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

Mark Crane


March 10, 2015

In This Article

The De Facto Standard of Care

Alan C. Woodward, MD, an emergency physician and past president of the Massachusetts Medical Society, says, "It's now almost the standard of care to do a CT scan for every head or neck injury, especially in motor vehicle accidents. We practice maximalist medicine to avoid missing any problem, even though our clinical judgment may tell us it's extremely remote."

Physicians will err on the side of doing too much rather than face a plaintiff's attorney, years later, asking them on a witness stand, "Why didn't you do this simple test to rule out ...?" "So youngsters who fall and hit their heads will get CT scans. Many patients who complain of heartburn may get a full cardiac work-up and referral to a cardiologist. Most ankle sprains will get x-rays," says Woodward.

Defensive medicine is rampant because "the threat of being sued is pervasive and doctors simply don't trust the legal system," he adds.

"Doctors do win the vast majority of lawsuits, but they fear entering the world of the lawyer," says Marc Siegel, MD, an internist, author, professor of medicine at NYU Langone Medical Center and a senior Fox News medical contributor. "Courts are unpredictable, and the stress of being sued—with years of depositions, worry, and damage to your reputation—is a devastating experience, even if there's no payment to the patient."

Much of what's been called "defensive medicine" occurs in emergency departments. Emergency department physicians argue they need to test extensively so they won't miss serious diagnoses, such as heart attacks, strokes, and blood clots, which can be fatal. After all, these doctors don't have ongoing relationships with patients and worry that many won't get the follow-up care they recommend. Emergency department physicians rightly fear that they'll be sued if a patient's condition deteriorates after discharge. It's hard to draw a line between being appropriately cautious and being overly aggressive.

Some attorneys say defensive medicine is actually good medicine. "There are certain tests that the condition or injury require for a proper diagnosis," says James Lewis Griffith Sr, a veteran malpractice attorney in Philadelphia who represents both patients and physicians.

"If after you do those tests you still don't have a diagnosis or the tests show that your initial diagnosis was wrong, you have to do other tests and procedures. If the patient doesn't respond as anticipated, you have to question that diagnosis and treat the patient until the treatment produces a cure. This isn't defensive medicine. It's careful, patient-centered medicine," he says.

On the other hand, when laboratory and other tests are done with a frequency that's unrelated to any diagnosed illness, "it does raise an issue of either defensive medicine, or perhaps income-generating medicine," says Griffith.


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