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Dermatologists share views on practicing, teaching defensive medicine

Karen Nash
Recently, Northwestern University Feinberg School of Medicine surveyed their third- and fourth-year residents and found that even though it is not on the official curriculum, the residents are learning defensive medicine.

Whether it's an attending mentioning that a particular biopsy isn't necessary or deciding not to offer a patient a particular medication because it of a potential lawsuit, the residents are seeing defensive medicine in practice.

On Call asked dermatologists around the country whether they think it is appropriate for medical students to be taught to practice medicine defensively. We also asked their opinions about the role that defensive medicine plays in dermatology and whether they practice defensive medicine themselves.

As Tory Sullivan, M.D., explains, the definition of defensive medicine can be in the eye of the beholder.

Howard Goldberg, M.D.
"It's a whole constellation of factors. I do what is called defensive medicine, but I don't really order tests because I'm worried I'll get sued. I do it for a variety of reasons," says Dr. Sullivan, who practices in Miami. "If the patient comes in and I do a surgical biopsy, they feel their visit was worthwhile. If I look at something and think hard about it, I'm not compensated as much as doing a biopsy. So the patient is happy, I get compensated more, and the last thing: Nobody sues me because I didn't do a biopsy."

Dr. Sullivan says he does not avoid high-risk patients just to practice defensively. "I take on people others would consider high-risk, such as those taking Accutane (isotretinoin, formerly manufactured by Roche) and cyclosporine. I know I'm taking a risk and some of my colleagues won't do that, but I enjoy taking care of those patients and making people better if I can."

Necessary and needed

In Georgetown, Texas, Monica Madray, M.D., says practicing defensively is almost a necessity, one that is often pushed by patients.

Kyle Garton, M.D.
"I think everybody does," she says. "It's the way we're trained. We probably order unnecessary labs, especially with certain patient populations. I live near a large, fairly wealthy retirement community, and we have a lot of well-informed patients.

"For example, one patient came in with pityriasis rubra pilaris (PRP)," she says. "I told him the diagnosis, did the biopsy, and by the time he came back to get his sutures out, he said, 'I understand there's a risk of cancer with this diagnosis. I smoked for two years, so I really want to make sure I don't have an underlying lung cancer.' What could we do except order a chest X-ray?

"You have a lot of well-informed, educated patients and they know all the miniscule associations and they walk in telling you what they think they have, so you're kind of behind the eight ball. You have to check," Dr. Madray says.

G.P. influence

Sarah Glorioso, M.D., in Bossier City, La., says sometimes it's the general practitioner who pushes a dermatologist into practicing defensively.

"I try to do what is medically necessary, but I do play a little defense just to make sure I'm covered," she says. "Sometimes, the patient has a primary care provider who says a lesion should probably be biopsied. Even though clinically I look at it and say it's fine, if the referring doctor has asked for a biopsy, I may well do one.

"You can tell the patient no biopsy is needed, but when the physician they've probably seen for 30 years tells them it should be done, you don't have much of a choice," she adds.

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