"Defensive" medicine defends docs, not patients

Further reflections on the difference between Canadian and US health care models, as seen by an American medical student in Canada

By: Dr. Gordon Guyatt

  HAMILTON, ON: Jay Schuur, a medical student from New York spending a month in a Canadian hospital, had never seen anything like this.
  Late one Friday evening, a 43 year-old previously healthy man began to experience severe chest discomfort. The pressure sensation in his central chest spread to his left shoulder and down his left arm. He felt sweaty and short of breath. After a couple of hours, he came to the emergency department.
  The patient's story told the doctors that, as a result of narrowing of the arteries to the heart, his heart muscle was not getting enough blood. The emergency department doctor ordered an electrocardiogram. The test, which records the heart's electrical activity, showed typical changes of impaired blood supply.
 

Canadian doctors are more careful than Americans when ordering tests and diagnostic procedures, saving risks for patients and expense for health system

  The emergency department doctor prescribed a medication to ease the strain on the heart, and the patient's pain quickly resolved. The emergency department doctor then referred the patient to our internal medicine team for further care.
  Jay Schuur had been working with me for about a week when we saw the patient together early Saturday morning. The patient felt back to his normal self, blood tests showed that he had no damage to his heart, and the electrocardiogram had returned to normal.
  Nevertheless, the problem was serious. The patient's pain of the evening before meant that his heart was not getting enough blood and he was suffering from what doctors call unstable angina. Ordinarily, we would admit the patient to hospital, prescribe medication to decrease the risk of clots forming, and monitor the patient for 48 hours.
  The patient was very unhappy at our suggestion that he stay in hospital. Today was his son's 13th birthday, and the family had planned a very special day.
  I told the patient that we could prescribe medications, including aspirin, that would lower his risk. Nevertheless, if he went home, there was a small risk of a heart attack, and even of sudden death. I told the patient that it was up to him whether his son's birthday was important enough to leave the hospital.
  The patient decided to go home, and his wife agreed with his decision. I received a call on Monday: the birthday had gone fine. A heart specialist whom the patient would be seeing would decide on the next steps in his care.
  Jay Schuur told me that, back in New York, the doctors would have handled the patient very differently. They would do everything possible to persuade the patient to stay in hospital. If the patient still insisted on leaving, they would demand he sign a paper saying that he was leaving against medical advice, and was assuming all responsibility.

Why the different approach?
  In the United States, patients are much more inclined to bring legal action against their physicians than are Canadian patients. As a result, malpractice insurance is much more expensive for physicians in the United States.

Defensive medicine
  This leads American physicians to practice what is sometimes called "defensive" medicine. In their patient care, American physicians are thinking not only of the patient's well-being, and the wise use of medical resources, but also of how they can avoid a subsequent law suit. The result is at times, decisions that are not in the patient's best interests.
  Another unfortunate consequence of defensive medicine is overuse of technology. Jay found Canadian physicians far more careful when they ordered tests, far more likely to avoid ordering unnecessary investigations. This may save the patient from unpleasant, or even dangerous, tests. More careful use of tests also helps explain why Canada spends approximately half as much per citizen on health care as the United States.
  Why are Americans so much more likely to sue their physicians than are Canadians? Canadians have a much stronger sense of what is sometimes called "social solidarity" than do Americans. Canadians are more inclined to think, "we're all in the same boat, so we need to look after one another."
  As I said to Jay when he told me of his surprise at my leaving the decision about staying in hospital to the man with unstable angina. "In Canada, we still trust one another." I was only partly joking.
  Social solidarity has lead Canada to develop a health care system that puts a premium on all citizens having access to the same, high quality care. Jay told me of working in New York at private and public hospitals across the street from one another, where patients received very different health care. Canadians' sense of fairness and equity prevents such a situation from happening here.
  Social solidarity is also why Canadians are reluctant to sue their doctors. Canadians receive care within a public system in which their ability to pay is not an issue, and in which they will receive the same quality of care as other patients. As a result, they are more likely to accept that even when doctors are doing their best, they will sometimes make mistakes.
  Practising defensive medicine is not pleasant. An atmosphere of mutual trust between doctors and patients leads to more rewarding interactions than an atmosphere of mistrust.
  Unfortunately, social solidarity is not as strong in Canada as in the past. One consequence is that law suits against doctors are increasing, and Canadian doctors are more inclined to practice defensive medicine. Still, as Jay Schuur observed, we remain far better off than those who live south of the border.

Dr. Guyatt is a founding member of the Medical Reform Group, and an MRG spokesperson for most of the last 20 years. He is a Professor of Medicine at McMaster University. A version of this article appeared previously in Hamilton Spectator.

Posted: April 30, 2001

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