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Volume 2, Issue 1 (January-March, 2012)

Defensive Medicine as a Bane to Health Care

Author: Rafia Afzal

Affiliation: Medical student, Dow Medical College, Karachi, Pakistan

Conflicting Interest: None declared

This article has been peer reviewed

Article Submitted on: 1st November 2011

Article Accepted on: 19th December 2011

Funding Sources: None declared

Correspondence to: Rafia Afzal, Medical Student

Address: Dow Medical College, Karachi, Pakistan

Email: [email protected]

 

Perspective Article 

 

Defensive medicine is currently the buzz word among doctors all over the world, particularly those practicing in developed countries. What actually defensive medicine means, something that I found out, is as follows: Defensive medicine on the part of doctor is the practice of ordering tests, procedures or visits that are unnecessary and usually undertaken by the doctors to avoid their liability to medical malpractice rather than to ensure patient’s benefit. [1] If this is the actual situation, it seems to be unlawful and unethical and brings doctors’ part under suspicion. Defensive medicine is a practice that may take two forms, assurance behavior and avoidance behavior. [2] Assurance behavior renders doctor to charge or order additional diagnostic or therapeutic tests to reduce the chances of misdiagnosis and possible risk of adverse outcome and also to please the patient. Responses to assurance behavior are also undertaken to ensure that the doctor is practicing conventional evidence-based medicine and to avoid future possibility of litigation. Avoidance behavior responses usually involve avoiding and refusing high-risk patients and procedures. [2]

The defensive medicine is most practiced in high-liability specialties [2] such as gynecology/obstetrics, emergency medicine, radiology, neurology etc. where doctors may get sued for misdiagnosing and not ordering tests. This fear influences their decision and leads them to order unnecessary tests which raise the healthcare costs. Defensive medicine is not only raising the healthcare costs to exorbitant rates but also puts the patients at risk posed by ordering unnecessary therapies and procedures. It is a sort of malpractice that doctors usually practice to safeguard themselves. [3]

Another contributing factor is the patient’s psyche. Many patients feel the treatment comprehensive and appropriate only when they are advised number of tests by the doctor. Also many doctors may practice defensive medicine to supplement their income. [4]

Furthermore, lawyers represent patients and file number of frivolous malpractice suits to earn money, which is not only becoming a source of torment for doctors but also causing defensive medicine to grow. [5]

Increasing rate of malpractice claims and skyrocketing cost of medical liability insurance premiums [6][7][8]  have put doctors under fear of litigation and forced them to practice defensive medicine to avoid damage of reputation and emotional traumas by litigation. Also, it is worth mentioning here that several less renowned companies find it cumbersome to afford full health insurance policies, rendering the patients to face the escalating costs of multiple tests and procedures.

These findings prompted me to write that not only doctors but also patients, attorneys and our current legal systems are all causing defensive medicine to grow, raising a prompt need to curb these factors.

The National Center for Policy Analysis conducted a study in 2007 which estimated the annual cost of defensive medicine to be between $100 billion and $178 billion in the year 2005. [9] The consistently rising cost of healthcare due to increased practice of defensive medicine have raised a concern and it is incumbent on the responsible authorities to look into it and take prompt actions.

After all these aspects of defensive medicine which prove to be ethically and legally questionable, authorities need to take measures to curtail this exploiting curse. Here I am mentioning some of the measures that have been taken and also those that could be taken to reduce adverse effects of defensive medicine on healthcare systems.

To control the ever increasing number of malpractice liability claims, many countries have recently passed laws to reduce such liability claims. For instance, an aggressive law was passed in Texas in 2003 as part of American Medical Association Medical Liability Reform that included an award cap of $250,000 on non-economic damages such as pain and sufferings. [7] Such capping malpractice awards may have an effect in lowering medical malpractice insurance premiums and also malpractice claim rates, but there is no consistent evidence for such effects. [1] [7][10]

In fact such capping awards on the other hand, may decrease supply of doctors by driving doctors out of practice due to escalating costs of medical malpractice coverage, [11] as evidenced in USA. Therefore, all these reforms need to be revised.

Alternative dispute resolution system and no-fault system [8][3] can be the alternatives to the conventional tort system for compensating patients for medical injuries.

The doctors should be recommended to follow the established medical guidelines which will prevent them from an unethical and illegal practice and its consequences [8], needing the doctors to be more knowledgeable and thorough in their profession. [12]

In conclusion, evidence-based medicine rather than defensive medicine should be practiced. Evidence-based medicine should be preferred because it uses the best available evidence gained from scientific method for the purpose of clinical decision making. Proper implementation of evidence-based medicine to improve patients’ care and to prevent the practice of defensive medicine requires the healthcare professionals to gain skills and assess, apply, integrate and communicate new knowledge in clinical decision making. [13]. If our healthcare system becomes successful in overcoming resistance to adopt evidence-based guidelines, evidence-based medicine will lead to improved performances and better clinical outcomes.

In my opinion, defensive medicine is really a bane to healthcare systems so stand against it and condemn this unethical act as a doctor’s sole duty is to practice medicine for the benefits of patients.

REFERENCES

1. Mello MM, Kachalia A, Goodell S. Medical malpractice – april 2011 update. Synth Proj Res Synth Rep. 2011;(21 Suppl 1). pii: 72097. doi: 72097.

2. 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(21):2609-17.

3. Epstein NE. It is easier to confuse a jury than convince a judge: the crisis in medical malpractice. Spine (Phila Pa 1976). 2002;27(22):2425-30.

4. Chen XY. Defensive medicine or economically motivated corruption? A confucian reflection on physician care in China today. J Med Philos. 2007;32(6):635-48.

5. Korcok M. Medicolegal hell in Texas. CMAJ. 1995;153(7):963-6.

6. Bovbjerg RR. Malpractice crisis and reform. Clin Perinatol. 2005;32(1):203-33, viii-ix.

7. Mello MM, Studdert DM, Brennan TA. The New Medical Malpractice Crisis. N Engl J Med. 2003;348(23):2281-2284.

8. Segal JJ, Sacopulos M. A modified no-fault malpractice system can resolve multiple healthcare system deficiencies. Clin Orthop Relat Res. 2009;467(2):420-6.

9. Available at the following link: http://www.ncpa.org/sub/dpd/index.php?Article_ID=18549

10. Morrisey MA, Kilgore ML, Nelson LJ. Medical malpractice reform and employer-sponsored health insurance premiums. Health Serv Res. 2008;43(6):2124-42.

11. McKinley A. Health care providers and facilities: medical malpractice and tort reform–2005. End of Year Issue Brief. Issue Brief Health Policy Track Serv. 2005;31:1-19.

12. Tsai WC, Kung PT, Chiang YJ. Relationship between malpractice claims and medical care quality. Int J Health Care Qual Assur Inc Leadersh Health Serv. 2004;17(7):394-400.

13. Khan KS, Coomarasamy A. A hierarchy of effective teaching and learning to acquirecompetence in evidenced-based medicine. BMC Med Educ. 2006;6:59.

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