Yes, it’s just an N of 74, but I think this data is pretty fascinating, and highlights why it’s so hard to estimate how much defensive medicine we “practice,” and why it’s so hard to define it: we can’t even agree on what it is. (If you’re confused, see this.) A quick review of the scenarios, followed by some beautiful graphs (thanks, Numbers App!):
- Scenario 1: 50s lady with a few cardiovascular risk factors with a few minutes of chest pain and a normal EKG. You admit for rule-out ACS.
- Scenario 2: 40yo guy with a history of PE on coumadin, therapeutic INR, with 3 weeks of chest pain. You scan for a PE despite adequate anti-coagulation.
Both of these were pretty split down the middle, which I thought was surprising. I thought fewer people would have wanted to scan the guy with the PE.
- Scenario 3: 4yo kid banged the side of his head on a door. Brief LOC, has a 2cm hematoma, looks like a normal kid here, no other concerning signs/symptoms. You CT the kid.
- Scenario 4: 26yo woman with vomiting and abdominal pain but a non-tender belly. You accidentally get labs with a WBC of 25. Feels better, belly’s still not tender, but you scan anyway, since the white count’s so high.
Apparently we don’t like scanning kids and non-tender bellies, since most people felt like these scans were unnecessary–but still a good 20% felt that the plan was reasonable.
- Finally, Scenario 5: 36yo female with a history of anemia with a story of heavy vaginal bleeding, but normal vitals and asymptomatic of anemia/blood loss, and some pooling in the vault. You send a CBC.
This seemed to be the least “defensive,” maybe because it’s just a lab test and doesn’t expose the patient to significant risk (just the cost of waiting in the department and the cost of a CBC.)
I also ran one more stat — were people who took the survey consistent in their values? (Obviously the scenarios are quite different, and everyone has their own issues, but were people likely to say most scenarios were defensive, or likely to say most scenarios were not?) Here’s a breakdown of how many respondents answered Yes to 0, 1, 2, 3, 4, or all 5 of the scenarios. This surprised me the most: most people were in the middle. I thought more people would be skewed toward the extremes.
I’d love to see ACEP or someone do this with a larger sample and more validated. But I think it’s a fascinating look into practice patterns and just more evidence that there’s no such thing as a “standard of care;” no one person can say what’s “right” or what “should” be done for a patient. We all have different ideas of what’s overly cautious or not cautious enough — and different ideas of what we should worry about. (And I’d hazard a guess that what we’re worried about for our patients is different from what we’re worried about for our patients’ lawyers.)