Medscape: What's the difference between 'defensive' and 'careful' medicine?

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A physician's decision to order a medical test or perform a procedure can be based on a number of factors— including a doctor's fear of being sued if forgoing a test leads to adverse outcomes, Mark Crane writes for Medscape Medical News.

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According to the U.S. Congress of Technology Assessment, "defensive medicine" is defined as physicians ordering tests, procedures, or visits, or avoiding high-risk patients or procedures "primarily (but not necessarily solely) to reduce their exposure to malpractice liability."

A lot of defensive medicine occurs in hospital EDs, because emergency physicians lack ongoing, steady relationships with ED patients and worry they will not get the recommended follow-up care. So, if a patient's condition worsens after discharge, physicians worry they could be sued.

But, Crane writes, "It's hard to draw a line between being appropriately cautious and being overly aggressive." The Government Accountability Office says that cutting-edge image technology can assist with the treatment of life-threatening diseases and help with early diagnosis.

Defensive medicine is expensive and has contributed significantly to the rise in health care spending. From 2000 through 2010, Medicare spending for imaging services increased by 80%, or about $11 billion per year, according to a 2012 report from the Medicare Payment Advisory Commission.

For orthopedists, defensive medicine costs $2B annually

Defensive medicine: On the rise?

A Medscape ethics report in 2014 found that 20% of physicians say they would practice defensive medicine to protect themselves, while 24% say it would depend on the situation. By comparison, just 16% of practicing physicians in 2010 said they would engage in such practices, which suggests that defensive medicine is on the rise. 

Oncologist Richard Anderson—CEO of The Doctors Company, the largest physician-owned liability insurer in the United States—says, "Defensive medicine is pervasive, insidious, and incredibly expensive, and it contributes nothing to improved outcome [and is] the fundamental driver of the cost of health care in America."

However, Anderson notes the practice is unlikely to stop "without fundamental changes in medicolegal jurisprudence," because right now "any adverse result is subject to litigation, regardless of its cause or the standard of care." Even if physicians end up winning the lawsuit, as they usually do, "the stress of being sued.... and damage to your reputation... is a devastating experience, even if there's no payment to the patient," says Marc Siegel, a professor of medicine at NYU Langone Medical Center.

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In recent years, evidence-based guidelines have helped reduce over-testing. For instance, the Ottawa ankle rules now help doctors to decide whether a patient experience foot or ankle pain requires an X-ray. In 1992, before the rules were created, 80% to 95% of patients with ankle injuries in Ottawa would have undergone imaging testing, even though just 15% of x-rays were positive for fracture, writes Crane. After the rules were put in place, the number of x-ray procedures decreased by nearly 36%, according to several studies.

Defending defensive medicine

Some attorneys argue that defensive medicine is good for patients. If a patient undergoes routine tests and doctors cannot find a definitive diagnosis, a physician will typically recommend additional tests. Then, "if the patient doesn't respond as anticipated, you have to question that diagnosis and treat the patient until the treatment produces a cure," says James Griffith, a malpractice attorney in Philadelphia, adding, "This isn't defensive medicine. It's careful, patient-centered medicine."

Siegel also notes that patient choice plays a role in defensive medicine. He says, "I'd never order a test if it isn't indicated. But there are gray areas where an elective test can be either deferred or done early." He adds, "I'll explain my thinking. But if the patient insists and the test won't hurt him, I'll probably go along. It's ultimately his choice" (Crane, Medscape Medical News, 3/10).

The takeaway: Experts disagree on the difference "defensive" and "careful" medicine.

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