COMMENTARY

Physicians Are Talking About: The Culture of Defensive Medicine

Nancy R. Terry

Disclosures

March 19, 2010

The practice of defensive medicine -- the ordering of excessive tests and procedures by physicians -- is regularly targeted as a major contributor to the high costs of healthcare. But how widespread is it?

A recent posting on Medscape's Physician Connect (MPC), an all-physician discussion group, asked the question: Do you practice defensive medicine? Most physicians responded with an emphatic YES.

"Defensive medicine is practiced everywhere, everyday. And the costs have got to be simply enormous," says a radiologist.

"Here in southeastern Michigan, home of [notable] malpractice attorneys, we practice defensive medicine every day, with every patient," replies a neurologist.

Why do physicians practice defensive medicine? A second neurologist says it is to save your behind in the unlikely event of a 1:1000 outcome.

Reports from physicians suggest that defensive medicine is widespread, and recent studies appear to confirm this. The Massachusetts Medical Society found that about 83% of physicians responding to a survey reported that they practiced defensive medicine, with an average of between 18% and 28% of tests, procedures, referrals, and consultations, and 13% of hospitalizations ordered for defensive reasons.[1] An earlier study published in the Journal of the American Medical Association (JAMA) surveyed physicians in 6 specialties affected by high malpractice liability costs (ie, emergency medicine, general surgery, neurosurgery, obstetrics/gynecology, orthopaedic surgery, and radiology) and found that 93% of respondents reported practicing defensive medicine. Assurance behavior -- such as ordering tests, performing diagnostic procedures, and referring patients for consultation -- was found to be very common (92%).[2]

The JAMA study suggests that defensive medicine is more prevalent in certain settings. A health maintenance organization (HMO) medical director gives examples of what he views as routine in the emergency department and in-patient care. "A hospitalized patient with pneumonia will be seen by the primary care physician, an infectious disease physician, and even a cardiologist if his chest hurts when he coughs. Every patient in the emergency room gets a CT [computed tomography] scan and a cardiac cath." And equivocal tests frequently lead to more tests. The HMO director says that as many as 80% of imaging studies are normal or show insignificant findings that require another study.

An emergency medicine physician remarks that excessive testing has become a regrettable necessity. "In the ER [emergency room], patients often give histories that could conceivably (less than 2%) be from a life-threatening condition," says the emergency physician. "In our current system, we really can't miss these things anymore."

"Nobody wants to get sued, especially in the ER setting," comments a radiologist. "Why else would a 22-year-old with a tummy ache but no fever, no white count, and no localizing symptoms get a CT of the abdomen and a pelvic ultrasound before she leaves?"

"Most doctors would agree that the threat of a potential lawsuit significantly adds to the cost of medicine in the ER and in the hospital setting," says a radiologist. A second radiologist agrees. "The cost to the system for CYA medicine is enormous."

In fact, the actual cost of defensive medicine is open for debate, depending on whether you talk to doctors or lawyers. According to an article in The Seattle Times,[3] doctors estimate that defensive medicine and malpractice insurance accounts for up to 10% of healthcare spending. Lawyers say malpractice settlement costs amount to less than 0.5% of the $2.5 trillion spent each year on healthcare.[1]

Protection against possible malpractice litigation is the most frequently cited reason for ordering extra tests and procedures. Yet, defensive medicine is a more complicated issue than one provider's decision to order an additional test. Some MPC contributors suggest that defensive medicine is culture driven.

"Fear of lawsuit is a big issue," explains an emergency medicine physician. "However, patient demand and peer pressure are huge components. No one wants to be in the hot seat at peer or chart reviews when someone asks why didn't you get this or that test."

Accountability to other physicians is a significant factor in the practice of defensive medicine. "I'd estimate that 50% of my testing," says a vascular surgeon, "is at least partly influenced by the need to demonstrate objective proof of something that I've already diagnosed by taking a history and physical examination."

"It is not just the fear of liability," says an internist, "but more often the fear of being perceived as a lesser-quality physician."

"This pattern [to overtest] becomes the standard of care," says a radiologist, "and the geometric progression of unnecessary testing becomes self-promulgating."

The pressure to overtest comes from patients as well as colleagues. "I practice defensive medicine daily," says an internist, "and order excessive, costly, unnecessary laboratory tests and imaging studies because patients demand them. They want to be tested 'to be sure' -- regardless of the results of my evaluation or recommendations."

"A lot of the time patients come into the ED or clinic expecting certain investigations to be done," says an emergency medicine physician. "For example x-rays for a simple ankle sprain. It takes 30 minutes of trying -- and often failing -- to convince patients they don't need an x-ray versus 5 minutes to send them off for an x-ray."

An MPC contributor points out that to the patient or the patient's family, "an unnecessary test is something done on a different patient."

"There is a lot of pressure to overtest," agrees a pediatrician. "I tell my residents, 'this is what you would do in the office, and this is what we do in the ED.' We train them to overtest, especially at academic centers, where everyone is playing House."

"In most of our teaching hospitals," says a cardiothoracic surgeon, "defensive medicine seems to be practiced as an unconscious routine."

A pediatrician admits that he learned his lessons in defensive medicine during residency. "The first time a resident is bitched at by an attending physician for not ordering an unnecessary MRI [magnetic resonance image], head CT scan, EEG [electroencephalogram], and tox screen on a patient who is malingering with pseudoseizures, he'll start doing it. At that point, defensive medicine becomes ingrained, and the resident takes it into practice with him."

"Defensive medicine," says a general surgeon, "is so ingrained that most of us don't even realize we are doing it."

A culture of defensive medicine has arisen in response to a pandemic of malpractice litigation and has become an undeclared standard of care -- the inherent costs of which are passed along to patients and healthcare providers. Until physicians have protection from frivolous malpractice suits, defensive medicine can be considered the price Americans pay for healthcare.

The full discussion of this topic is available at: http://boards.medscape.com/forums/.29f865f3/165

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