Does 'Defensive' Medicine Differ From 'Careful' Medicine?

Mark Crane

Disclosures

March 10, 2015

In This Article

The Lawsuit Danger Is Real

Defensive medicine is the bogeyman that drives up healthcare costs—and drives doctors crazy. Is a test or procedure necessary to find the right diagnosis and treatment plan? Is it for financial gain? Or is the doctor mainly trying to protect himself from a plaintiff's attorney attacking him years later if there's a poor outcome?

The decision to order a specific test or perform a procedure can be any of those, or a combination of all three. Often, the doctor himself isn't sure which factor influenced him the most, malpractice experts say.

What motivates a physician to order a specific test? Ruling out serious problems and referral to specialists often benefits patients, gives them peace of mind, and can be justified. But to what extent is the doctor's decision influenced by fear of being sued?

In Medscape's Ethics Report 2014, a significant percentage of physicians noted that they would or might engage in defensive medicine to protect themselves. When asked, "Would you ever perform a procedure that may not be medically warranted because of malpractice fears?" 20% responded "yes," 24% said "it depends," and 56% said "no." In Medscape's 2010 survey, only 16% responded "yes" to that question.

Some years ago, the US Congress Office of Technology Assessment defined defensive medicine as: "When doctors order tests, procedures, or visits, or avoid high-risk patients or procedures primarily (but not necessarily solely) to reduce their exposure to malpractice liability."

"Defensive medicine is pervasive, insidious, and incredibly expensive, and it contributes nothing to improved outcomes," says Richard E. Anderson, MD, an oncologist and CEO of The Doctors Company, the nation's largest physician-owned professional liability insurer. "It is a fundamental driver of the cost of healthcare in America, but it will not be eradicated without fundamental changes in medicolegal jurisprudence. Any adverse result is subject to litigation, regardless of its cause or the standard of care."

Evidence-based guidelines have reduced excess testing around the world. For example, the Ottawa ankle rules, established in 1992, help physicians decide whether a patient with foot or ankle pain should get an x-ray to diagnose a possible fracture. Before the rules, an estimated 80%-95% of patients with ankle injuries would have undergone imaging, even though only 15% of x-rays were positive for fracture. When these well-regarded rules are followed, they significantly reduce unnecessary costly x-rays by as much as 36%, according to several studies.

Yet as one skeptical internist from North Carolina quipped at a recent medical conference, "It may be the patient's ankle. But it's my career. I'll do the x-ray."

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