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8/6/2019 Defensive Medicine Exists and How to Fix It__tmp4e350807

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Whatis defensive medicine?

Defensive medicine is the deviation from sound medical practice to avoid the threat of malpractice litigation.

According to a 2005 study in JAMA, over 90 percent of physicians surveyed admitted to practicing defensive

medicine. This can range from positive defensive medicine, like ordering unnecessary tests, referring toconsultants, or performing unneeded procedures to negative defensive medicine, like avoiding high-risk

patients or procedures.

Why practice defensive medicine?

Physicians practice defensive medicine to avoid malpractice litigation. A malpractice lawsuit is the most scarring

ordeal that a physician can undergo, both emotionally and financially. There is an expectation that doctors have

to be 100% accurate with their diagnoses. A missed diagnosis, whether its a 1 in a 100, or 1 in a million case,

makes a physician vulnerable to a malpractice lawsuit. However, medicine by nature is an imperfect science, and

the expectation of perfection is not realistic, nor possible. There is no test that is 100 percent accurate an

unfortunate outcome can occur even if a doctor practices textbook medicine. Arecent study in the NEJMshowed that almost 40 percent of malpractice cases were found to be without medicalerror.

Due to this uncertainty regarding unfortunate outcomes, physicians err on the side ofcaution and practice

defensive medicine. It is much easier to defend the fact that a doctor ordered a test, as opposed to not ordering

the test at all.

Whatare the downsides to defensive medicine?

Defensive medicine is expensive, has no basis in evidence-based study, and exposes the patient to a host of

complications.Contrary to popular opinion, more medicine does not equal better medicine.

Ifa physician is 99 percent sure of a diagnosis, how much more will a patient be willing to pay for that added 0.5percent certainty? A CT scan costing hundreds of dollars? An MRI costing thousands?Now, there may be some

patients who are willing to spend that money for the most thorough workup possible. However, it is not feasible

to routinely spend that kind of money to achieve minimal improvements in diagnosticcertainty which may not

benefit the patient at all.

Defensive medicine is one of the most important drivers in rising health care costs today. There are few reliable

studies to back this up. This is because defensive medicine is impossible to quantify.There is a fine, and largely

undefined, line separating thorough care and defensive medicine. What one doctor may interpret as a being

cautious, another may say is defensive. Because defensive medicine cannot be quantified and is so subjective,

its impact on the cost of health care has been minimized and under-publicized.

The practice of ordering extra tests is also bereft of evidence. There are no studies suggesting that ordering PSA

screening tests saves lives from prostate cancer, or ordering routine abdominal CT scans saves lives from

appendicitis. Is relying on the evidence good enough? The answer is no. The standard of care used in medicine

cannot be applied to the courts. Standard of care varies from jury to jury.

Take the case ofDanielMerenstein. Major clinical guidelines, including the American Cancer Society and the

American College of Physicians, suggest that the physician discuss the pros and cons of PSA screening tests with

the patient. Since there is no evidence that this test saves lives, and may in factcause damage by leading to

unnecessary prostate biopsies, it is recommended that the decision of whether the test is ordered be shared

between the doctor and patient. Dr. Merenstein did just that, and documented the discussion appropriately.

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Unfortunately, the patient later went on to develop late-stage prostate cancer, andsued Dr. Merenstein and the

hospital for not ordering the PSA test. Citing the clinical guidelines of the ACS and ACP did not help the

hospitalwas found to be at fault. Again, it is much easier to defend the fact thata physician ordered the test, as

opposed to not ordering the test at all.

Many would think that the more tests, the better. Nothing could be further from the truth. Tests themselves

have their own risks: ranging from radiation exposure from CT scans to serious complications like bleeding and

infection from needle biopsies.

Since no test is 100% accurate, unnecessary testing can lead to false positives. This is defined as having a

positive test result in the absence of disease. False positives lead to progressively more invasive tests, which may

eventually lead to a non-dangerous diagnosis, or even nothing at all. As the tests become more invasive like a

needle biopsy or cardiac catheterization the complications become more dangerous.Exposing patients to these

unnecessary complications, for the sake of avoiding malpractice litigation, is bad medicine.

Whatcan a patient do to help curb defensive medicine?

A patient should understand why a test is being ordered. Ask questions. How necessary is the test? What

diagnosis are you looking for? What are the risks of not doing the test? What are the risks of the test itself?

Understand that the goal of perfection in medicine is impossible, and that simply orderingmore tests is not

necessarily better medicine.

How can defensive medicine be reduced?

Obviously a difficult question, since it is a difficult entity to even quantify. The focus of the question is, What

does the physician want to avoid? The answer of course, is the ordeal of malpractice litigation. Even if

physicians do win the majority of malpractice cases that make it to trial, the mereprocess of a malpractice suit is

tremendously scarring. Remember, the vast number of cases are settled, never reaching a jury. And the solution

is not simply, practice better medicine or make less mistakes. Keep in mind that almost 40 percent of

malpractice cases do not involve medical error. Unfortunate outcomes despite textbookmedicine are a fact of

life that is a hard truth that one has to accept.

Some have suggested that capping malpractice awards, no-fault insurance, arbitration, or health courts as

approaches to curb defensive medicine. Although I suspect that these options will help curb defensive medicine,

the probability of such sweeping reforms happening in the near future appear minimal.

A simpler way would be to have clinical, evidence-based, guidelines globally applied to malpractice cases. That

way, standard of care would be more consistent, and not vary from jury to jury. It will lessen the impact of hired

gun experts, who can support whatever standard of care is convenient to the lawyers. Doctors can then focus

on practicing evidence-based medicine, confident that the standards they are held to in the community, will be

the same in the legal world. Only when that confidence is gained, will defensive medicine start to decline.

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