There has been a lot of criticism of defensive medicine as a major contributor to the rapidly rising high cost of medical care in the United States. Although the real financial cost of defensive medicine is one issue, it is not the only problem with defensive medicine. Defensive medicine also has the risks of incidental findings on tests that are unnecessarily ordered, the risks patients encounter due to evaluation and treatment of these findings, and overdiagnosis.
Screening for prostate cancer has been all over the news recently, with the USPSTF proposed recommendation against routine PSA screening, and is a classic example of the risks of screening tests. The strongest argument against PSA screening is overdiagnosis and exposure of men to invasive prostate biopsies, and potentially dangerous therapy for prostate cancers that will never become clinically significant in some unknown but likely high percentage of cases. One of the primary reasons I don’t anticipate a dramatic reduction in PSA testing in primary care is because it is perceived by physicians that they are much less likely to be sued for complications of care caused by overdiagnosis of prostate cancer than if a patient is diagnosed with advanced prostate cancer and who has not been offered PSA screening. I suspect at least some physicians are going to be afraid to do the right thing even if they are convinced that the evidence supports not doing PSA screening.
Far less emotional and dramatic are consequences of defensive medicine precipitated by the ordering of imaging tests. It is commonplace for a physician to order an MRI of a patient’s knee early in the course of management of a knee injury. In an NEJM study of randomly chosen men without a complaint of knee pain the incidence of finding a meniscus tear on knee MRI was 31%. A finding of adrenal masses on abdominal CT scan is very common. In one study the incidence of an adrenal mass finding on abdominal CT in patients without a known malignancy was 5%. In this same study of 973 consecutive patients of the 973 zero were found to be malignant. This is exactly my experience, i.e. I’ve never had one of these turn out to be a cancer. Yet once an adrenal mass is found it is almost always recommended as a part of the radiologists report to have it reevaluated at least one, often twice or more to assure “stability.” It is unusual for a primary care physician not to order these follow up tests, more defensive medicine. The risk of radiation exposure from abdominal CT scanning is not insignificant.
Treatment of sore throat, acute short-duration sinusitis, otitis media and acute bronchitis with antibiotics is very common. It may be defensive medicine or just taking the path of least resistance, but there are very real risks of antibiotic therapy and almost all the evidence and expert opinion argues against the use of antibiotics in these conditions. With the increasing incidence of Clostridium difficiele infections, and increasingly virulent and antibiotic resistant C. diff as well as the other risks of side effects of specific antibiotics their use is far from risk free.
Nearly every new highly sensitive imaging technique is also very good at finding incidental variations of normal and abnormalities for which radiologists are reluctant to recommend no further evaluation, This is defensive medicine on the part of radiologists, as well as good business on their part in our fee-for-service environment. What business person of sound mind is going to put themselves at legal risk and at the same time recommend against a test that is in their financial interest. The risk to patients is more than just the risk of further radiation. Often the tests also lead to invasive tests or treatments, all of which have their own risks.
Many blood tests have the same risks, including tests like CA-125 for ovarian cancer, of course PSA, but also things as simple as a CBC. A CBC with a low white blood cell count is usually either normal or the result of a recent viral illness. Still it usually leads to a follow up test to assure a return to normal. If it persists low it may lead to referral to a hematologist who often orders a bone marrow evaluation. These are not only moderately painful but can have uncommon serious complications.
Essentially every test or procedure we do entails some risk. Ordering tests for defensive medicine reasons when the chances of finding clinically important and helpful results is fairly low makes the chances of finding false positives or overdiagnosis and leading to complications that would never have happened if the testing had not been done relatively higher. The cost of defensive medicine is not just in dollars.
And then there are tests allopathic doctors and hospitals don’t want to even bother with, like checking levels of B12 or other nutrients, doing complete thyroid panels, testing for food allergies/intolerances, determining lipoprotein particle size.
The results from such low-cost tests really only help self-determined individuals who wants to heal their own bodies holistically. They do not lead to lucrative surgeries, cancer treatments, or long-term pharmaceutical sales.
Sure, the hospital is happy to crush my breasts and expose them to radiation every year, but getting a free T3 count is like squeezing water from a rock.
And my lipid profile? My triglycerides are low, my HDL is good, my blood pressure is excellent, but my LDL and total cholesterol is supposedly too high. They don’t even know the size of the LDL particles or why my body is producing them, but keep pushing those statins!
I recently suffered a second bout of appendicitis (last was four year ago). I fasted and when the pain began to subside I went to the hospital. CAT scan revealed inflamed appendix with no perforation or abscess. My white cell count was normal (I’d already had a 102 fever that dropped on day 3). I was on the mend. But they still wanted to go in and surgical remove my organ. A case of CYA and profit, not science.