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The Debate Surrounding Defensive Medicine

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In the U.S., with a population of 300 million, patients undergo around 15 million nuclear medicine scans, 100 million CT and MRI scans, and almost 10 billion laboratory tests each year. “Often, these are fishing expeditions,” writes Atul Gawande, New Yorker staff writer, surgeon, and public health researcher.

Excessive testing is problematic for many reasons, from the radiation exposure from certain diagnostic tests that’s believed to increase cancer rates, to the financial impact on patients and the health care system overall. Is practicing “defensive medicine” helping patients? Is it helping doctors ward off malpractice lawsuits? Or is neither of these things true?

What is defensive medicine?

Although most people who use the term equate defensive medicine with excessive testing, a more precise definition was drafted by the Congressional Office of Technology Assessment (OTA) in 1994:

“Defensive medicine occurs when doctors order tests, procedures, or visits, or avoid high-risk patients or procedures, primarily (but not necessarily or 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.”

Interestingly, while media references to defensive medicine almost always imply unnecessary and costly procedures, OTA’s definition does not exclude practices that may benefit patients.

The issue of whether defensive medicine benefits patients is not cut and dry, as Gawande explores at length in his New Yorker article. A patient with even the tiniest indication of cancer may prefer erring on the side of doing too much rather than too little, for example. However, what is clear is that patients aren’t to blame for over testing in medicine, according to at least one study. A paper published in JAMA Oncology showed that only one percent of cancer patients ask for a clinically inappropriate medical intervention.

The costs of defensive medicine

“Defensive medicine is commonplace in medical practice,” write Hal Scherz, MD, and Wayne Oliver in an opinion piece for Forbes. A national physicians’ survey in 2013 found that 75 percent of doctors said they order more tests, procedures, and medicines than are medically necessary in an attempt to avoid lawsuits.

In specialties with a high risk of costly malpractice claims, such as neurosurgery, obstetrics/gynecology, and orthopedic surgery, that number is the same if not higher. More than three-fourths of U.S. neurosurgeons practice some form of defensive medicine, reports the journal Neurosurgery. “Defensive medicine practices do not align with patient-centered care, and may contribute to increased inefficiency in an already taxed health care system,” the coauthors conclude.

However, the actual costs are difficult to calculate. A Cleveland Clinic study estimated a national cost of $46 billion related to defensive medicine, but noted that such costs have been measured only indirectly, according to Medical Economics. “Other studies, along with the American Medical Association, put the cost impact much higher.”

In 2013, a Gallup survey, commissioned by health care management company Jackson Healthcare, attributed a cost of about $650-$850 billion annually to defensive medicine. “These costs are passed along to everyone,” notes Forbes, “significantly driving up health insurance premiums, taxes to cover public health insurance programs, co-pays, and out of pocket costs.”

A ‘deep-seated dilemma’

“Defensive medicine is viewed by many as a deep-seated dilemma,” writes Judy Packer-Tursman in Medical Economics. This is true for many reasons, not least because it appears that defensive medicine actually does lower malpractice risk, according to a recent study. Using data on thousands of physicians and millions of hospital admissions in Florida, researchers found that the more a hospital billed, the less likely the doctor was to be sued, reports the New York Times’ Well blog.

Of course, not getting sued is not the same thing as delivering exceptional patient care. The “hidden harm” of defensive medicine is that “unnecessary care often crowds out necessary care, particularly when the necessary care is less remunerative,” writes Gawande. As it stands now, the health care system is to blame, he says: “The system gives ample reward for overtreatment and no reward for eliminating it.”

Beyond fear of malpractice suits and issues of cost, doctors are faced with the fact that medicine is not an exact science. They must balance patient demands with their own judgment about what tests are necessary. As in every aspect of medical care, patient communication and education play a key role.

“Patient education ‘has a huge part to play’ in avoiding defensive medicine,” Kisha Davis, MD, tells Medical Economics. “People come in wanting antibiotics, wanting studies, wanting to see the specialists.” Taking the time to explain why such steps may not be necessary is important: “You really have to make it a priority,” she says.

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