IN DEFENSE OF GOOD DOCTORS Two current and hot topics today are "Medical Reform" and Tort Reform". I believe that insurance companies who seek “Tort Reform” often mislead the public. They often blame Health Care costs on lawsuits. Those who seek to weaken our Civil Justice system want to take decisions away from juries.
An allegation they often make is that doctors practice “preventative” medicine, allegedly driving up health care costs by ordering needless tests. I disagree.
I suggest that a doctor being thorough, and ordering tests without omissions, is both required in the practice of good medicine and is done so by competent, efficient and ethical doctors. Please allow me to explain.
A basic rule in practicing medicine is that whenever a physician treats a patient with any kinds of abnormal signs or symptoms the doctor is required to use a method called “Differential Diagnosis” to determine the cause of the patient’s signs or symptoms.
A physician is not allowed to make conclusions without using a Differential Diagnosis. Any doctor who you ask will likely agree with this statement. Every patient who has ever been diagnosed by a physician has had a Differential Diagnosis.
A Physician cannot assume or guess that the cause is one thing as long as there’s a reasonable possibility that the cause could be something else instead or something else different altogether. The physician is always required to consider and deal with every reasonable possibility. No matter what the abnormal signs or symptoms are, no matter who the physician is, the required diagnostic method is always the same. This is Differential Diagnosis; the “standard of care” requires this method. It is required with every patient by every doctor, every time. When would a patient ever want or expect less?
The key phrase to remember about a Differential Diagnosis is “rule out.” It means that a physician must “rule out” every possible cause of any abnormal signs or symptoms. A physician is not allowed to ignore any reasonable possible cause, until ruling it out with a test or other methods. For example, if a patient has the symptom of a lump in her breast, the doctor is not allowed to ignore the possibility of cancer, not even if he’s almost certain that it’s something else. The doctor is required to proceed as if the cause is cancer, until he rules cancer out with tests or other methods. The physician cannot say, “Well, it’s probably just some calcium or a minor cyst, so let’s forget about cancer.” The physician must consider and deal with every reasonable possibility until he rules it out. This method works in diagnosing patients, and it’s always required.
As you learn and understand how a Differential Diagnosis works, you’ll come to understand why doctors order tests. They are following the required rules of a compassionate, caring doctor and not just “protecting themselves from lawsuits”. A physician is often required to treat a patient for a medical problem even before the physician knows whether or not it’s the real problem. For example, when someone has chest pains, the doctor might have to give the patient medication for the heart even before being sure that a heart problem is causing the chest pains.
Exactly how does a Differential Diagnosis work? The standard of care requires several steps. No doctor is allowed to skip a step.
Step One: Gather information. The doctor must first gather all the information he or she can about the problem; all the signs and symptoms, any risks factors, the medical history.
Step Two: The list. Based on all signs, symptoms, risk factors, and medical history, the doctor must list everything that could reasonably be causing the signs and symptoms. There can be just a few causes or many causes but they all need to be listed.
Two important things about a Differential Diagnosis list: 1) The list has to be complete. If a doctor leaves something off that turns out to be the real cause, it goes untreated, a patient can worsen or even die. 2) Second, the doctor must put any dangerous possible causes at the top of the list. The more dangerous a possible cause is, the higher it goes on the list. For example, chest pains can be caused by stomach gas or by heart attack. Stomach gas is not dangerous, so the doctor would put it low on the list. Heart attack as a cause of chest pain is dangerous, so the doctor must put heart attack high on the list.
A doctor is not allowed to ignore the possibility of a heart attack even if he thinks the cause is gas. Even if the doctor proves the cause is stomach gas, he still cannot ignore possible heart attack at the same time. In other words, one cause does not rule out any other cause. Test and other methods are the only way to rule out causes.
STEP THREE: Rule Out. The doctor cannot ignore any cause on the list until he has ruled it out. That’s the standard of care. “If there’s any doubt, you cannot rule it out.” That is a basic rule of Differential Diagnosis: No guessing. No "almost sure.” Every possible cause stays listed until it is ruled out. This is especially important with any dangerous causes. This method is how the medical profession makes sure doctors do not miss anything.
Medical schools teach medical students this way. Doctors do not have a crystal ball to see the future; they always have to use a Differential Diagnosis to be sure they do not miss anything in the present. Every medical school teaches that doctors who take shortcuts-instead of following this method - will make mistakes. When doctors make mistakes it can harm patients.
Some people feel that there is no requirement in medicine more important than using Differential Diagnosis properly. Clinics and hospitals all over the world use Differential Diagnosis tens of thousands of times a day. Remember: If there’s any doubt, you cannot rule it out.
How do doctors rule things out? They use tests, or they treat the possible cause to see if it goes away, or they refer the patient to a specialist. As each possible cause is ruled out, the doctor crosses it off his list. When the doctor finds a cause that cannot be ruled out, he knows it can be the real cause, so he starts treatment. When any possible cause on the list is dangerous, the doctor must test and take other steps soon enough to save the patient if that dangerous cause turns out to be the actual cause. Delay can endanger the patient’s life. True, sometimes the problem turns out to be what the doctor would have suggested from the start. But very often it is something else. That’s why the doctor must list every reasonably possible cause and leave it on the list until he rules it out.
STEP FOUR: Urgent danger. Often a possible cause can be an urgent danger or something that can quickly cause serious harm or death. When an urgent danger is a possible cause, even if it is not very likely, the physician must immediately rule it out or treat it. So even if a doctor thinks a patient’s chest pain is caused by stomach gas, he must still test for heart problems right away because a patient can have both stomach gas and a heart attack. With such symptoms a doctor may also include gall stones and other illnesses.
When following the standard of care method of a Differential Diagnosis, as long as the danger remains possible, a doctor must rule it out or treat it. No delay. Ironically, often needed tests are delayed by insurance company clerks who may be denying or questioning the need for a test.
AN EXAMPLE: Suppose a child has a head ache following a car wreck.
Step One: Gather information. The medical provider would ask the child and the parent for every symptom. A physical exam would be performed to obtain more information. Has the child been groggy, have they been sleepy, did the headache come on quickly or gradually, how severe is the pain?
Step Two: The list. Based on the information, the treating doctor will list every reasonable possible cause. The doctor may list nervous or tension headache, sinus headache, migraine, neck strain, brain bleed. The brain bleed would be on the top of the list.
STEP THREE: Rule Out. Tests would be ordered including neck x-rays and a CT of the head and other steps to see what causes can be ruled out.
STEP FOUR: Urgent danger. The headaches and the neck strain are not urgent dangers, however, a brain bleed can be dangerous and even deadly. So the doctor would make no delay treating the possible brain injury or steps to rule it out. A doctor couldn't say later “Well the child passed away of a brain bleed because I thought he had a cold and sinus headache”.
The standard of care requires that the doctor proceed as if the urgent danger is the real cause. The doctor would give treatment before the tests are all final, if a delay could result in serious harm or death to the patient. What contentious doctor would do otherwise?
What parent would expect less for their child?
I believe that good doctors don't practice “defensive medicine” because of lawyers, they are careful because they care about their patients.
Make it a great day!
For 25 years The Spiva Law Group has been dedicated solely to the representation of individuals with serious and catastrophic personal injuries, wrongful death and with an emphasis on brain injuries and claims involving children.