What is defensive medicine?

Defensive medicine (DM) refers to medical practices undertaken primarily to avoid liability rather than to benefit the patient. The article, Defensive Medicine: A Bane to Healthcare," provides the following definition, "Defensive medicine in simple words is departing from normal medical practice as a safeguard from litigation. It occurs when a medical practitioner performs treatment or procedure to avoid exposure to malpractice litigation. Defensive medicine is damaging for its potential to pose health risks to the patient. Furthermore, it increases healthcare costs. Not the least, defensive medicine also paves way for degradation of physician and patient relationship."

As researchers in a 2023 qualitative study, published by BMC medical Ethics, explained, "DM manifests in both positive and negative forms, illustrated by instances like ordering unnecessary lab tests, imaging, or consultations, reluctance to admit high-risk patients, and avoiding high-risk procedures." 

It typically takes two forms:

• Positive defensive medicine involves performing additional tests, procedures, or consultations beyond what might be strictly necessary. This includes ordering "just to be safe" tests or referring to specialists even when clinical judgment might suggest they're unnecessary.
• Negative defensive medicine occurs when physicians avoid certain high-risk patients or procedures due to liability concerns, potentially restricting access to care for those who need it most.

As the Defensive Medicine article further explains: "Defensive medicine may be positive or negative, depending on the situation. The former includes performing unnecessary diagnostic tests and invasive procedure, prescribing unnecessary treatment and needless hospitalization. The latter comprises avoiding risky procedures on patients who could have benefitted from them, thereby excluding patients from treatment and hospital admission. Both practices are increasingly becoming professional behavior in medical practice, thus increasing the cost of healthcare and sometimes lowering the quality of the service provided."

Both forms stem from physicians' fears of medical malpractice claims, but their impacts on healthcare delivery differ.

The scope of the problem

Defensive medicine is not a small-scale issue. Studies suggest that between 75-99% of physicians admit to practicing some form of defensive medicine. According to a study on the types and reasons for defensive medicine, "In the USA, DM costs are estimated to be between $46 billion and $300 billion annually, which is about 3.0% of national health spending, a study of physicians caring for elderly patients estimated that DM costs ranged from 8.0 to 20.0% of total health costs."

Research consistently confirms the widespread nature of this practice. According to the article Defensive Medicine, a study conducted  in Pennsylvania among 800 physicians, revealed that "92% of physicians were found to be ordering imaging tests and diagnostic measures for assurance and 42% were eliminating high risk procedures and avoiding patients with complications." The same article notes that "Gallup and Jackson Healthcare in 2010 found 73% and 92% of private sector physicians, respectively, admitted practicing defensive medicine, which was high compared to 48% of government physicians."

Beyond financial concerns, defensive medicine changes the nature of healthcare delivery. When physician decision-making becomes clouded by liability concerns, the traditional focus on what's best for the patient can become secondary to what provides the best legal protection.

Root causes of defensive medicine

Several factors contribute to the prevalence of defensive medicine:

• Medical-legal environment: The United States has one of the most litigious healthcare environments in the world. According to an article by BioWorld, the U.S. has 350% more malpractice suits per capita than Canada and 50% more than the UK and Australia. With high rates of malpractice claims and potentially devastating financial consequences, physicians understandably take steps to minimize their legal exposure.
• Media coverage: High-profile malpractice cases receive media attention, heightening physician anxiety about similar claims against them.
• Rising malpractice insurance costs: Premiums for malpractice insurance have increased in many specialties, creating financial pressure that encourages defensive practices. A 2024 poll by the Medical Group Management Association (MGMA) revealed that 68% of medical groups reported an increase in their doctors’ malpractice premiums since 2022, with an average rise of 11%
• Documentation requirements: The burden of documenting every decision and rationale takes time away from patient care while reinforcing the mentality of practicing for the potential lawsuit rather than for the patient.
• Professional reputation concerns: As noted in the Defensive Medicine article while "the personal finances or professional status of most physicians is not affected by a lawsuit as they have malpractice insurance... some physicians show symptoms of anxiety, depression, behavior or personality changes due to reputational consequences that might undermine their professional career and respect."
• Medical experience level: Medical researchers, in the qualitative study, observed that "Physicians with lower experience and knowledge levels tend to request more para-clinical services to avoid complaints. Therefore, one of the significant reasons for the prominence of this issue in the health system is the reduced involvement of senior faculty members [in patient care]." 
• Insurance status of patients: The Defensive Medicine article points out another factor: "Insurance status of patients has also added to the keenness to use resources. It was clearly seen in various researches that hospital patients with private insurance stay in hospitals longer and receive many procedures compared to patients with Medicaid coverage or patients who lack health insurance."

Case study

An example provided in Defensive Medicine: A Case and Review of Its Status and Possible Solutions states that in 2004, a physician treated a patient with back pain and a leg abscess. The patient presented with a normal neurologic exam and what appeared to be cellulitis around a venous stasis ulcer. Based on clinical judgment and the relatively low rates of methicillin resistance at that time, he treated the patient with cephalexin and ibuprofen.

A year later, the physician was served with a lawsuit. He learned that he had missed an epidural abscess that paralyzed the patient below the diaphragm and contributed to his death nine months after the visit. The physician had treated the patient according to standard practice, and as noted in the case review, "Only the most defensive (or brilliant) diagnostician would have ordered an MRI" for this presentation. Nevertheless, the case was settled for $400,000.

Six years after the initial case, the physician saw another patient with atraumatic, nonspecific thoracic spine pain, a normal neurologic exam, and cellulitis on the leg. This patient had no risk factors for paravertebral infection, and under normal circumstances, he would not have ordered an MRI of the spine.

However, the memory of the previous lawsuit  influenced his medical decision-making. Despite his clinical judgment suggesting otherwise, the physician ordered an MRI primarily out of fear of litigation rather than medical necessity—a textbook example of defensive medicine, specifically "assurance behavior."

Surprisingly, the MRI revealed a positive finding. The patient received timely antibiotics and surgery and recovered well.

This case shows several aspects of defensive medicine:

1. The psychological impact of litigation on physician decision-making, even years after the event
2. The paradox that defensive practices can occasionally benefit patients, complicating the assessment of their true value
3. The complex interplay between clinical judgment and legal self-protection
4. The reality that defensive medicine is not always wasteful, though its primary motivation remains fear rather than patient benefit

The case also demonstrates how defensive medicine becomes self-reinforcing through experiences, where a defensive practice that would normally be considered unnecessary resulted in catching a serious condition. As the author notes, "Malpractice attorneys like to say they save more lives than physicians. While physicians might strongly disagree with the statement, the lawyer who represented the first patient certainly helped the second."

This experience aligns with research showing that in-patient providers with higher hospitalization costs had a lower risk of malpractice claims compared to those with lower costs , who faced a risk of claims annually—suggesting that in some contexts, assurance behavior can indeed be effective at reducing malpractice risk, even if it isn't always medically necessary.

FAQs

Does defensive medicine always lead to negative outcomes?

Not necessarily—some defensive actions may inadvertently catch serious conditions, though this is not their primary intent.

How can defensive medicine be reduced?

Reforms include improving malpractice systems, enhancing physician education, and reducing the fear of litigation.

What is the financial impact of defensive medicine in the U.S.?

It is estimated to cost the U.S. healthcare system between $46 billion and $300 billion annually.

How does medical experience affect defensive practices?

Less experienced physicians tend to practice more defensive medicine due to knowledge gaps and fear of litigation.

Is defensive medicine unique to the U.S.?

While it exists globally, it is particularly prevalent in the U.S. due to its highly litigious healthcare environment.