Panda Bear, MD recently blogged about how he and other hospital staff deal with notorious hypochondriacs. I’m pasting some of it here without endorsing all the sarcasm (in other words, be offended by him, not me!).

In one month I have had Mary as a patient four times. I have also noticed her roaming restlessly through the department on days when some other resident had the bad luck to pick up her chart. I would not be exaggerating if I said that she has been a patient in our department thirty times this year and the Lord only knows how many times at other Emergency rooms in the area. She is a huge consumer of emergency services and no one dares tell her to pound sand when she presents with one bogus complaint or another because one day, after crying wolf for her whole life, she is really going to be sick and if she dies the usual compassion fascists will descend on us like self-righteous harpies.

Thus do we regularly ignore common sense and, putting on our best kabuki faces, take every episode of chest pain, abdominal pain, shortness of breath, and near-syncope completely seriously pretending that we have not spent hundreds of thousands of the taxpayer’s dollars ruling out everything except drug addiction. It would be more cost effective if we just gave her perscriptions for all the oxycontin she wanted provided she limited her visits to once a month. Instead we enact the the traditional Kabuki drama where she assumes the role of a patient and we pretend to be her doctors. We stamp and posture, reciting our ritualistic lines while she demurely assumes the character of someone we actually can treat. Five acts later we discharge her, plus or minus a six-pack of vicodin, depending on how badly we want to get her out of the department.

File this under getting what you pay for. Putting asided the usual policy wonkery, the real problem of American medical care is the complete absence of common sense. Mary is not unique. She is just a very visible symbol of a society that is ridiculously risk averse and consequently ridiculoulsy over-doctored. In a perfect world, someone would meet her at the door and say, “No. You are not getting drugs here.” If she departed chastened from our door and died…oh, let’s just say from a perforated bowel… a reasonable jury, assuming the case ever went to trial, would decide that it was a darn shame but understandable given her pattern of abusing emergency services.

Sarcasm aside, it seems reasonable to me that this risk-aversion is not rational and points to a problem with litigation. I notice others have noticed that overuse of the medical system is a problem. “Our health care system is plagued with under-use, overuse and misuse,” Hillary Clinton has claimed.

With due respect for the Senator, I’m not a big fan of having some sort of centralized director trying to come up with guidelines for what counts as “overuse.” But it would be nice if we could make liability rational enough that doctors would be able to follow common sense judgments rather spend money on unnecessary medicine. Panda goes on to hold up “the typical cardiac work-up” as an example of overuse.

A young male with no risk factors for heart disease should not need a complete cardiac work-up when he presents with chest discomfort as it is almost certainly going to end up being musculoskeletal pain, reflux, or anxiety. And yet the patient inevitably gets the whole enchilada including an expensive stress test and occasionally an admission if he is deemed to be unrealiable for follow up (because if he is told to return in the morning for his stress test, forgets, and dies three years later it is our fault).

Read the whole thing and tell me if you agree with his basic point that, “Because of the highly litigious nature of American society, there is no incentive to exercise common sense.”

Because it is not paranoia if everyone really is out to get you.