I recently posted about a former Surgeon General of the United States who was complaining about a large emergency department bill. Even though he admitted that all of the tests and treatment he received was necessary, he saw fit to complain that too often unnecessary tests and treatments are ordered because doctors are afraid of losing their licenses or being sued for malpractice. I observed that doctors like to complain about having to engage in defensive medicine even though it is unethical to order tests or treatments the patient does not need just for the sake of the doctor.
I then came upon this study of almost ten years of hospital admissions in Florida. The authors were trying to determine if the doctors who ran up the largest bills for their patients were sued less frequently than those whose ran up smaller bills. While they found that the doctors whose patients received the largest bills were somewhat less likely to be sued in the year following the hospital admission, they concluded this did not demonstrate either that the treatments and tests were unnecessary or that they were a factor in whether the doctor got sued or not.
After noting what an article of faith it was among doctors that they were forced to practice defensive medicine to avoid malpractice claims, the authors expressed surprise that there was no real proof that what the doctors claimed was defensive medicine actually worked in preventing claims. They observed that there are many reasons to believe that so-called defensive medicine makes little or no difference in avoiding claims.
In the first place, they noted that a substantial percentage of malpractice claims arise out of problems with communication between doctors and patients or between members of the health care team itself. Ordering additional tests or giving more treatment won’t fix these problems.
Next, they noted that, while diagnostic errors were a leading cause of malpractice claims, they were usually found to be the result of problems with the system or with the thought process of the doctor rather than a failure to do more testing.
Finally, the authors observed that there is no real evidence to support the proposition that tests and treatments allegedly ordered for defensive purposes did not benefit the patients and result in better outcomes. Unless the additional tests or treatments were ineffective in producing a better outcome, they were not wasteful and should not be condemned.
With all of that in mind, the study authors analyzed the records of over 7,000,000 hospital admissions. They ended up not being able to draw any truly useful conclusions. There were multiple reasons they were unsuccessful. For example, they were unable to determine whether or not the higher hospital bills were the result of defensive motivation by the admitting doctor or were medically necessary. They were unable to determine if the additional treatment and tests which caused the higher bills were the reason the doctors were less likely than their colleagues to be sued in the following year. They were unable to determine if the additional treatment and tests reduced errors or not. They were unable to determine the effect of illnesses that may not have been evident in the medical record. They identified a number of other potentially confounding factors as well.
Defensive medicine is unnecessary testing or treatment ordered by a doctor to protect himself or herself from potential malpractice claims or medical board action. It requires both a defensive motivation and tests or treatments that do not benefit the patient or lead to better outcomes. This study makes clear that there are so many factors involved in medical decision making and outcomes, it is not possible to determine what is truly defensive medicine. Maybe the best we can do is recognize that defensive medicine is an article of faith among doctors. Whether it actually exists and whether it helps patients remains unknown and unknowable.
