9


WHAT IS IT?


Defensive medicine is commonly defined as the ordering of tests, treatments, etc, to help protect the doctor rather than to further the patient’s diagnosis. Although this is not “unnecessary care”, defensive medicine offers more economic and psychological benefit to the doctor than to the patient.4


Dr David Studdert identified two types of


defensive medicine: Assurance behaviour (positive defensive medicine)


– providing services of no medical value with the aim of reducing adverse outcomes, or persuading the legal system that the standard of care was met, eg, ordering tests, referring patients, increased follow up, prescribing unnecessary drugs. Avoidance behaviour (negative defensive medicine)


– reflects doctors’ attempts to distance themselves from sources of legal risk, eg, forgoing invasive procedures, removing high-risk patients from lists.5


psychologist Professor James Reason said that the worm at the heart of the medical system was that it was predicated on the belief in “trained perfectability”, where doctors are expected to get it right, and if they don’t we “name, shame, blame and retrain” them.


Lawyer phobia According to leading psychiatrist Dr Tellefsen, who argues that more doctors practise defensively because they fear being sued, an anticipatory attitude could lead to avoidance and overcompensation.6


“Just in case” A male Emergency Department (ED) registrar, who wishes to remain anonymous, says that many junior doctors request “pointless” blood tests “just in case”, which creates more problems, such as investigating a test that is not needed. This suggests that poor clinical knowledge or lack of experience drives defensive medicine.


Many doctors describe litigation as a dagger at their back. However, it is good evidence- based practice, not defensive practice, that will deflect the blade


Colleagues’ expectations According to the same registrar, in ED lots of tests are done because they are expected by other specialties, but are not necessary, eg, ordering a chest x-ray for someone who has angina, or testing the blood of a child with a broken arm, in case the surgeon asked for the results, even though this is not evidence-based.


HOW PREVALENT IS IT? What is defensive medicine to one person may be high quality care to another.7


were adopting to avoid complaints


and claims. These statistics show: ■ 41% had chosen to stop dealing with certain conditions/ performing specific procedures to avoid complaints and claims


■ 37% changed prescribing habits ■ 61% conducted more investigations.


However, not all examples of defensive medicine can be considered negative. The following statistics demonstrate


“positive” defensive medicine: ■ 54% referred more patients for a second opinion


■ 76% were more careful to ensure follow-up arrangements were in place


■ 83% kept more detailed records. The results suggested that female doctors were more cautious than their male colleagues, as women referred more patients for a second opinion, kept more detailed records and were more careful to follow up than their male counterparts. The results also indicated that male


doctors practise more negative defensive medicine, compared to female doctors. They conducted more investigations and had a lower threshold for removing patients from lists, and more of them chose to stop dealing with certain procedures than their female colleagues. Other surveys and reports suggest


that defensive medicine is a prevailing aspect of healthcare. According to Kessler it might add as much as 5% to 9% to overall health costs in some countries.8


A An international Casebook


survey (see Box A overleaf) asked more than 3,000 MPS members from seven countries whether they practised defensively to avoid complaints and


claims. The key findings were: ■ 73% said they practised defensively to avoid complaints and claims


■ 77% said they practised more defensively now than in the past


■ 78% noticed their colleagues practising defensively, eg, ordering more tests than were medically necessary.


The survey attempted to find out how this translated into clinical practice, and identify what practices doctors


widely-used example of defensive practice is the dramatic increase in caesarean sections, which have more than doubled in the UK over the last 20 years. A UK study explored the view of 151 clinical directors about why this was the case. One of the top three reasons given was the fear of litigation. Three in five respondents thought the local rate was too high.9 Last year, an American study looked


at the issue of overtesting in late-stage cancer for the first time; it raised questions about overtreatment in healthcare. It identified a “culture of screening on autopilot”, where cancer patients with advanced cancers were being screened for other cancers that couldn’t possibly kill them.10


Another factor linked to this is the increased risk CT scans pose


SPECIAL FEATURE


UNITED KINGDOM CASEBOOK | VOLUME 19 | ISSUE 1 | JANUARY 2011 www.mps.org.uk


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