Why Practice Defensive Medicine?

What is defensive medicine? Defensive medicine, also known as defensive medical decision making, is the practice of advocating diagnostic tests or therapeutic procedures in order to guard against malpractice lawsuits. Such tests and procedures may not necessarily be the ideal option for the patient; however, they generally serve as a safeguard to doctors from potential exposure to malpractice litigation. In the United States, doctors are at high risk of being sued and the number of lawsuits has greatly increased within the last 20 years. Therefore, defensive medicine merely serves as the outcome that has arisen from the growing costs of healthcare, more specifically, malpractice insurance.

Examples of defensive medicine include ordering a test that a patient doesn’t necessary require or performing a procedure in order to confirm a diagnosis or establish the seriousness of a medical condition. Numerous studies have been conducted in order to indicate whether additional tests and procedures can, in fact, reduce a doctor’s risk of being sued. The greater factor taken into consideration has been whether a doctor is prone to be sued if they have been sued previously. From 1991 to 2005, it was estimated that 6% of U.S. doctors were responsible for 58% of all expenses related to malpractice. Another study, conducted among 800 doctors in Pennsylvania, showed that 92% stated to ordering additional tests and procedures for assurance, while 42% stated to eliminating high-risk procedures and passing up patients with complications. In 2010, Gallup and Jackson Healthcare conducted a study on a national level in order to determine doctors’ attitudes regarding defensive medicine in light of healthcare reform. The findings from Gallup revealed that 73% agreed to having practiced some form of defensive medicine within the last year and 26% recognized healthcare costs to be associated with defensive medicine. The findings from Jackson Healthcare revealed that 92% agreed to practicing defensive medicine and of that number:

• 35% of diagnostic tests were issued in order to avoid malpractice lawsuits;
• 29% of laboratory tests were issued in order to avoid malpractice lawsuits;
• 19% of hospitalizations were issued in order to avoid malpractice lawsuits;
• 14% of prescriptions were issued in order to avoid malpractice lawsuits;
• 8% of surgeries were performed in order to avoid malpractice lawsuits;

The Massachusetts Medical Society conducted a study that found 83% of doctors to be practicing defensive medicine, with 59% using avoidable tests are the most widespread form of defensive medicine and 55% using uncalled for referrals to other specialties. Gathered findings from the above studies and several others have revealed that most doctors appear to be frightened in their own judgment among the clinical setting and find that confirming test results not only help to avoid misdiagnosis but also help to prevent being sued for postponement in diagnosis. Conversely, other doctors found that defensive medicine had become the new standard of care.

In defensive medicine, it has been noted that doctors, such as you, go beyond what is necessary and perform tests and procedures in order to keep patients satisfied. For such reasons, defensive medicine has led to overtesting and overtreatment. Furthermore, it has led most doctors to avoid high-risk patients by choosing a medical specialty with a lower risk of malpractice lawsuits. This can result in decreased number of doctors in medical fields that fit with their most suitable skills and capabilities.

Defensive medicine can be both positive and negative, depending on the given situation that you find yourself in. For instance, through ordering diagnostic testing and procedures, unnecessary treatment and hospitalization time can be avoided (positive defense medicine). On the other hand, avoiding performing high risk tests and procedures on patients, which could have been of great benefit to them, raises an issue of professional behavior and credibility (negative defensive medicine). Furthermore, while defensive medicine may make medical malpractice insurance savings available to doctors, it increases healthcare costs for patients. Estimates reveal defensive medicine results in $850 billion dollars being spent yearly, contributing to more than 30% of overall healthcare costs in the United States.

When you practice defensive medicine, not only are you trying to protecting yourself from legal issues but you are also taking measures that might subject patients to unnecessary methods. The irony is that while some elements in defensive medicine are considered violations of standard care – such as ordering unnecessary treatments – they are also prompted as a way to reduce the fear of lawsuits and confirm patient results. The fact of the matter is that nowadays, if you were to cut back on tests, malpractice lawsuits would begin to increase. The current system cannot find a middle ground for both doctors and patients. As a doctor, you would not change your belief for one patient if it has worked for thousands and thousands of other patients. As a patient, optimal justice would not be provided as the outcome to defensive medicine is satisfying a patient’s need or demand. Therefore, there is no mechanism for lessons learned from defensive medicine.

A study conducted in 1994 looked at the association between doctors’ history of malpractice lawsuits and patients’ satisfaction with care. The results from the study were seen from two different aspects: the patients and the doctors. Patients revealed that they are most likely to report doctors who rushed them and did not offer answers to their questions or test results. Doctors, on the other hand, revealed that being sued previously leads to fear of being sued again and having a limited window to examine a patient may not be enough time to communicate with them as necessary. Therefore, in order to define defensive medicine in terms of standard of care, it can be considered a safe approach in decreasing the number of malpractice lawsuits if you spend time listening and communicating with your patients. By simply being clear in addressing their concerns and answering their questions regarding treatment options, this can lead to better doctor-patient relationships.

Richard Roberts, Professor of Family Medicine at the University of Wisconsin, states that when it comes down to it, practicing defensive medicine is about being able to properly communicate with patients. “The best we do is basically ask people, is this defensive or not? Would you be comfortable stopping at 95% certainty, and not doing three more tests for 98% certainty?. I think Choosing Wisely is a great idea, looking at the evidence and expert opinion, and letting people know you don’t have to do x, y and z, because there’s no benefit to the patient. There may be harm” Roberts said. He continued “Imagine I’ve been your family doctor for years, helped you, your kids, your husband. We’ve had this relationship over time, and one of your kids comes in with an ankle sprain. I say, ‘I don’t think [your child] needs an X-ray right now.’ I say, ‘I’m here tomorrow, you have my cell phone.’ My patients know we’ll be closely connected until the situation is resolved, even if they don’t get every test.”

Some researchers label defensive medicine as an unnecessary approach to patient care, while others describe it as an economic and psychological benefit to both doctors and patients. In any case, for now defensive medicine is widespread and still ongoing. Yet, the growth in legal liability with equivalent effect in increasing healthcare costs has not and will not lead to improvement in healthcare quality. With time, however, fear of legal issues that cannot be predicted or controlled can slowly be eliminated. By taking care of patients and providing proper guidance and quality of care, anxiety on both ends can be reduced. “If you want to fix defensive medicine, develop trusted therapeutic relationships using effective communication skills and be available to patients, period. And then practice medicine using the best science available. That to me is about as good as it can get for a doctor. You can’t consistently look at the lawyer behind you or you’ll run into the wall” Robert concludes.