Curbing Defensive Medical Practice: How NP's Can Make a Change

Earlier this week I discussed defensive medicine, you know, ordering extra tests or additional procedures to protect yourself as a provider from lawsuit rather than based on medical necessity.  Consciously or subconsciously, we all practice defensively, at least from time to time.  Unfortunately, protecting yourself legally comes at a cost.  How can we as nurse practitioners change the defensive tactics in our practice?

Excessive testing may mitigate the occasional lawsuit but it puts our patients at risk. It doesn't take too many unnecessary CT scans to significantly increase one's risk of cancer.  Not to mention, the billions and billions of dollars defensive medicine costs our country each year.  We must begin to curb these expensive practices and begin protecting ourselves legally in a different manner.

Do You Practice in Fear of Lawsuit?

For most providers, myself included, the answer to this question is "Yes".  In treating hundreds of patients each month, the chances of making a mistake are high.  For most patients presenting to the ER with shortness of breath, for example, the culprit is COPD or a simple case of pneumonia.  But, we must be sure not to miss the rare but life-threatening pulmonary embolism.  Sorting the not-so-sick from the critically ill is a delicate balance.  Some patients react calmly in times of distress, others dramatically.  How do we tell who's who?  Medical testing, CT scans and MRI's etc. allow us to break through the uncertainty providing a clear answer.  Ordering these tests prevents mistakes and therefore a medical malpractice lawsuit.

How Do We Break Away from Excessive Testing to More Responsible Practice? 

Although expensive imaging and testing often gives us definitive diagnoses, we can't order them on everyone.  These tests are incredibly expensive and can confer risk (ex. radiation) to the patient.  I'm not saying these studies aren't warranted at all, in many situations they are necessary.  However, we must begin to order these studies less frequently reserving them for cases of medical necessity.

Thorough history and physical exam must take priority in making our diagnoses.  Rather than lazily performing an abdominal or neurological exam knowing the CT or MRI will tell all, we must approach these basic techniques as the most important diagnostic component.  Taking a thorough patient history is time consuming, typically taking longer than a CT scan itself.  But, listening to a patient can provide the clues you need to diagnose without imaging.  As nurse practitioners, we must become more proficient in our physical exam techniques and take time to listen to our patients.  This will allow us to become more responsible stewards of our medical resources. 

What Steps Can You Take to Prevent Lawsuit?

Yes, cutting back on medical testing is a risk however there are still ways to protect yourself legally as a provider.  Documentation is key in protecting yourself from a medical malpractice lawsuit while cutting back on costly imaging and procedures.  Note in the patient's chart why you choose not to order a CT.  Did you use a proven algorithm such as the PERC criteria to rule-out pulmonary embolism in a patient presenting with chest pain or shortness of breath?  Write it down.

Patient education is also imperative.  Tell your patients what signs and symptoms they need to look for that indicate worsening of their condition.  Give them a list of warning signs they should watch for instructing them to go to the emergency department should any of these symptoms develop.  And then, document what you discussed.

We must learn to practice more responsibly rather than letting the fear of lawsuit determine our actions.  Small changes to our individual styles of practice have the potential to impact the healthcare system as a whole.  Spend time taking a thorough patient history.  Brush up on your exam skills.  Not only will these skills help you avoid costly medical testing but also help you avoid making mistakes.  Use risk scores and other tools to help you determine if higher level testing is in order.  Documenting your actions and reasoning behind them will provide you legal protection in your efforts to curb defensive practice.

To what extent do you practice defensively?

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