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:
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.
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.
Several factors contribute to the prevalence of defensive medicine:
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:
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.
Not necessarily—some defensive actions may inadvertently catch serious conditions, though this is not their primary intent.
Reforms include improving malpractice systems, enhancing physician education, and reducing the fear of litigation.
It is estimated to cost the U.S. healthcare system between $46 billion and $300 billion annually.
Less experienced physicians tend to practice more defensive medicine due to knowledge gaps and fear of litigation.
While it exists globally, it is particularly prevalent in the U.S. due to its highly litigious healthcare environment.