Defensive Medicine Among High-Risk Specialist Physicians in a Volatile Malpractice Environment

Abstract

ABSTRACT Defensive medicine is a departure from sound medical practice that is mostly a response to threatened liability. It has been reported widely in the United States and abroad. Defensive medicine may supplement care such as by adding tests or treatments; replace care, as by referring the patient elsewhere; or reduce care, for instance by refusing to treat certain patients. A “positive” form of defensive medicine involves supplying added services of marginal or no medical value so as to reduce the risk of an adverse outcome, deter a patient from filing a malpractice claim, or demonstrate to the legal system that the standard of care has been met. The investigators undertook a postal survey of physicians working in 6 specialties at high risk of litigation: emergency medicine, general surgery, orthopedic surgery, neurosurgery, obstetrics-gynecology, and radiology. The 824 respondents represented 65% of those surveyed. Nearly one fourth of respondents practiced obstetrics-gynecology. All but 7% of respondents reported having engaged in some form of defensive medicine. Nearly 60% acknowl-edged that they often ordered more diagnostic tests than were medically indicated. Approximately half the respon-dents reported having frequently and unnecessarily referred patients to other specialists; this was especially true of obstetricians-gynecologists. One third of respondents had frequently prescribed more medications than were medically indicated. Imaging studies were very often the most recent defensive act carried out. The need to detect cancer led to increased diagnostic imaging, specialist referral, and invasive procedures. Obstetricians-gynecologists reported ordering ultrasonograms for both pregnant and nonpregnant patients. Nearly 40% of respondents intend to avoid caring for high-risk patients or have already begun to do so. Occasionally certain high-risk procedures were avoided. In all, more than 40% of respondents had taken steps to limit their practice and eliminate procedures prone to complications such as trauma surgery. Patients with complex medical problems and those seen as litigious also were avoided. Practicing defensive medicine correlated closely with a lack of confidence in liability insurance and the burden of paying insurance premiums. Women's health may be especially affected by defensive medical practices because both obstetrics and breast cancer detection are high-liability areas. Measures are needed to lessen the frequency with which physicians practice defensive medicine because of its negative effects on the quality of care from both technical and interpersonal points of view.