David Gergen Gets It Oh So Very Wrong

Anderson Cooper is hosting a special on CNN with a panel of familiar CNN faces. At one point, Dr. Sanjay Gupta began discussing tort reform and defensive medicine. Then David Gergen followed up with his own example of what an ENT he talked to calls defensive medicine.

Here's the problem. The example is an absurd one. Unfortunately, Dr. Gupta didn't speak up to point out how asinine the example was. Like an episode of House, the example had that far fetched medical practice sound to it. I'm sure physicians everywhere groaned in disbelief, just as they do when watching House.

I don't know what ENT David Gergen spoke to about defensive medicine, but physicians I work with don't order tests just because the patient asks for them to be done. I certainly don't bend over backwards to appease a patient asking for a test just for the sole purpose of getting the test done.

Let's use the example Gergen gave us.

Patient X comes in and asks for an MRI. Doctor gives the patient the MRI, afraid that the patient will sue him or her for not providing the investigation the patient asked for.

That's not evidence based medicine. If your doctor gives in to that sort of thing, he or she is not a good doctor and cannot seem to muster up the sense to explain to the patient why they do not need the MRI. The patient did not go to medical school. The patient, no matter how informed, cannot just snap their fingers and order any test they'd like.

Here's how the situation should have been handled. Communication! The ENT should have asked the patient why they wanted the MRI. Then, after listening to the patient's own reasoning, the physician should have explained what an MRI would tell them and whether or not the reason is really justified.

An MRI is a peculiar example to use because the patient is not exposed to radiation. Let's twist the story a bit and show you how doctors really behave when it comes to patients who demand tests that could do a little more harm.

Instead of an MRI, let's say the patient is asking for a CT or a chest x-ray. If there is no justification for the test, the doctor is going to expose the patient to an unnecessary dose of radiation. That's malpractice. That's bad medicine. That is something they could be sued for, not denying the patient the CT.

Let's go a little further because the next example is a more common form of defensive medicine. A mother brings her child in to the pediatrician. The child has a cold and the mother says she wants antibiotics. The physician has determined the infection is viral. Antibiotics would not treat the viral infection.

Here are the choices the physician has at this point.

1. Deny the patient antibiotics because it's not evidence based medicine. Tell the mother to treat symptoms, have the child rest, and drink plenty of fluids. No lawsuit.

2. Give the child antibiotics to make the mother happy because they know unhappy mothers tend to complain and want the magic pill to make the infection go away. To avoid confrontation, the physician practices some defensive medicine. It's a bad practice and paves the way for superbugs resistant to antibiotics. Lawsuit.

There are other options if the physician feels the mother is confrontational. Those other options are not relevant to this discussion, although again, an open line of communication would have been the best course of action.

In clinics across America, physicians have regular conversations about the overuse of antibiotics and the rise of bacterial resistance to those antibiotics. Superbugs are the last troublesome obstacle we want to face. Just because a patient demands antibiotics is no reason for a physician to throw those concerns out the window.

Let's give an example of defensive medicine that is also evidence based. For the sake of clarity and understanding, let me skip some of the jargon and clinical details and just go for the basics.

Let's say a patient presents with a set of symptoms. The physician recognizes these symptoms and orders the tests to confirm the diagnosis he or she already suspects. However, these symptoms could also be a sign of a malignancy, something that if missed, could result in a much worse situation for the patient. If missed and the malignancy were to progress to the point where outcomes vary tremendously (surgery, removal, and recovery vs metastatic disease and palliative care for example), you've got a lawsuit on your hands. The physician orders the initial tests for the most likely diagnosis and will probably order the other investigation soon to make sure cancer is not the underlying cause.

In that case, the physician is covering his or her ass, but at the same time, understands that cancer is in the list of differential diagnoses. At some point prior to ordering these tests, the physician would have sat down with the patient and discussed his or her concerns and possible diagnoses which warranted the investigations.