Barry Lyons and Mary Donnelly discuss a study funded by the Medical Protection Society (MPS) Foundation aimed to develop a greater understanding and awareness of defensive medicine and its impact on doctors’ wellbeing
Defensive medicine is the subject of at least 1,000 published journal articles. These papers come from a wide range of countries and medical specialties, and from a number of quite different academic disciplines including health policy, economics, moral philosophy, law and, most frequently, medicine. However, despite this extensive analysis, the prevalence, impact, or even existence, of defensive medicine, remain controversial.
The idea that doctors might be practising defensive medicine first emerged in the US in the 1970s, when it was linked to the growth in medical negligence claims. The basic understanding was that physicians were potentially engaging in practices aimed at reducing their possibility of being sued. When examining the spiralling costs of healthcare in 1994, the US Congress identified two types of defensive medicine behaviours:
- Avoidance – avoiding high-risk patients or procedures
- Assurance – ordering extra, and likely unnecessary, diagnostic tests or procedures
Subsequently the Bush administration set about a process of tort reform, having directly linked a broken system of litigation with increased costs of care, diminished access to treatments, and impaired efforts at improving patient safety.
However, our understanding of the link between defensive medicine and litigation has gradually changed. While economists and policy experts did track some changes in behaviour and costs with legal amendments, such as the capping of awards in some US states, it became clear that this was neither linear nor uniform.
Defensive medicine also appears to have become a prevalent feature of practice outside of the US. For example, one survey of more than 4,000 healthcare professionals in the UK, conducted by MPS in 2017, found that:
- 75% said the fear of being sued has resulted in them ordering more tests or making more referrals
- 41% said it has resulted in them prescribing medication when not clinically necessary
- 2% said it impacts on the services they feel able to offer
- 28% said it has made them hesitant to undertake intimate examinations.
The reasons for this might be found in the widespread growth of surveillance and scrutiny of medical practice, and in the number of avenues available for complaint, investigation and the determination of accountability that have developed since the 1990s. And each of these carries the additional risk of exposure through mainstream or social media, and the consequent threat of personal or reputational harm.
But often lost in all of the quasi-legal dialogue around defensive medicine is the personal stake that many doctors have in the outcome of their patients’ illnesses. The fear of ‘missing something’ which subsequently has a negative impact on the patient’s health can have profound consequences for the clinician, independent of the possibility of any external accountability.
A deep sense of empathy alone carries personal costs. But medicine is also often tied to repeatedly reinforced notions of perfectionism, where getting something wrong has implications for personal evaluations of self-worth, and for negative assessments of one’s capabilities as a doctor. Perceived failure is attached to feelings of guilt and shame, emotions that are exacerbated in organisations that are reflexively critical, or by colleagues that are unsupportive. Under any of these circumstances a tendency to test for all clinical possibilities is heightened.
One of many questions that remain about defensive medicine is whether it occurs due to doctors requesting investigations in order to engender personal assurance, or to avoid the possibility of painful self-conscious emotions.
A notable feature of the literature on defensive medicine is that the concept is viewed very differently depending on the discipline. For instance:
- Medicine: Defensive medicine is widely practised and is a rational response to the actual risks confronting physicians. It has both fiscal and opportunity costs and, despite being rational, is bad for medical practice, for patients, and for the health system. It also impacts on clinicians’ willingness to disclose mistakes (to patients, colleagues, and organisations), and to contribute to patient safety learning and other initiatives.
- Economics and policy: One goal of health policy is to identify how to balance quality, accessibility, and affordability in care provision. There is a general acceptance that defensive medicine is widely practised. Thus, the focus is on how much it costs, what changes we can make to reduce these costs, and how and whether those changes would work. However, it has proven difficult to quantify the economic costs of defensive medicine.
- Moral philosophy: Defensive medicine is ‘indefensible’ medical practice. It is ethically iniquitous as doctors place their self-interest above the needs and interests of the patient.
- Law: There is scepticism that defensive medicine is actually a real thing. It is frequently noted that the data is empirically unconvincing. Thus, there are references to ‘imagined’ defensive practices as ‘spectral’, a ‘bogeyman’, a ‘red herring’, and a ‘jaded cliché’. There are also arguments that defensive medicine may actually enhance standards of care.
One of the odd things about all of this analysis is that despite the volume of academic output there is no uniform definition of defensive medicine, no clear agreement on what the constituent elements might look like, nor on what the triggers might be. This deficiency makes it difficult to collate or systematically review studies, and is plausibly at least partially responsible for the varying interpretations between academic disciplines.
In all of this, the legal analysis is correct in highlighting a number of problems within the medical/economics literature, particularly that the research agenda has tended not to disaggregate the intensity of defensiveness, the causes of defensiveness, or any positive impact it might have.
But what the legal perspective fails to appreciate is that defensive medicine is a reality for doctors – an everyday consciousness of vulnerability that may impact on their relationships with patients, families, and institutions.
One of the under-researched aspects of defensive medicine is the role of organisations, particularly the role of management structures and institutional culture in creating defensive medicine practices. It would seem reasonable that physician trust in their own organisation and its accountability systems may directly impact on patterns of practice, although this has never been well evaluated.
Similarly, where the ‘costs’ of defensive medicine have been assessed, these have been largely determined by economic calculation, a counting of the overuse of scarce resources, and a reflection on the possible benefits or harms that might accrue to an individual patient.
We suggest that this misses the important point of how defensive medicine might impact on the psychological and emotional state of the practitioner. The overriding medical narrative of defensive medicine is that making decisions which are self-protective rather than patient-centred is ‘demoralising’. This may have affective costs for the clinician over time, impacting on their wellbeing, and potentially adding to mental health burdens such as anxiety, depression, and burnout.
But it is also likely that the narrative is more complicated than this; that defensive medicine might induce positive or negative feelings in a clinician (such as reassurance or guilt), possibly at the same time.
Defensive medicine may also impact on trust between parties in the clinical relationship in unpredictable ways, as it forces patients to endure potentially unnecessary interventions, but also addresses increasingly frequent requests for everything possible to be done.
Thus, the story of defensive medicine is incompletely told, and is often recounted in unnuanced, or occasionally apocalyptic, terms. The various academic perspectives all have something meaningful to say, but we think that defensive medicine cannot simply be dismissed as a spectre or a jaded cliché.
What is needed is a better-quality engagement with defensive medicine in order to bridge the gap between the various perspectives. Our research hopes to do just this, and we are thankful to have the support of the MPS Foundation – a global not-for-profit research initiative that invests in research into patient safety and the wellbeing of healthcare professionals – to progress this work. The survey has generated almost 3,000 responses from clinicians around the world, and we look forward to sharing our findings in due course.
