Choosing to Practice Good Medicine

“We need you to counsel a pregnant patient about getting an MRI.”

In my public, inner-city emergency room, when the medical student calls requesting an OB/GYN consult, I know it’s been a bad night down there. Heading over, I could already envision the rows of patients shivering in half-open gowns, waiting hours to get answers to the emergent reasons that brought them to the hospital.

The medical student led me to the patient, asleep and huddled under her coat. “Her temperature is normal, but her pulse is on the high end and she has vomited 2 times. We think she has appendicitis. The ultrasound shows an 11-week pregnancy, but couldn’t visualize the appendix. Surgery team hasn’t seen her yet, but recommended an MRI.”

I flipped through the chart as the medical student spoke. The patient had been driven in by a co-worker, who found her vomiting in the bathroom at work. Since her arrival to the ER, she has been given intravenous fluids and a single dose of nausea medication. Her care had now passed on to the next shift. The new team wanted to do further testing.

“Why do you think she has appendicitis?”

“She came in with abdominal pain, hasn’t wanted to eat and has a slightly elevated white count.”

“That can be normal in early pregnancy. Tell me about her chief complaint and initial exam.”

The medical student sheepishly admitted that he didn’t have the details. The patient spoke minimal English.

A surgeon by training, I tend to tread carefully when it comes to medical interventions. My mentor taught me early on that I should think through every history question, physical exam element, and diagnostic test, as judiciously as I would for major procedures. His mantra was: What is the indication? Clinical decisions should be focused on doing the appropriate thing for the specific individual. “Every patient is your grandmother, mother, sister, or daughter,” he liked to say. I took his words to heart.

I set up the translator phone, and gently tapped the patient’s shoulder to wake her up.

“Can you please take out this tube?” She winced and pleaded, pointing towards the catheter that led from her bladder to a bulging bag of clear urine on the floor. Sympathizing, I took out the catheter, figuring this would build rapport. She exhaled with relief and gratitude.

“How are you feeling? How’s the pain, the vomiting?”

“Much better now.” She elaborated that she always had terrible morning sickness with her pregnancies. But because she didn’t want her new boss to know she was pregnant, she had allowed herself to be taken to the hospital.

Finishing up my evaluation with an abdominal exam, I concluded that the patient probably didn’t have appendicitis. What she needed was not an MRI, but prenatal vitamins and a prenatal appointment. I gave her the obstetric clinic’s business card and told her to follow-up within 2 weeks, or call if her condition worsened. She nodded and said, “I need to get home to my kids. What time is it?”

My ER colleague was hesitant about my plan. “The MRI is already ordered. We don’t want to miss anything.”

I understood that my colleague wanted to be thorough, though critics may call it defensive medicine – performing additional tests on the patient primarily to protect the physician from potential malpractice claims. In my mind, appendicitis was not likely enough of a diagnosis to warrant extra hours in the emergency room and an uncomfortable, hi-tech imaging study. The MRI would contribute little to our therapeutic decision-making, especially since the patient has improved already. Moreover, we could find ourselves trying to explain physiologic cysts, pelvic fluid, and other routine incidental findings, causing undue distress for the patient.

That, in a nutshell, is my problem with defensive medicine. The weight falls disproportionately on the patients. They and their families lose time, money, and sleep for no health benefit. Over time, this phenomenon erodes the essential trust between doctors and patients. It gets harder and harder for patients, already in a vulnerable state, to differentiate when their doctors are advocating for them, versus when their doctors are fearfully responding to a mix of real and imagined pressures on their reputations and bottom lines. This only adds fuel to the fire.

Malpractice litigation is a hostile, inefficient, and sometimes unjust process in our society. Most suits are dropped and most plaintiffs never get any money. Defense costs are high whether or not there is a payout. Existing laws try to pin the blame for failures of a broken health care system on individual physicians. My OB/GYN counterparts working in underserved areas get sued more, not because of bad outcomes, but because the patients are poor enough to become easy targets for solicitations on TV, public transportation, or the hospital doorsteps.

Despite this harsh reality, defensive medicine, or shifting the burden onto the sick, is not the answer for anyone involved. The solutions are tort reform, better communication, and meticulous documentation. While doctors push for change, we can’t budge on our responsibility to make the tough judgment calls that match the right tests to the right patients. It’s not acceptable to create an illusion of excellence by doing more; we have to provide actual, evidence-based, clinically rigorous quality care. More is just more, not better.

In this case, I chose the diplomatic path. “I don’t think your approach is unreasonable. Given my observations, I think she is safe to be discharged for outpatient management. Here is my full consult note. I won’t be offended if you don’t use my recommendations.”

My ER colleague sighed deeply. “Ok. I hope you’re right. Sometimes, I feel like we’re playing Russian roulette.”

“I hope I’m right too. I have a large bottle of Pepto-Bismol in my office if you need it.”

“Don’t worry. I’m prepared.” He showed me the package of Tums in his pocket.

We laughed. It takes guts and a very strong stomach to practice good medicine.