Fearing suits, doctors use defensive medicine Expensive tests and scans become part of legal strategy

May 23, 1993|By Jonathan Bor | Jonathan Bor,Staff Writer

Dr. Thomas Ducker says 30 years of treating people's head, neck and back pains have taught him to recognize a patient's tension headache without ordering an expensive brain scan.

So what does the Annapolis neurosurgeon do when all his instincts and experience tell him a patient is suffering from stress, not a brain tumor?

He orders a CT-scan, a $400 picture that he's sure will prove him right better than 99 percent of the time.

For every 100 patients with all the signs of tension, he will order $40,000 worth of tests. Perhaps he'll find one tumor, he says, and in all likelihood it will be benign. In a simpler era, Dr. Ducker wouldn't want any of the patients scanned unless they developed more serious symptoms.

Now, he tests them all.

There are many reasons he does it -- patients, for one, have come to expect the fanciest diagnostic tools available -- but he says the fear of getting sued is the main force driving him to lean so heavily on tests.

"They're expecting me to do something and they will shop around until they get the scan. So why not do it?" said Dr. Ducker, 55, the former chief of neurosurgery at the University of Maryland Medical Center. "You've got a society that wants all the answers. And if you're wrong, you've got lawyers who are looking for business."

From family doctors to neurosurgeons, doctors say they are forced to order expensive scans, blood work and urine tests just to protect themselves from lawyers and their clients. In such cases, tests are less diagnostic tools than legal records -- charts and pictures that establish what they knew and when they knew it.

Fear of malpractice has even driven doctors to perform unnecessary surgery.

The classic example is the Caesarean section -- a surgical method of rescuing a baby who could suffer brain damage or other medical complications if delivered vaginally.

In New York, a recent study found that obstetricians are most likely to perform Caesarean sections in regions where the risk of getting sued is highest.

In Maryland, a quarter of all babies are delivered surgically, a rate considered twice as high as is medically justified.

It's not only specialists who feel the pressure to practice defensively.

Dr. Alan M. Davick, a Cockeysville pediatrician, said he used to tell a patient suffering from abdominal pain to watch for certain symptoms if, upon physical examination, he didn't think there was a serious problem such as a tumor or stone.

Now, rather than relying on time and judgment, he might order ultrasound ($150), blood work ($40 to $50) and urinalysis ($10 to $15) as a matter of routine.

"It was viewed that there was a social contract between doctor and patient," said Dr. Davick, in practice for 25 years. "The doctor provided information, the patient provided compliance and respect. And the doctor was available for the patient to call back.

"Nowadays, we have to document the directions that were given, call the patient back, even send over an ambulance to the house if we can't get a hold of them. Nowadays, we rely on the lab tests and less on the patient."

He said he used to keep a child's medical file on just a few index cards. Now, he is forced to keep cross-referenced records of each child's immunizations -- recording not only the dates and types of immunization, but also the brand names and lot numbers.

Nurses and secretaries also record each lab result, phone message and response to a worried parent's telephone call.

A 3-year-old's record can occupy many pages. Some of this is good medicine, he admits, but much of it is legal protection against a parent's suit for a real or imagined error.

"I think the lawyers are very protective of their source of income," Dr. Davick said. "We can look at the TV and see them advertising. Some of the most obnoxious situations were almost inconceivable 10 years ago -- showing a wheelchair and indicating that if your child has CP [cerebral palsy] your physician made a big mistake."

'Hugging a cloud'

This year, physicians will pay an estimated $9 billion in malpractice insurance premiums, but many analysts say doctors ring up a far bigger tab with unnecessary practices that are rooted in their fear of litigation.

Earlier this year, Lewin-VHI Inc., a private consulting firm in Fairfax, Va., estimated that defensive medicine cost $25 billion in 1991.

The nation, it said, could save $36 billion over a 5-year period by taking steps to eliminate the wasteful practices.

Critics argue that defensive medicine doesn't occupy a major slice of the national health bill, even if one accepts hefty estimates.

If the nation managed to trim $36 billion over five years by limiting defensive practices, the savings wouldn't reach 1 percent of total health costs.

And cost estimates vary wildly, from a fraction to many times the Lewin figure.

One reason is that it's extremely difficult -- some say, impossible -- to separate defensive practices from legitimate efforts to catch elusive tumors, obstructions and ailments.

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