Defensive Medicine

Unnecessary imaging tests for establishing a diagnosis, serological tests for tuberculosis, denial to basic life saving measures, broad spectrum antibiotics for self-limiting viral conditions. These are examples of defensive medicine that can be found as a rampant Medusa all around us.

Defensive medicine occurs 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. When physicians do extra tests or procedures primarily to reduce malpractice liability, they are practicing positive defensive medicine. When they avoid certain patients or procedures, they are practicing negative defensive medicine.

Defensive medicine brings with it exponential increases in the costs associated with clinical practice. Practitioners, the public, and third party insurers all experience the same impact on the price of medical care in the form of additional testing (even unnecessary testing). More importantly, fear among health care practitioners and administrators has contributed to a different kind of cost expressed in the shut-down or unavailability of services in sectors of high-risk exposure. Yet, most problematic of all, the practice of defensive medicine compromises not only the cost but the quality of care given. In short, the fear of malpractice litigation has a tangible effect on the manner in which all clinical decisions are made, not just risky ones, but all varieties, from the mundane to the most profound.

Physicians receive “signals” from the malpractice system in a variety of ways, including personal litigation experience, the experience of their colleagues, the media, risk management and quality assurance activities, and their malpractice insurance premiums. Although it is unclear whether and to what extent these “malpractice signals” affect physician practice, it has been documented that physicians consistently overestimate their own and their colleagues’ risk of being sued. Physicians are concerned about the professional, financial, and psychological consequences of litigation but, on balance, they tend to overestimate the risk of these effects as well.

Perceptions of increasing risk may also arise from the continual development of new diagnostic techniques and improved therapies for serious debilitating conditions. Both of these trends could make the consequences of not testing more serious. The availability of more accurate or early tests or new therapies changes a natural risk—for example, the risk of death from disease—into a preventable risk, and places a new burden on the physician to correctly interpret the results of the test. When a medical technology is new, physicians may have greater uncertainty about the appropriate indications for its use and therefore more conscious concern about the potential for liability.

Like other widespread phenomena, the medical malpractice crisis does not occur in a social vacuum: indeed, we live in a litigious climate where everyone seems to be suing everyone else on very little provocation. Another factor leading to fear of litigation may be the perception that the medical profession requires outside scrutiny and regulation. In this context, public awareness of malpractice suits creates a self-fulfilling prophecy: the more the public becomes aware that the medical profession is vulnerable to litigation, the more likely the number of suits is to increase.

The primary benefit that may derive from the fear of malpractice liability is strengthened therapeutic alliance between clinician and patient. Once clinicians openly acknowledge their own fears of liability, they may then choose to address these concerns by putting their energies into building mutually supportive relationships with their patients. The therapeutic alliance promotes these "good feelings" by establishing as a shared goal the well-being of the patient. Instead of being pitted against each other as adversaries, clinician and patient can work together against the common enemy of disease.

Today malpractice is a topic that seems to make people in the medical field shiver. Understanding the legal issues, such as negligence and the penal code, is important to understanding new reforms and developments in this area. Thus it is clear that the various components that make up the practice of defensive medicine can only be unravelled with the help of physicians, patients and government. Finally it’s the patient’s welfare that should be of paramount importance in any clinical/emergency setting because that’s what we swear to protect in the Hippocrates Oath.