Defensive medicine is prevalent in all specialties of medicine. Physicians may not even consciously realize they are practicing defensive medicine since it has been engrained in our thought process early on in our careers, especially over the past few decades. From my experience, physicians-in-training are usually not exposed to defensive medicine until residency, since medical schools usually shelter us from the “real life” thought process.
In medical school, physician mentors or professors stress the importance of physical examination and history and believe the majority of diseases or disorders can be diagnosed without ordering further tests for consultations. It is not until residency, when we are taking care of real-life patients in the real world, far from the ivory tower medical school atmosphere, that we slowly immerse ourselves into the practice of defensive medicine.
Defensive medicine is usually the result of two issues, one is the fear of being sued and the other is the continued decrease in time spent taking care of a patient. Both result in the increased utilization of additional consultation and testing. The increased utilization of mid-level providers such as physician assistants and nurse practitioners have also attributed to increasing costs, given their lower level of training, which likely ultimately leads to overutilization of services.
I recently came across an article in Forbes Magazine – Defensive Medicine: A Curse Worse Than The Disease. This article discusses the issue of defensive medicine and how it is engrained in our health care system. One in four health care dollars is attributed to defensive medicine which amounts to about $650 million annually. The article also addresses the likely worsening of the problem due to the Affordable Care Act creating more insured patients, as well as the decreasing physician workforce due to retirement of baby boomers.
From my personal experiences, I see the practice of defensive medicine in all specialties including my own specialty of radiology. In my daily radiology reading grind, I can think of many situations where I may recommend an additional study, or my non-radiology physician colleague ordered a follow-up of a benign nodule. For instance, one case I read today was a renal ultrasound that demonstrated a likely renal cyst but given the slight debris within it (likely artifact), I recommended a CT abdomen. Since I practice in a litigious state, I recommended the study mainly for the fear of a malpractice lawsuit that this likely cyst may turn out to be cancer in a rare instance. Another example is seeing likely cysts within the kidney on lumbar spine MRIs which usually get an ultrasound or CT scan next to verify that they are cysts. I am sure most of you can come up with examples on a daily basis as well.
Another article I recently came across was in the Journal of American College of Radiology – Are Chargemaster Rates for Imaging Studies Lower in States That Cap Noneconomic Damages (Tort Reform)? The article caught my attention since it seemed to evaluate the effect of tort reform on health care spending. However, after reading the article, I realized that the authors may have missed the underlying issue of defensive medicine as the real issue is overutilization of health services not increasing charges of individual tests.
The article addressed the significance of whether tort reform (cap awards for noneconomic damages (NED) influences the chargemaster rates by hospitals and diagnostic testing centers for certain imaging studies. The authors concluded that chargemaster rates for select imaging services were not lower in states that have capped NED and were higher in some cases. One of the states that had tort reform, but had higher chargemaster rates was California. I am not surprised by this, given the high cost of living in California, which would likely increase costs for all business sectors within the state. Hopefully, future studies will address the correlation between defensive medicine and overutilization of services.
The solution to combating defensive medicine is not an easy one, especially in a system that rewards physicians for doing more. Decreasing the risk of a malpractice lawsuit for physicians and limiting damages paid to patients while maintaining the right for patients is a difficult balance. The article in Forbes points out that the practice of defensive medicine did not significantly change in Massachusetts after legislatures enacted “Disclosure, Apologize, and Early Offer” as well as in Texas despite a cap on damages related to pain and suffering. Georgia and Florida legislatures are considering “Patients’ Compensation System,” which would eliminate the possibility of any physician or hospital ever being sued again. This system would replace our current system and would have a panel of experts to hear the medical claims of patients.
Although there has been much attention on curbing defensive medicine, I am not sure we will reach the “Patients’ Compensation System,” given the lobbying efforts of trial lawyers in this country. Even if we enact such as system, I don’t think the behaviors of physicians will change much in the short term. It may take decades to reverse the defensive medicine behavior in physicians, including myself. Parallel reform of physician compensation from fee-for-service to outcomes-based may also help align the goals of high quality and efficient care.