Editorial: Is defensive medicine a good practice?

January 1, 2010
Norman Levine, M.D.

Norman Levine, M.D., is a private practitioner in Tucson, Ariz. He also is a member of the Dermatology Times Editorial Advisory board and a co-medical editor.

Recently, a 27-year-old woman consulted me about hair loss of several years' duration. She was in otherwise good health, and she proved this by showing me an impressive list of perfectly normal laboratory results indicating, among other things, that she did not have anemia or thyroid disease.

Key Points

It so happens that her mother and grandmother developed nearly identical patterns of alopecia early in life. Examination revealed fairly advanced, patterned, nonscarring, noninflammatory alopecia, mostly involving the top of the scalp. This was a characteristic distribution of androgenetic alopecia.

This case is illustrative of a major issue emerging in medicine today, namely whether medical care should be rationed (some would use the word "denied").

We were also taught that a history and physical examination is sufficient to diagnose most skin conditions, without the need for further laboratory evaluation.

Some dermatologists have had the experience of uncovering a previously undiagnosed case of hyperthyroidism after thyroid function studies are performed.

My own personal experience is that I have evaluated thousands of patients with alopecia, and have never seen a single patient who was clinically euthyroid and had alopecia directly related to thyroid dysfunction.

Is a lack of laboratory testing a form of rationing of healthcare? Am I saving a few dollars at the expense of denying the patient a chance at a reversal of her hair loss problem?

I would argue that what separates dermatologists from others is our ability to formulate final diagnoses based on clinical examination. My patient had female pattern hair loss. In my view, she did not need thyroid function studies to confirm this.

Defensive medicine

Now that I am in private practice, I have developed a new appreciation of the medical legal pressures that are all around us. Defensive medicine is a reality. I really do not want to be sued or reported to the state medical board for failure to properly evaluate a patient with androgenetic alopecia.

However, I also do not wish to lose the prerogative of using my clinical judgment. A note in the patient's medical record explaining the rationale behind a course of action should suffice in the vast majority of cases.

Throughout the past 15 years, the phenomenon of the routine skin examination has evolved to the point where it is akin to a routine blood pressure check. In many patients, this type of examination is extremely valuable in identifying and treating potentially serious dermatoses at an early stage. Does this mean that every person should undergo this yearly checkup? I don't think so.

Throughout the past 15 years, the phenomenon of the routine skin examination has evolved to the point where it is akin to a routine blood pressure check. In many patients, this type of examination is extremely valuable in identifying and treating potentially serious dermatoses at an early stage. Does this mean that every person should undergo this yearly checkup? I don't think so.

We have all cared for healthy 25-year-old people with completely normal baseline skin examinations who ask how frequently they should be re-examined. It is easy to advise a yearly exam regardless of the findings on the first checkup. In many instances, this is wasteful and not good medicine. Just because we have the capacity to provide additional medical services and the patient has the financial resources and the time to undergo additional medical examinations, does not mean that it is necessary or indicated in most people.

The 'less vs. more' debate

Today, good epidemiological data exist to support the conclusion that ultimate outcomes may not be that different if low-risk individuals are examined less often. Undoubtedly, there is great resistance to the notion that less care is just as beneficial as more medical attention.

The recent firestorm of protest over new recommendations concerning mammograms and Pap smears shows that it may be easier to accede to the wishes of anxious patients and continue a method of practice that lacks a scientific basis. Until it can be shown that yearly skin examinations in otherwise-healthy young people without risk factors are beneficial, we might be doing our patients a favor by not encouraging frequent dermatological examinations.

Every dermatologist has had the experience of uncovering a previously undiagnosed melanoma in a young person. These one-in-a-thousand cases should not necessarily lead us to examine the other 999 patients more regularly. Nelson Rockefeller used to get his blood pressure checked daily. Perhaps he could afford it, but our healthcare system cannot, unless there is a proven benefit to the population at large. Some would call this a form of rationing, but one might consider it sound medical practice which results in less unnecessary medical care.

Tangible evidence

One of my professors in medical school gave the fourth-year students some sage advice on how to build a successful practice. He suggested that no patient should leave the doctor's office without some tangible evidence that medical care was delivered, namely a prescription for at least one medication and/or a Band-Aid over something that was biopsied, excised, scraped or cauterized.

We have all made diagnoses of skin conditions for which there is no effective therapy, which has led to the patient remarking in a disparaging way that the office visit was a waste of time and money because "nothing was done." I am never happy about these encounters, but I know that in many instances there is no treatment for the disease in question, or the condition is completely self-resolving.

At the risk of alienating a good-paying patient, it is our responsibility to educate and counsel about the nature of the disease and its natural history. Plying the patient with ineffective and costly medications in an effort to remain popular may not be in anyone's long-term interest. We must face the fact that we have little or nothing to offer patients with granuloma annulare, necrobiosis lipoidica, pityriasis rosea, twenty-nail dystrophy, keratosis pilaris, post-inflammatory hyperpigmentation and many others.

Before the era of major medical advances and high patient expectations, medicine was a thriving and well-regarded profession in which the physician's role was to diagnose, prognosticate and comfort the patient. This remains a major part of what we do. Sometimes we can deliver high-quality care by doing less and targeting our management based on the needs of the individual patient.

Norman Levine, M.D., is a private practitioner in Tucson, Ariz.

Related Content:

News | Practice Management