And this all depends on where the line is drawn between excess and standard of care. (I think one of the major concerns here is that if excessive medicine is practiced long enough, it will soon become the standard of care.)

I’m going to go out on a dataless limb here and say that I believe there are more tests being ordered, and I’ll even back it up with a theory. Now, there are multiple diseases that we’re taught are “cannot miss” diagnoses. Mainly because if you miss the diagnosis and don’t detect it, it can be fatal. Heart attack, aortic dissection, pulmonary embolism are three common examples. I’d argue that it’s standard of care to rule these diagnoses out if you at all suspect them. This standard of care, combined with out better technology, has gotten us into trouble.

Before CT scans and labs tests were widely available and so very, very routine, I imagine physicians had to use their physical examination skills to rule a “cannot miss” diagnosis out. But now that you can pop a patient in a CT scanner, and 30 seconds later, get a really good idea if they’re having an aortic dissection or pulmonary embolism, it’s become much easier to rule these things out. And therefore, we (as a society, or as physicians) have come to have a decreased threshold for testing a patient. If we used to feel 99.9% comfortable a patient doesn’t have an aortic dissection, we wouldn’t worry about it. But now, unless we feel 99.999% comfortable, we might as well check. What are the physician’s incentives? If he or she checks, he or she can feel even more comfortable (0.001% more comfortable) that the person is fine, and this means, in many physicians’ eyes, less chance of getting sued. What are the physicians disincentives? Having to interpret the results, good or bad, and hopefully some concern for medical costs, those that are either passed on to the patient or to their insurance company. But really, which will the physician choose? (I’m not going to debate the malpractice world in this post, but I think it’s safe to say that many physicians are worried about lawsuits, whether or not they have reason to be.)

So, putting it all together, I’d say that we’re doing excessive testing on patients, sometimes for fear of lawsuits, sometimes because they’re somewhat of a new standard of care. It’s a gray zone, like all of medicine and much of the world.

In medical school, if we suggest ordering a lab test or a study, a superior will often ask, “How’s it going to change your management?” That is, what are you going to do differently based on the data? If you know someone has a pneumonia, you’d expect their white blood cell count to be high. If they’re on antibiotics and seem to be getting better, why order another test? You’re not going to stop their antibiotics based on it. (This is, of course, great in theory and med student pimping practice, but I have yet to be a fully responsible party for a patient’s care.)

Fixing this vicious cycle will take a lot of education and cultural change. We’ll only be getting more and more technology, not less, with faster and easier tests. The urge will be to order more and more tests, and this will affect patients and physicians on an individual level, as well as everyone on a societal level, with higher costs for medical care and health insurance.

We’re nowhere close to addressing these issues, nowhere near solving these problems. And so costs will continue to climb, and tests will continue to be ordered, defensive or not.

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