Defensive medicine - who defends themselves from whom, and who is the loser

Defensive medicine - who defends themselves from whom, and who is the loser?

It is commonly believed that a doctor who orders a lot of tests is a good specialist. They are committed and they care about the patient’s health. One that refuses to refer a patient for examination is suspicious. Hence, to avoid being suspected of bad faith, to prevent grievances from patients or complaints from families, doctors undertake defensive medical decision-making. What it means in practice and what consequences it has - prof. Tomasz Pasierski from the Doctors’ Ethics and Palliative Medicine College at WUM Medical University of Warsaw.

What is the meaning of defensive medicine?

These are interventions or series of interventions undertaken by a doctor, which are apparently done for the patient’s good, yet their hidden agenda is the doctor’s safety. Safety in the legal sense.
Hence, whether or not an intervention is defensive depends on the doctor’s intention. Does the medic do a test or examination to find a disease, to discover something? Or do they do it to secure themselves, so that the patient does not protest? Or, alternatively, so that their family do not complain in the event of some complications, for example. From the legal perspective, the doctor will be covered.
It should be noted that being defensive may involve doing too much, e.g. too many tests, but also doing too little, or nothing at all. For instance, if the patient is very ill - the doctor will not operate, they will overestimate the risks of the surgery so that the patient does not agree to it. In this way, the doctor avoids responsibility that could be involved in case of a failed surgery.

What is the scale of this phenomenon?

This is very difficult to assess. Such a survey has been conducted e.g. among Italian gastroenterologists. They admit that they are conducting 30% diagnostic tests for defensive purposes. Research from the United Kingdom indicates that defensive behaviors constitute approximately 40% of a doctor’s activity. However, I do not know of any such research from Poland. 
We can still try to assess the scale of defensive medicine objectively. We focus on a certain disease or a certain group of patients and we compare the procedures which are given to patients at different locations. For example, we can compare how much CNS imaging is done at different hospitals at emergency wards. If we discover a few per cent on one site and several dozen per cent on another, it will tell us that either someone is doing too much or someone else is not doing enough. In that case, we may be dealing with defensive medicine.

A patient comes in with a headache and demands a CT scan immediately - does this situation cause the doctor to behave defensively?

I suppose a lot of such examinations can indeed be done without specific medical indications. Just like it is the case with other types of diagnostic imaging, such as an ultrasound in a stomachache. Yet defensive measures occur in all medical specializations. We can encounter it at a family doctor’s office, in a hospital, or in the offices of various specialists.

Why do doctors undertake defensive measures? 

It often occurs under pressure from the patient or their family. This pressure is an essential issue for medicine in Poland. When a serious illness occurs, the patient’s family will start a race, competing in the category of “who is trying hardest” to care for the patient. The winner of this race is the person who demands more tests and who keeps finding more and more specialists/consultants. The problem is that the more consultants are involved, the higher the risk of contradictory opinions to emerge, so that a super-expert will be necessary to resolve the issue.
Back to the question why. Another reason can be uncertainty. This is illustrated by a typical scene from a medical drama show. A patient gets to emergency. The family are asking “what’s wrong with him”, and the doctor replies: “we don’t know, we have to do more tests.” 
But what if we have done more tests and we still don’t know what the patient is suffering from? Here, a doctor’s experience plays an enormous role, where we are aware of what is important and what resources to use in order to reach the goal.
There is also the matter of fearing a lawsuit. A doctor will order a test to keep themselves safe and not for the patient’s good. A young doctor, a resident doctor asks their boss: “Why are we doing all these tests, doctor?” What they hear in reply is: “Because we don’t want to be prosecuted.” Such situations are most risky because they adversely affect the concept of primacy of the patient’s good, which is so important in our job.

 
From the patient’s viewpoint, a doctor who orders all the tests the patient may ask for is a good, caring specialist. What is the truth though?

Patients have different attitudes. Some of them prefer to be left alone, others - to be diagnosed all the time. Generally, the younger the patients are, the more they demand tests. It gives them a misleading feeling of being safe. They believe that a huge volume of information is the key to success. 
In fact, a lot of examinations and tests create a white noise effect. The results will sometimes be inconsistent. There is actually a certain optimum threshold of tests that provides grounds for making the right decision. Once that threshold is exceeded, more tests imply more chaos.
There are reports (on patients’ consent to surgery) showing that we take decisions on the basis of 3-4 pieces of information. This is sufficient for people to make even major decisions. 
Putting that in a doctor’s context, you can say that there is no need to accumulate a lot of information. Being a good medic means that you take as many tests as are necessary and you draw conclusions from the results of such tests.

What damage is done by defensive medicine?

The system is always strained by that. Our healthcare system is extremely overburdened. Some tests are hard to get, such as MR. Patients who get their referrals for defensive reasons make the lines and the waiting times longer for those with actual medical indications. 
The patients themselves suffer, too. Referring them for unnecessary tests, even non-invasive ones, extends the time needed for the ultimate diagnosis and starting treatment. Unnecessary invasive examination, such as angiograms, may cause even more damage, as they may involve complications. 
I know of a patient who got a coronary angiography before a major cancer surgery. That patient had had a myocardial infarction 20 years earlier. His physical performance was great. According to the guidelines, the surgery as such is not an indication for a coronarography in such a case. Yet it was given to that patient. As a result, the cancer surgery had to be postponed by 4 weeks. The surgery went out smoothly. But one month after the surgery, metastases were found in the patient’s liver. Would they have occurred had the cancer surgery been done earlier? We can’t know that. The extension of the time before surgery could have been completely irrelevant as well. There are no perfect solutions. You need to follow your common sense.

Let’s now return to the matter of lawsuits. Statistics show that the more tests are conducted at a clinic or hospital, the fewer malpractice suits are filed. Is this true?

The data differs according to country. Details of U.S. hospital networks indicate that the risk of lawsuit was lower at those hospitals where more diagnostic tests were taken than at those giving fewer tests. However, there is a stronger correlation between the number of lawsuits and communication disruptions. My experience is that sometimes even greatest malpractice would go unnoticed whereas some minor failures in treatment will end in court. And these lawsuits are largely based on doctor-patient communication issues. The complaints are mainly about families being offended, or someone not having been informed of something... We were saying that defensive medicine may give the patient a feeling of safety. But this is only fake safety. The key to a good doctor-patient relationship is good communication, discussion, responding to the patient’s needs and replying all their questions. Ordering more tests is a rather mechanical attempt at winning the patient’s trust. It’s a shortcut.

Interviewer: Iwona Kołakowska
Photo by Michał Teperek
University Communication and Promotion Office