Could accusing a damaged patient of whining and not taking
responsibility for his/her life-altering and disabling adverse effects
to a prescribed drug be the first step in "defensive medicine"?

Zee

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Practice of Defensive Medicine Widespread Among Physicians in
Specialties at High Risk of Lawsuits

CHICAGO - More than 90 percent of surveyed physicians in Pennsylvania
reported defensive medicine practices such as over-ordering of
diagnostic tests, unnecessary referrals and avoidance of high-risk
patients, according to a study in the June 1 issue of JAMA.

Defensive medicine is a deviation from sound medical practice that is
induced primarily by a threat of malpractice suits, according to
background information in the article. Defensive medicine has been
reported widely in the United States and abroad. However, its
prevalence and characteristics remain controversial.

According to the article, defensive medicine may supplement care (e.g.,
additional testing or treatment), replace care (e.g., referral to
another physician or health facility), or reduce care (e.g., refusal to
treat particular patients). Some practices, described as "assurance
behavior" (sometimes called "positive" defensive medicine), involve
supplying additional services of marginal or no medical value with the
aim of reducing adverse outcomes, deterring patients from filing
malpractice claims, or persuading the legal system that the standard of
care was met. Other practices, described as "avoidance behavior"
(sometimes called "negative" defensive medicine), reflect physicians'
efforts to distance themselves from sources of legal risk. Defensive
medicine, particularly avoidance behavior, encompasses both day-to-day
clinical decisions affecting individual patients and more systematic
alterations of scope and style of practice.

David M. Studdert, L.L.B., Sc.D., M.P.H., of the Harvard School of
Public Health, Boston, and colleagues conducted a study to determine
whether during a more volatile period in malpractice insurance markets,
physicians' uncertainty about the costs and availability of coverage
may induce a wider array of defensive practices, affecting not only the
cost of health care but also its accessibility and quality. In May
2003, the researchers surveyed Pennsylvania physicians in six
specialties at high risk of malpractice claims about the frequency and
nature of their defensive practices. The specialties were emergency
medicine, general surgery, orthopedic surgery, neurosurgery,
obstetrics/gynecology, and radiology.

A total of 824 physicians (65 percent) completed the survey. Nearly all
(93 percent) reported practicing defensive medicine. "Assurance
behavior" such as ordering tests, performing diagnostic procedures, and
referring patients for consultation was very common (92 percent). Among
practitioners of defensive medicine who detailed their most recent
defensive act, 43 percent reported using imaging technology in
clinically unnecessary circumstances. Avoidance of procedures and
patients that were perceived to elevate the probability of litigation
was also widespread. Forty-two percent of respondents reported that
they had taken steps to restrict their practice in the previous 3
years, including eliminating procedures prone to complications, such as
trauma surgery, and avoiding patients who had complex medical problems
or were perceived as litigious. Defensive practice correlated strongly
with respondents' lack of confidence in their malpractice insurance and
perceived burden of insurance premiums.

"Higher levels of defensive medicine are part of the social costs of
instability in the malpractice system. The most frequent form of
defensive medicine, ordering costly imaging studies, seems merely
wasteful, but other defensive behaviors may reduce access to care and
even pose risks of physical harm. Because both obstetrics and breast
cancer detection are high-liability fields, women's health may be
particularly affected," the authors write.

"Efforts to reduce defensive medicine should concentrate on educating
patients and physicians regarding appropriate care in the clinical
situations that most commonly prompt defensive medicine, developing and
disseminating clinical guidelines that target common defensive
practices, and reducing the financial and psychological vulnerability
of individual physicians in high-risk specialties to shocks to the
liability system," the researchers conclude.

(JAMA. 2005;293:2609-2617. www.jamamedia.org)

Editor's Note: This study was funded by a grant from the Pew Charitable
Trusts as part of the Project on Medical Liability in Pennsylvania.