Atul Gawande Versus Sanjay Gupta On Defensive Medicine
In contrast to the demanding world of blogging, where every typo results in an avalanche of criticism, the beauty of speaking on network television in quaint soundbites and writing 750 word op-ed columns in national newspapers is that you rarely have to explain yourself. You will rarely, if ever, be put in the position where you are expected to fully explain your argument, and, hiding behind the presumed credibility of established newspapers and networks, it isn’t likely that you’ll face a thoughtful critique of your argument. Just say something and, ipse dixit, it’s true. (There are, of course, rare exceptions, like when you make up Bob Dylan quotes, forgetting the legions of obsessed Dylanites out there.)
What else explains how Sanjay Gupta of CNN fame thought he could stick this whopper into his New York Times op-ed piece:
Certainly many procedures, tests and prescriptions are based on legitimate need. But many are not. In a recent anonymous survey, orthopedic surgeons said 24 percent of the tests they ordered were medically unnecessary. This kind of treatment is a form of defensive medicine, meant less to protect the patient than to protect the doctor or hospital against potential lawsuits.
Herein lies a stunning irony. Defensive medicine is rooted in the goal of avoiding mistakes. But each additional procedure or test, no matter how cautiously performed, injects a fresh possibility of error. CT and M.R.I. scans can lead to false positives and unnecessary operations, which carry the risk of complications like infections and bleeding. The more medications patients are prescribed, the more likely they are to accidentally overdose or suffer an allergic reaction. Even routine operations like gallbladder removals require anesthesia, which can increase the risk of heart attack and stroke.
Isn’t it amazing how Dr. Gupta just knows that every last medically unnecessary treatment is a “form of defensive medicine?” There’s a word for Dr. Gupta’s argument. To find that word, let me quote Dr. Atul Gawande in The New Yorker three years ago, himself quoting a discussion among surgeons about defensive medicine:
Some were dubious when I told them that McAllen was the country’s most expensive place for health care. I gave them the spending data from Medicare. In 1992, in the McAllen market, the average cost per Medicare enrollee was $4,891, almost exactly the national average. But since then, year after year, McAllen’s health costs have grown faster than any other market in the country, ultimately soaring by more than ten thousand dollars per person.
“Maybe the service is better here,” the cardiologist suggested. People can be seen faster and get their tests more readily, he said. Others were skeptical. “I don’t think that explains the costs he’s talking about,” the general surgeon said. “It’s malpractice,” a family physician who had practiced here for thirty-three years said. “McAllen is legal hell,” the cardiologist agreed. Doctors order unnecessary tests just to protect themselves, he said. Everyone thought the lawyers here were worse than elsewhere.
That explanation puzzled me. Several years ago, Texas passed a tough malpractice law that capped pain-and-suffering awards at two hundred and fifty thousand dollars. Didn’t lawsuits go down? “Practically to zero,” the cardiologist admitted.
“Come on,” the general surgeon finally said. “We all know these arguments are bullshit. There is overutilization here, pure and simple.” Doctors, he said, were racking up charges with extra tests, services, and procedures.
There’s the word for Dr. Gupta’s argument: bullshit.
One of the great things about American federalism is that the various states can serve as the “laboratories of democracy,” and for the last decade Texas has made itself a useful experiment for the rest of us to observe by effectively destroying its malpractice liability system. Thanks to their “tort reform,” it’s virtually impossible for injured patients to hold doctors accountable for anything, and, if you happen to hold them accountable, your damages are capped at a figure so low that the case will not be worth the cost of the experts you had to hire to prove it.
If “defensive medicine” were a major contributor to the dramatic growth in unnecessary treatment we seem to have in this country, then it would stand to reason that, with a decade of tort reform under their belt, they would have made significant strides in this area. As Dr. Gawanda explained three years ago, that didn’t happen, and as Eric Turkewitz explained yesterday, it still hasn’t happened. Far from being a model of medical cost control, Texas is actually seen above-national-average growth in medical costs. Indeed, even inside Texas the possibility of malpractice liability makes no difference, and “high risk” counties with high malpractice claims rates didn’t increase spending any faster than other counties. The Texas “first, we cheat all the injured patients” experiment was a complete failure.
Of course, we’ve known for decades that tort reform does not reduce so-called “defensive medicine” and does nothing to control health expenses, as shown by the Indiana and California examples. Indeed, as medical costs continue to skyrocket, malpractice payments continue to plummet, down to a measly 0.12% of total healthcare costs in 2011, an all-time low. (The all-time high was in 1992, when malpractice payments were 0.3% of nationwide healthcare costs.)
After seeing the excellent “Choosing Wisely” campaign designed to discourage doctors from performing tests and procedures with no supporting empirical evidence, I wrote back in April that the healthcare costs debate had moved beyond defensive medicine. I was wrong: this “defensive medicine” falsehood will just keep being repeated by people who should know better, apparently because talking heads like Sanjay Gupta can’t be bothered to read even The New Yorker, much less the research.