A report on defensive-medicine practices presented this week at the American Academy of Orthopaedic Surgeons' annual conference in San Diego reminded me of how, nine years ago, the AAOS was struggling to get orthos to a adopt a specific defensive-medicine practice: signing or marking the proper body part to be operated on.
Defensive medicine still strong
The newly released report is based on a survey conducted by researchers at Children's Hospital of Philadelphia of 72 members of the Pennsylvania Orthopaedic Society. The researchers studied the decisions behind 2,068 diagnostic imaging orders and calculated that defensive medicine—defined as the use of tests or procedures primarily to avoid the risk of a lawsuit—figured into 19% of the orders and almost 35% of the costs associated with the imaging orders studied.
It's unknown how widespread these percentages are across the country, and Pennsylvania is known to be a particularly litigious state, with Philadelphia ranked No. 1 on the American Tort Reform Foundation's list of "Judicial Hellholes."
In December 2001, however, the AAOS and the Joint Commission sounded an alarm about how reported wrong-site surgeries had increased from 50 in 2000 to 58 in 2001. According to AAOS past President Dr. S. Terry Canale, surveys showed that only 60% of orthopedic surgeons were signing surgical sites.
In a telephone interview from San Diego, Canale said the AAOS was frustrated because it had spent $140,000 (when that was real money) on promoting the program and trying to change people's behavior. But it hadn't worked.
It wasn't until the Joint Commission made its presurgery "universal protocol" mandatory that habits changed, said Canale, who chairs the orthopedic department of the University of Tennessee-Campbell Clinic, Memphis.
"Now everyone in the U.S. has to sign their site and also have a timeout or huddle and make sure this is the exact patient, this is the exact site and this is the exact operation," Canale said. "It doesn't cost much."
He compared the cost of 95-cent marker to that of an MRI, which runs from $900 to $1,300. But he says marking your site and ordering a test are unrelated. "One is a preventive measure, which is not at all, in my mind, defensive," Canale said. But he adds that he's surprised that the report found defensive medicine more common among more-experienced surgeons.
"Guys in this day and age don't do as good an exam as they did in the past—both the physical exam and listening to the patient—and it was sort of an art and a science," Canale said. "Today, orthopedic surgeons just lie back and say 'I'll rely on the MR.' "
My attempts to get wrong-site surgery statistics from the AAOS, Joint Commission, National Patient Safety Foundation and the U.S. Agency for Healthcare Research and Quality came up empty.
The Joint Commission does have some stats (PDF) combining all wrong-site, wrong-patient and wrong-procedure incidents. There were 116 in 2008; 149 in 2009; and 93 in 2010—which at least shows how pens can make nice, useful gifts.
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