It is the practice of diagnostic or therapeutic measures conducted primarily not to ensure the health of the patient, but as a safeguard against possible malpractice liability. Defensive medicine takes two main forms: assurance behavior and avoidance behavior. Assurance behavior involves the charging of additional, unnecessary services in order to a) reduce adverse outcomes, b) deter patients from filing medical malpractice claims, or c) provide documented evidence that the practitioner is practicing according to the standard of care, so that if, in the future, legal action is initiated, liability can be pre-empted. Avoidance behavior occurs when providers refuse to participate in high risk procedures or circumstances. [Wikipedia]
While the direct costs of defensive medical practices is being debated, it is clear that the indirect costs are large and insidious. For example, a study-- Investigation of Defensive Medicine in Massachusetts shows the fear of being sued is a serious burden on health care and it dramatically increases health care costs:
The results showed that 83% of the physicians surveyed reported practicing defensive medicine and that an average of 18 to 28% of tests, procedures, referrals and consultations and 13% of hospitalizations were ordered for defensive reasons.
A discussion on this topic typically begins with knee-jerk over-testing from xrays for a simple sprain, to sinus films, to the overuse of uterine sonograms in normal pregnancies, to CT and MRI scans for early, minimally symptomatic trauma.
In a discussion elsewhere, I offered an unexpected example - the easy prescribing of PPIs. I was asked, "Is this really an example of DM? I responded it was related to defensive practices in that PPI's are prescribed with reckless abandon. It's almost as if not prescribing isn't an option. And what about having to deal with long-term adverse effects? There's 7 degrees of separation and the risk of messing with calcium metabolism and subsequent osteoporosis and/or fractures; pneumonia and C. Difficile? Well, that's someone else's problem. Here are cautionary notes:
Fredrick (MD, PhS, JD) responded:
"Defensive Medicine" is not a general pejorative that includes "prescribing with reckless abandon." What it specifically means is: "Prescribing to protect oneself from a possible lawsuit." Anyway, what lawsuit is prescribing PPIs is a protection from?
Certainly there are plenty of other alternatives for GERD, such as H2RAs, but ANYTHING that reduces stomach acidity will have those same side effects.
If you're just upset that PPIs are too expensive, why not just say so?
From: jgk 4/27/10
I am concerned about the abuse of anti-reflux medications and the long-term untoward effect they may have. Speaking as a Pediatrician, here's something from the British Medical Journal Group that we all can relate to:
Are you uneasy about the medicalisation of babies who have reflux but are otherwise thriving? This article says
- Functional reflux in babies is common and the prognosis is benign
- Management includes positioning, avoidance of overfeeding, and consideration of thickening feeds
- Consider a period of excluding cow's milk if symptoms are severe
- Try these strategies before embarking on investigation or drug treatment
Another area where we tend to over-diagnose and/or over-treat is rheumatic fever prevention as it relates to Strep. Rheumatic fever (RF), a systemic illness, may occur as an autoimmune reaction following group A beta hemolytic streptococcal (GABHS) pharyngitis in children; its most serious complication rheumatic heart disease (RHD).
"Studies in the 1950s during an epidemic on a military base demonstrated 3% incidence of rheumatic fever in adults with streptococcal pharyngitis not treated with antibiotics.1 Studies in children during the same period demonstrated an incidence of only 0.3%. The current incidence of rheumatic fever after GABHS infection is now thought to have decreased to less than 1%. Cardiac involvement is reported to occur in 30-70% of patients with their first attack of rheumatic fever and in 73-90% of patients when all attacks are counted."
"After an incubation period of 2-4 days, the invading organisms elicit an acute inflammatory response, with 3-5 days of sore throat, fever, malaise, headache, and elevated leukocyte count. In a small percent of patients, infection leads to rheumatic fever several weeks after the sore throat has resolved. Only infections of the pharynx initiate or reactivate rheumatic fever.
Direct contact with oral (PO) or respiratory secretions transmits the organism, and crowding enhances transmission. Patients remain infected for weeks after symptomatic resolution of pharyngitis and may serve as a reservoir for infecting others. Penicillin treatment shortens the clinical course of streptococcal pharyngitis and more importantly prevents the major sequelae."
Clearly, common practice does not follow the above highlighted observations.