Better care is the best defense: High-value clinical practice vs defensive medicine
THE ROLE OF EVIDENCE-BASED GUIDELINES
Evidence-based practice guidelines can help support the provision of clinically (and ethically) appropriate care. Medical custom—the care expected of reasonable clinicians under similar circumstances—is generally the legal standard in determining whether a clinician has met a duty of care to a patient in a lawsuit.14 But practice guidelines can provide strong evidence of what constitutes reasonable care and can, over time, help set the standard for quality of care.
Clinical practice guidelines have grown in recent years, especially after the Institute of Medicine embraced them as a means to address variation in practice patterns and quality of care. But guidelines can conflict. Their effective implementation relies on clinical judgment. If a guideline is not appropriate in a particular case, documentation of why the guideline was not followed may prove prudent. Guidelines are not a safe harbor and have and will be used both defensively and offensively. They are not the last word, but rather another type of expert evidence.15 However, they are an important one. At the end of the day, the best care is the best defense.
Guidelines not only educate physicians, they also should be used by physicians to educate patients. In addition to developing guidelines for physicians, professional societies should develop and disseminate public education materials that inform patients and their families and caregivers about clinically appropriate care and the problems resulting from overuse and misuse of care.
GETTING BACK TO BASICS
Kroenke noted that preliminary data suggest that the history typically accounts for 75% or more of the diagnostic yield when evaluating common symptoms, the physical examination 10% to 15%, and testing generally less than 10%.16 Yet health care reimbursement in the United States contains incentives in precisely the reverse order. So, not surprisingly, we keep on testing away. Kroenke says that countering the rush to test will be as challenging and slow as trying to reverse a generation of antibiotic overprescribing.16
Over time, our reliance on technology as a diagnostic tool has increased, with less emphasis on the history and particularly on the physical examination to solve diagnostic puzzles. Yet most diagnostic errors in a study of outpatient primary care visits were related to breakdowns in the clinical interaction, including the taking of the medical history, the performance of the physical examination, and the ordering of tests. Technologies such as the electronic health record, which can assist in the care of patients, are also a potential source of error and shortcuts in care, as when copying and pasting is used inappropriately.17 Recognizing the increasing use of technology in practice and team-based approaches to improving care, Singh et al have called for caution and for more “focus on basic clinical skills and related cognitive processes.”18
The erosion of physical examination skills, discomfort with diagnostic uncertainty, and fear of malpractice litigation have combined to create a perfect storm of technologic overuse and misuse. Unfortunately, this means that our modus operandi is all too frequently built around testing rather than touching.19
At the same time, it is well established that patients often sue because of dissatisfaction, especially with physician communication and interpersonal skills.14 Emphasizing the basic skills that include taking a carefully crafted history, performing a skillful physical examination, and communicating effectively and compassionately with patients at every encounter is probably the most successful strategy for simultaneously avoiding malpractice litigation, reducing overused and misused diagnostic testing, and conserving precious health care resources.
Another part of the strategy should include routinely considering a number of straightforward questions before ordering diagnostic tests, such as “Will the test result change my care of the patient?” and “How does ordering this test compare in value with other management strategies for the patient?”20,21
RETURNING TO THE CASES
Regarding patient 1, the 32-year-old woman with intermittent headaches, the American College of Radiology identified imaging for headache in its list of five areas submitted to the Choosing Wisely campaign in which care may be overused or misused. Specifically, the American College of Radiology says, “Don’t do imaging for uncomplicated headache” in the absence of specific risk factors for structural disease, noting that “incidental findings lead to additional medical procedures and expense that do not improve patient well-being.”22
For patient 2, the 60-year-old man with pleuritic chest pain, both the American College of Physicians and the American College of Radiology strongly recommend against CT pulmonary angiography for patients in whom calculation of pretest probability indicates a low pretest probability of pulmonary embolism.22,23 Patients such as these should undergo D-dimer testing rather than CT pulmonary angiography. In this setting, a negative D-dimer test effectively rules out pulmonary embolism and avoids both the radiation and cost associated with the unnecessary imaging study.
According to the Ethics Manual of the American College of Physicians,6 “physicians have an obligation to promote their patients’ welfare in an increasingly complex health care system. This entails forthrightly helping patients to understand clinical recommendations and make informed choices among all appropriate care options… It also includes stewardship of finite health care resources so that as many health care needs as possible can be met, whether in the physician’s office, in the hospital or long-term care facility, or at home.”6 The basic principles of beneficence and nonmaleficence are aligned with doing the right thing for our patients—ie, providing the appropriate care at the right time and avoiding too much care or too little care. Guided by scientific evidence as well as by guidelines and official recommendations based on such evidence, we are in the best position to provide optimal care for our patients while simultaneously minimizing the risk of malpractice litigation.
As is the case with overprescribing, we must look critically at the inappropriate use of tests and other care applied under the rationale of not wanting to “miss anything”—and the unspoken drivers of financial incentives, new or advanced tests and procedures, and defensive medicine. We know what needs to be done. And nothing short of evidence-based high-value care will do.
Acknowledgment: The authors would like to thank Kathy Wynkoop for editorial assistance.
