Leaders Weigh in on Defensive Medicine

This article appears in the April 2012 issue of HealthLeaders magazine.

Our annual Industry Survey shows that 8% of healthcare leaders count malpractice insurance and litigation among their organization's top three drivers of healthcare costs. And 58% of physician leaders say they have, in the past year, ordered a test or procedure for primarily defensive medicine reasons. How serious is this issue and what can healthcare leaders do about it?    

Alan Fisher, MBA, FACHE
CEO, Advanced Specialty Hospitals of Toledo, OH
Defensive medicine remains a very serious issue, but our focus can't be on practicing defensive medicine. We need to be proactive in looking at what can be done from a quality standpoint first. If we practice good-quality healthcare, that should minimize the unnecessary and sentinel events.

At our hospital, we do a thorough examination of our benchmarks and look at those items that can be prevented. For example, if we have issues of back transfers, because we are a long-term acute care hospital, it begs the question: What could we have done proactively to avoid this? In the past couple of years, more specifically within the past 12 months, we have seen an increase in quality by being more proactive in our practices, resulting in a decrease in practicing defensive medicine.

We can practice defensive medicine all we want to, but if it is for the wrong reasons—and that is not to provide good outcomes for patients—then we are hurting both patients and ourselves.

Helen M. Kuroki, MD
Vice President of Medical Affairs
Riddle Hospital, Main Line Health System, headquartered in Bryn Mawr, PA

As physicians and healthcare leaders, patient safety should be our primary concern when treating each and every patient. Unfortunately, we find that many physicians are forced to practice "defensive medicine" to avoid the possibility of being charged as negligent in a lawsuit. This practice comes in many forms, from ordering extra tests to performing additional procedures on patients.

While the threat of medical malpractice presents an enormous problem for physicians from the standpoint of both cost and reputation, it is often the patient who is impacted, spending time and money to undergo procedures that may not be medically necessary.  As a result, the United States has spent billions of dollars in avoidable healthcare costs.

In general, I believe medical malpractice is in need of an overhaul. It is a selective and expensive process that does not allow fair representation for all cases, does not provide appropriate and timely compensation to deserving patients and families, and does not address the critical issue of physicians who are repeatedly sued for the right reasons and should no longer be permitted to practice medicine.

As healthcare leaders, change will only come if we work together and with our legislators to insist on the enactment of meaningful tort reform.

Lawrence Shombert, MD
Radiation Oncologist
Peninsula Regional Medical Center, Salisbury, MD

I don't know that we order tests for defensive medicine, but whenever there is a doubt, you don't take the risk. If you really believe your risk of being sued was a whole lot less you might err on the side of clinical judgment.

With all the debate about tort reform I don't know if the answer is that simple. It is definitely a move in the right direction. But even if you changed it tomorrow, physicians are still going to have the mentality of being careful. Some doctors are extremely cautious because they want to do the right thing, rather than to just protect themselves. I don't think we do anything that is unnecessary; we just do maybe more studies than we have to in order to be sure of our clinical decisions.

You can complain all you want about unnecessary studies, but if you can't protect the physicians, you can't change it. Doctors can justify a study clinically because any good plaintiff's lawyer is going to justify it clinically. "Couldn't you have ordered that test, doctor?"

You can't come down on radiologists because all they are doing is a study that has been requested by another physician. It is not their decision to say clinically whether it is warranted or unwarranted. They bear the brunt of "You guys are overusing the machine." Nonsense! We were asked. We can't tell you what is a valid request and what is not.

Susan L. Davis RN, EdD
CEO
St. Vincent's Health services Bridgeport, CT

The breakdown: The problem of defensive medicine is very real, and I am honestly surprised that only 58% of physician leaders said they had practiced defensive medicine in the past year.

The drivers: There is so much information out there now for healthcare consumers on the Internet, and more often than not they come to physicians with a test that they believe they need to have done given the symptoms they have. It is a very real concern for physicians because while they may not believe the test is appropriate or needed, they feel compelled to order it because of the chance that they may be wrong. It may be only a 1% or 2% chance that they are wrong, but they are exposing themselves to litigation.

The solutions: The tough part is what do you do about it? Many would say that there is a tremendous need for malpractice reform. That is important, but that is not the only thing we need to do to address this issue. When you look at it on a broader scope, there are two things that come to mind: One is practicing evidence-based medicine and having the relationship with the patient that enables the physician to explain why that test is not needed or appropriate for the symptoms the patient has presented. The second solution comes with information technology: connecting all of the providers for that patient on the continuum of care so physicians see what has been done for the patient either at a hospital or by another provider. When those results are available, the physician is able to explain to the patient what the results of the test were and why duplicative testing is not necessary and in fact not good for them.

This article appears in the April 2012 issue of HealthLeaders magazine.

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