Everybody talks about defensive medicine as a necessary evil to practice medicine in an increasingly litigious environment. But, what is it actually? How pervasive is it? What impact does it have on the quality, safety and costs of care? Does it likely increase or decrease the chances of getting sued – why or why not? Does it help or hurt the defense of a suit? What, if anything, can be done to minimize at least its negative aspects and impact?

Defensive Medicine: What it is and its prevalence

All physicians over the life of their careers come to embrace certain practice styles. These styles could be characterized as systematic, deliberative, aggressive, focused, patient-centered, collaborative, and, in some cases, even obsessive, not to mention any number of other descriptors. Physicians’ practice styles may be influenced by their specialties, types and numbers of patients seen in a particular day, practice settings or any number of other factors. Regardless of these factors, most physicians come to practice certain ways, based mainly on what they believe best serves their patients’ short and longer term medical needs.

However, with the increasing threat of litigation, there has developed what has come to be known as the practice of defensive medicine. One highly quoted study from Harvard and Columbia researchers (as well as the Harris Interactive Survey group) found that fully 93% of physicians in six specialties (general surgery, orthopedic surgery, neurosurgery, obstetrics/gynecology and radiology) have admitted to practicing defensively (Studdert, DM, Mello, MM, Sage, WM, DesRoches, CM, Peugh, J, Zapert, K, Brennan, TA, Defensive Medicine Among High-Risk Specialist Physicians in a Volatile Malpractice Environment; JAMA; 2005:293:2609-17. http://jama.ama-assn.org/cgi/content/short/293/21/2609).

Defensive medicine involves a process of treating patients differently than what may be the physician’s predominant style of doing what he or she believes is in the best interests of improving the patient’s overall health. Physicians practice medicine defensively either to avoid litigation, or, at least, to be able to defend it better should it occur.  Defensive medicine may involve both the ordering of unnecessary tests, procedures, consultations and even hospitalizations as well as the avoidance of specific types of clinical interventions which physicians might feel would best benefit their patients, but which they deem to be too risky given the prevailing medico-legal environment.

In some cases, physicians might practice defensively by avoiding the treatment of certain types of patients altogether, either because of the precarious or complex nature of their clinical conditions and/or their being perceived as litigious (Cf. Studdert, et. al., supra at 2609). Whatever form defensive medicine might take, it is clearly a major problem which could add substantially to the cost of care.

But just how much does it add, and, is it somehow “worth it” because it results in improved quality and safety of care, while decreasing the risk of litigation, or a bad outcome from that? Answers to those questions follow in subsequent sections of this article.

Cost
There has been much speculation about how much the practice of defensive medicine contributes to the overall $2.3 trillion annual healthcare bill in the U.S. Many governmental and professional society groups usually peg the cost at somewhere in the 1 – 2% of total healthcare expenditures range. However, these groups may have not taken into account all of the downstream costs deriving from the practice of defensive medicine. That is what Pricewaterhousecoopers’ Health Research Institute (PwC) and the American Health Insurance Plans (AHIP) organizations have most recently tried to take into account in their projections.