On the Defensive

Covering the 2008 NAMDRC conference in San Francisco recently, I was re-introduced to a term I hadn't heard or thought about in many years.

Chatting with members of NAMDRC after-hours always bears ripe journalistic fruit. This group, composed of medical directors of respiratory care departments, includes many of the "top dogs" in cardiopulmonary medicine and clinical research. 

During the opening night reception inside the elegant marbled confines of the 93-year-old Flood Mansion, I posed my perennial question to many NAMDRC delegates: what articles would you like to see in ADVANCE? 

One physician mentioned the forever-lurking threat of drug-resistant TB. Another wanted a story on the many ways therapist-driven protocols save hospitals money. Then I pulled up a chair next to Randall M. Fulchiero, MD, medical director of the respiratory care department at Miami Valley Hospital, in Dayton, Ohio.

"The cost of defensive medicine is the most significant (cost-driving) item in medicine," he said emphatically. "It's mind-boggling that this hasn't been written about...Talk to doctors off the record and they'll confirm it."

Yes...defensive medicine, that compulsion felt by physicians-out of self-preservation-to run every test in the book on every patient, lest some hawk-eyed prosecuting attorney seize on a bad patient outcome and haul them into court. I had lost sight of this problem.   

Minus defensive medicine, health care costs in this country would decrease by "at least 50 percent," Dr. Fulchiero insisted. But the need to practice defensive medicine "is so ingrained in people they don't question it," he said with a shrug.

"Rational, intense oversight" of medicine, rather than the looming threat of litigation and financial ruin, would properly incentivize medicine to improve itself, Dr. Fulchiero concluded. "My fear should be practicing poor medicine," he said. "Doctors will respond to threats to their reputations."

What are your thoughts on defensive medicine? How great a factor is it in health care inflation? Is it a "sleeper" issue in the debate on how to lower America's runaway health care costs?

by Michael Gibbons