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Fear drives doctors to practise defensive medicine

The issue of defensive medicine has been in the limelight lately. In response to a parliamentary question, Senior Minister of State for Health Lam Pin Min cautioned doctors against practising defensive medicine, saying that this deviates from good clinical practice and would unnecessarily increase healthcare costs.

The issue of defensive medicine has been in the limelight lately. In response to a parliamentary question, Senior Minister of State for Health Lam Pin Min cautioned doctors against practising defensive medicine, saying that this deviates from good clinical practice and would unnecessarily increase healthcare costs.

Defensive medicine is generally regarded as the practice of medicine with the main purpose of reducing the threat of malpractice liability, rather than to further diagnosis or treatment for patients.

Why do some doctors adopt such a practice?

To begin with, culture plays a role. When I was a house officer at a surgical department back in 1994, the standard practice in managing patients with stable head injuries was to admit for observation for 24 hours.

This was the norm at the department and, as a junior doctor, I never questioned it.

Admitting patients for observation was a defensive practice. If the patient’s condition deteriorated after admission, it would be diagnosed at the hospital and treatment could be given without delay. As a result, not a single case of delayed injury would be missed.

But by the end of my four-month posting, I realised the actual number of delayed injuries picked up during the 24-hour hospitalisation period was practically zero. This means such a practice of admitting patients for observation was probably unnecessary and a misuse of resources.

Secondly, recent experience with other patients with serious illnesses could also affect a doctor’s practice. If a doctor diagnosed a case of ovarian cancer in a patient with abdominal bloating, the doctor is more likely to consider ovarian cancer as a possible diagnosis in other patients with bloating.

He was hence likely to order further tests, such as a CT or MRI scan, for all patients who suffer from bloating, fearing he may miss one who may have ovarian cancer.

But while ovarian cancer is a serious diagnosis, it is uncommon among patients with abdominal bloating.

I see patients with abdominal bloating daily, but I have diagnosed only two cases of ovarian cancer over the past five years. So while scanning all patients with abdominal bloating would ensure I would never miss a case of ovarian cancer, such a practice is not only a waste of resources, it exposes patients to unnecessary ionising radiation.

Thirdly, medical negligence cases might also affect a doctor’s practising habits.

In a recent case in which a senior paediatrician missed the diagnosis of Kawasaki’s Disease (KD), the paediatrician was rapped for several acts that were unacceptable to the expert witness of the Disciplinary Tribunal.

These included not ordering tests for the erythrocyte sediment rate and C-reactive protein — both markers for inflammatory diseases — discharging a child with ongoing fever, and not doing further tests to diagnose KD, which is an uncommon condition.

The punishment meted out by the Singapore Medical Council (SMC) was a suspension of three months, which is considered harsh by many medical practitioners.

The verdict has prompted doctors to spend more time on each patient, and to consider all possible (even rare) diagnoses and perform the appropriate investigations.

Doctors are also more willing to refer their patients to other doctors for a second or third opinion if they are unable to solve the patient’s problems.

Lastly, it would nudge doctors towards discussing all possible diagnosis with the patients and letting the patients decide if they would want further investigations.

Yet the unintended consequences are that the doctors would order more tests than necessary, so as not to miss a diagnosis for rare diseases.

Take a patient with prolonged fever, for example. Besides KD, prolonged fever can be caused by many other diseases, such as melioidosis, tuberculosis, occult cancer, lupus, sarcoidosis, infective endocarditis, inflammatory bowel disease, rheumatoid arthritis, occult abscess and so on.

The same goes for symptoms such as abdominal pains, headaches and backaches.

Dr Lam is right in saying that doctors should not over-investigate all patients with these symptoms.

To society as a whole, defensive medicine would increase healthcare costs, as extra tests and procedures are costly.

Besides, the extra procedures and investigations would jam up healthcare facilities, making every patient wait longer.

The patients who really require the investigations, procedures and even hospital beds would, ironically, have to wait longer.

All stakeholders — doctors, patients, the SMC and the Government — ought to have a greater debate on the issue and come to a consensus. The important question would be how to avoid the practice of defensive medicine.

For instance, institutions ought to audit all medical practices regularly to study their cost-effectiveness.

Is keeping all patients with stable head injury cost-effective in diagnosing delayed head injuries?

Is performing a CT scan on all patients with bloating just to diagnose ovarian cancer reasonable?

Patients should also ask their doctors the indications, risks and benefits of tests that they are asked to undergo. In particular, before a test is done, patients ought to ask their doctors how the test results could change the management of the illness.

However, if doctors are really concerned about missing diagnoses of rare diseases, they may still try hard to persuade patients to undergo extra tests. And patients may be paralysed by anxiety while waiting for another test.

At the same time, patients also ought to understand that, in medicine, the only certainty is uncertainty. Doctors can provide a probability of a diagnosis after a set of investigations and a certain treatment period. The more tests a doctor performs, and the longer a doctor manages a patient, the higher the chance the doctor makes the correct diagnosis — but that would also mean a higher cost.

Many doctors are deeply concerned over the unintended consequences of the penalty meted out on the paediatrician in the KD case. In an unprecedented move, more than 1,000 doctors have petitioned the Director of Medical Services to revoke the three-month suspension. The SMC responded by reiterating that the paediatrician had fallen short of the standard of care.

It is hoped that doctors will be reassured, but many are still anxious.

Member of Parliament Lim Wee Kiak asked Minister Lam if his ministry could issue guidelines on diagnosing rare diseases such as KD. Such guidelines would help protect doctors in case they fail to diagnose rare diseases. But Mr Lam said no.

If missing a diagnosis for a rare condition equates to medical negligence and is penalised harshly, it is no surprise that doctors practise defensively.

At the end of the day, we have to ask ourselves these questions: Are doctors expected to not miss any diagnoses at all? How can doctors not miss a diagnosis without doing unnecessary checks?

And how should doctors treat patients appropriately without the fear of being sued?

Practising medicine is as challenging as ever.

 

ABOUT THE AUTHOR:

Dr Desmond Wai is a gastroenterologist and hepatologist in private practice.

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