Posted by: notdeaddinosaur | August 27, 2007

An Inexact Science

Medicine is frequently and correctly described as an inexact science. What this really means isn’t just that we aren’t always right, but that it is expected — and fully appropriate — that “errors” will occur a certain percentage of the time.

This post was originally inspired by a line by Susan Palwick about handouts to the homeless, attributed to her father:

If you aren’t getting scammed occasionally, you aren’t being generous enough.

That struck me as an accurate restatement of my views about being duped by drug-seeking patients. I would rather be fooled on occasion than run the risk of leaving a genuine sufferer in pain. This stance in no way relieves me of the obligation to exercise caution not to fall for every drug scammer. I use my knowledge and experience to make the best decisions I can based on the information I have, knowing I will not always be right. The art of medicine lies in balancing the risks against the consequences of a given course of action in the event that I am wrong.

This issue comes up quite often in surgery. It’s often said that if you don’t have a certain percentage of “normal” appendices going to pathology, you are taking dangerous risks by not taking enough people to the OR, presumably increasing the risk of appendiceal rupture. Sid Schwab could tell you better than I what actual numerical level of “false alarms” would be considered — respectively — excessive, too conservative and “just right.” The fact remains than a “zero” error rate is neither achievable nor desirable.

Similar risk-benefit analyses happen with c-sections, only here the “risk” side of the equation includes the always subjective, always nebulous “risk of litigation.” Set that variable high enough and it’s a wonder anyone is allowed to deliver vaginally anymore. Although the consensus might be that the present US rate of 29% is too high, surely if it were “too low” there would be some babies being put at unnecessary risk from labor. How are we to calculate what the “just right” rate is?

I bring up this subject now in the context of the recent Medicare rule changes about no longer paying for “preventable complications.” Dr. RW does a magnificent job of explaining why these rules have been given this ridiculous doublespeak name. But if the underlying assumption is that complications should have been prevented, caring for them should not have been necessary, and Medicare should only pay for “necessary care.” Think for a minute about the logical extension of the policy — oh so reasonable on its surface — of not paying for “unnecessary care.”

How long before Medicare refuses to pay for an appendectomy if the pathology is negative? If the appendix was normal, then it didn’t need to come out, right? What about a negative breast biopsy, or any kind of exploratory surgery that doesn’t yield positive pathological findings? Couldn’t a cardiac catheterization that showed clean coronaries be considered “unnecessary”?

What about imaging? Billions of dollars spent annually on diagnostic imaging means tremendous opportunities for reigning in costs by refusing to pay for studies that are normal. No brain tumor or other abnormality found on that MRI? Then why should we pay for it?

It’s the ultimate Catch-22 and a med-mal lawyer’s wet dream; the ultimate damned-if-you-do and damned-if-you-don’t for physicians: retroactive denials based on negative results that you needed the test to determine in the first place. I submit that the slope from these new Medicare regulations to this nightmare farce of medical care is as steep as it is slippery.

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