Study: Doctors order tests out of fear of lawsuits (AP)

By MARILYNN MARCHIONE, AP Medical Writer Marilynn Marchione, Ap Medical Writer – Wed Feb 16, 6:56 pm ET

SAN DIEGO – CT scans, MRIs and other pricey imaging tests are often more for the doctor's benefit than the patient's, new research confirms.

Roughly one-fifth of tests that bone and joint specialists order are because a doctor fears being sued, not because the patient needs them, a first-of-its-kind study in Pennsylvania suggests.

The study comes a day after President Barack Obama began a push to overhaul state medical malpractice laws as a way to reduce unnecessary tests that drive up health care costs.

"This study is a glimpse behind the curtain of what's happening in a doctor's mind," said its leader, Dr. John Flynn of Children's Hospital of Philadelphia. If doctors sense you might second-guess them or cause trouble, "you could potentially be risking more tests being done."

Results were reported Wednesday at an American Academy of Orthopedic Surgeons conference in California.

Patients expect the highest level of care and think this means the most advanced technology, Flynn said. Many patients feel better when a doctor orders lots of tests — until they get the bill.

Besides hurting your wallet and adding to health care costs, unnecessary tests can expose people to radiation that accumulates over a lifetime and can raise the risk of cancer. Ordinary X-rays are rarely a concern, but an MRI, or magnetic resonance imaging scan, can cost $1,000 or more. And super-sharp X-rays called CT scans involve relatively large radiation doses.

Yet doctors often order tests they don't really think a patient needs because they fear being sued if the diagnosis was wrong or they miss detecting a problem.

Previous studies of how often this happens have relied on doctor surveys. This is the first one to enlist doctors in advance to track their decisions over time.

It involved 72 orthopedic surgeons throughout Pennsylvania who tracked tests they ordered on 2,068 patients, mostly adults, in ordinary office visits, emergency rooms and other settings. Doctors checked a box saying a test was either required for clinical care or done "for defensive reasons."

Defensive imaging accounted for 20 percent of total tests — 11 percent of X-rays, 38 percent of MRIs, 33 percent of CT scans, 57 percent of bone scans and 53 percent of ultrasounds.

Defensive medicine also accounted for 35 percent of costs, nearly all of it from MRIs.

One example: a torn meniscus, a knee cartilage injury that is a leading reason for knee surgery. Studies have shown that a doctor's judgment based on symptoms and an exam is even better than an MRI to diagnose the condition. Yet patients hardly ever go to surgery without having the imaging test, Flynn said.

Surprisingly, the study found that newer doctors were less likely to be defensive.

"That's counterintuitive," Flynn said. "You would expect when you're new in practice, not as trustful of your clinical judgment, you'd order more."

Doctors who have been sued in the last five years were more likely to order tests defensively, said Robert Miller, a Temple University medical student who helped lead the study and presented the results at the conference. The authors said similar studies are needed on defensive imaging in other specialties.

Dr. Lawrence Wells, a Philadelphia surgeon who participated in the study, said doctors learn to develop "a radar" for problem patients.

"It's disheartening" to be sued, he said. "Someone's accusing you of a bad outcome or a wrong," and that can affect how a doctor behaves the next time he sees a similar case.

Patients need to trust their doctor's judgment on what is needed, Wells said.

On Tuesday, Obama made a budget proposal that includes money to help states rewrite malpractice laws. Possible measures include caps on awards. The administration also has proposed health courts where specially trained judges rather than juries would decide such cases.

Questions to ask about a medical test:

_Is it truly needed? How will it change my care?

_Have you or another doctor done this test on me before?

_Does the test involve much radiation and is there an alternative that does not?

_How many images are needed?

_Do you have a financial stake in the machines that will be used?

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Online:

Orthopedics group: http://www.aaos.org/

Consumer information: http://www.radiologyinfo.org and http://tinyurl.com/2wv5fg

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Will young doctors recognize melanoma? (Reuters)

NEW ORLEANS (Reuters Health) - Fourth-year medical students – at least those at the University of Illinois at Chicago -- are not very proficient at detecting melanomas, the most serious type of skin cancer, researchers from that school said this week at the 69th annual meeting of the American Academy of Dermatology.

Actors wearing a medical moulage (a simulated melanoma) were examined for carpal tunnel syndrome with the moulage clearly in view, but less than a quarter of the 190 students saw the lesion and recommended treatment, according to Dr. Claudia Hernandez.

"Melanoma is really very rare, and it is not uncommon for medical students to go through four years of training and never see the real thing," she told Reuters Health. "We know that medical students do not feel all that confident doing skin examinations, and in this study, we wanted to see how proficient they were in detecting melanomas."

The students saw the actors while undergoing a test that uses simulated patient encounters to assess their clinical skills.

The medical moulage measured 3 to 4 mm in diameter and was applied to the second digit of the actor's hand. "A moulage is like a very realistic tattoo, but it's more than a tattoo because it's thicker and it's got texture to it. You could call them medical grade, very fancy tattoos," Hernandez said.

The actors, who pretended to have wrist pain, were trained beforehand by a dermatologist to answer questions regarding the history and symptoms of the simulated melanoma.

Fifty-six students noticed the lesion, but 13 failed to comment on it further to the patient or in their written notes.

Of the 43 students who saw the lesion and recommended follow-up or a biopsy, only one felt to see whether the patients had swollen lymph glands, and one student examined other areas of the pseudo-patient's skin for other unusual spots. No student offered the patient a full body skin examination.

The students who recommended follow-up also asked if the lesion had changed recently and also about symptoms. "These are the two most important questions, so this was the one encouraging finding," Hernandez noted.

These results are disturbing because the awareness about the dangers of skin cancer, especially the deadliness of melanoma, does not seem to be getting through to medical students. If they are not getting the message, then the public may not be getting the message either, she said.

Clearly, more educational efforts are needed to bring medical students up to speed in diagnosing melanoma and evaluating patients for skin cancer.

"Even though we give the medical students lectures about melanoma we have to make sure that they have some (way) to go ahead and practice these skills," she said. "Only then will they probably feel comfortable doing skin exams and diagnosing skin cancer."

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