Medical Malpractice, Technology and Clinical Ambiguity: a not so positive feedback loop?
I did my medical school and surgical training in New York City and Philadelphia. I quickly learned that these were two of the most litiginous locales in the country. If I had a nickel for every time I heard a doctor begin a sentence with the phrase, “In this medico-legal climate…”. Others have tallied cost estimates that such a climate exacts on the system. I can speak only to my personal experience. Fear is there. Fear motivates me and my colleagues. Sometimes for the better. And sometimes not. One of the problems that irks doctors the most is that evidence based practice does not always protect them from malpractice.
We had an enormously productive joint replacement service in my residency- the program performs 60-80 joint replacements per week. It is a study in systems engineering (perhaps a future post). As a resident, I was the first responder for the medical care of these patients. It is very rare for one of these patients to have an adverse event such as a blood clot in the lung (PE) or heart attack (MI). Most people sail through joint replacement surgery quite well. But if the general population risk for such a complication is 1/100 and your institution performs 300+ joint replacements per month, you’re going to see the occasional PE or MI. Of note ALL joint replacement patients are at HIGH risk for blod clotting disorders due to the nature of the procedure and routinely are given blood thinners after surgery for prophylaxis.
There was a period of time during my residency in which it seemed like every joint replacement patient was getting worked up for a PE. Here was the typical scenario. The nurse would check the vital signs of the patient which included performing a simple test called a pulse oximetry (a small light sensor which detects blood oxygen content in blood). The pulse ox might read somewhere in the 87-89% range. The nurse would document his or her findings in the chart and then call the physician on call. He or would perform a blood gas (a painful test in which a needle is placed into an artery in the wrist to extract blood) and then await the result. Since every joint replacement patient is considered high risk for PE all of these actions would seem reasonable so far. The plot thickens…Almost universally the result would come back equivocal forcing the medical team’s hand once again. A CT scan with contraast dye would then be ordered. Contrast dye is a radiographically sensitive solution that is injected into the patient’s vein. It is usually safe but in some cases can cause allergic reactions or kidney failure. Alright, now we’ve brought out all of our big guns. The physician gets the scan result back which says something like this: “subsegmental pulmonary embolus left upper lobe.” Now what? Well I can tell you that once something is documented, it’s almost impossible not to treat in “this medico-legal climate.” So the patient gets an extra 3 months of anticoagulation or an IVC filter to prevent further clotting. What’s an IVC filter? That’s a little wire device that looks like a mini umbrella frame and is placed by a radiology team into the largest vein in your body. I won’t even get into the potential list of complications for these as I am sure you are all tiring of this by now . Suffice it to say, you can appreciate the diagnostic ambiguities and pressures that a physician might face in a pretty “straightforward” clinical scenario.
What is at issue in this example? A few things.
1. The nursing alert threshold was probably too low. Thankfully this protocol has since changed. Now a more streamlined protocol is performed which prevents a lot of unneccesary work ups.
2. Technology has inadvertently tied our hands. We now have CT scanners that can detect PE’s that are so small that they may or may not have any clinical significance.
So what’s the right answer? Where do we place the threshold to work up rare but serious events? Too far in one direction and we miss potential preventable events. Too far in the other and we do more harm than good. The evidence just isn’t clear enough yet. Nobody knows exactly. And even if you follow the literature by the book, if a PE occurs, some patients still sue. Will the doctor eventually be vidicated in court? Maybe.
But I sure as heck can understand why they wouldn’t discourage that extra test to cover themselves. Human perception being what it is, sins of ommision tend to be punished more severely than the unintended bad consequences of “doing something.”
Proposed solution to come. Stay tuned….
