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Defensive Medicine
*Corresponding author: Ashok Sangamesh Godhi, University Sains Malaysia / Karnataka Lingayat Education Society, International Medical Program, Belagavi, Karnataka, India ashok.godhi@gmail.com
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Received: ,
Accepted: ,
How to cite this article: Godhi AS. Defensive Medicine. Karnataka J Surg. 2025;2:55–57. doi: 10.25259/KJS_4_2025
Abstract
Defensive medicine is increasingly being practiced. In the west medical malpractice litigations are the main reasons for it. Where as in India physical assault on the doctors is an added cause for it. Defensive medicine manifests in various forms. It has adverse effects on the health economics and quality of health care.
Keywords
Adverse effects
Defensive medicine
Manifestations
INTRODUCTION
All professions have their own intrinsic risks. The main risks faced by medical professionals are consumer court cases, assaults on doctors, ransacking of the clinics and hospitals and contracting disease from the patients.
To cope with the risks, the doctors show a range of responses - at one end of the range are the doctors who develop anxiety and depression, and at the other end are the doctors who quit practice and retire prematurely or, at times, commit suicide.
The practice of defensive medicine is a strategy adopted by many doctors to avoid and deal with the professional risks.
Defensive medicine is described briefly under the following titles:
What are defensive medicine, prevalence, causes, methods, effects, prevention, and summary?
There are a number of definitions. The following is the best suited to describe defensive medicine.
Definition
Proactive/preemptive adoption of medical methods by doctors to defend themselves.
The definition has two terms which need to be further defined: Methods and Defend.
These methods are medical methods. Evidently there are nonmedical methods of defending which do not come under the definition of defensive medicine; they will be described later.
Defend
From whom? Defend from lawsuits and from patients and media.
PREVALENCE
There are a number of publications from the West on this topic.[1,2] According to some surveys, 98% of general practitioners in the UK and 93% of specialists in the USA practise defensive medicine.
The accurate prevalence in India is not known. It is quite likely that the prevalence in Indian doctors is not different from the West.
The surgical specialities are more vulnerable to the practice of defensive medicine than medical specialities, because surgical operation is an event which has no parallel in medical specialities. Patients often attribute adverse events in the postoperative period to surgical errors, and the surgeon is blamed. Clinicians belonging to specialities like emergency medicine, general surgery, neurosurgery, orthopaedics, obstetrics and gynaecology (OBG) and radiology are especially prone to practice defensive medicine.
Causes for defensive medical practice:
In the USA the main reason is malpractice lawsuits[1]; every year, about 195,000 deaths are due to alleged medical negligence. Many of them file cases in the courts and claim massive monetary compensation from the doctors and hospitals. This is a huge legal burden.
Doctors take malpractice insurance. The premium depends upon the speciality and varies from state to state. The neurosurgeons premium is the highest; they pay $100,000/pa in Texas and $300,000/pa in Pennsylvania. This amounts to almost 20% of their annual income. In the last 3 years there has been a 30% increase in the premium. The insurance premium is felt as a huge financial burden by most of the doctors in the USA. In spite of this heavy premium, many doctors in the USA feel that the coverage provided by the insurance companies is inadequate. That means they have to pay from their pockets part of the advocates fees and part of the compensation awarded by the courts.
The defensive medicine places a burden of about 62 billion dollars on the health care costs every year.
The Indian scenario is different from the West. In India, cases are filed against doctors in the consumer courts. Many consumer court cases are dismissed, and the doctors are exonerated. In some, the compensation is awarded. Both the exonerated and penalised doctors have to spend their valuable time in the consumer courts, where they experience agony and harassment. Medical indemnity insurance premium is less compared to the West. And it is not felt as a burden by the doctors in India. In addition, in India, doctors are assaulted, and their clinics and hospitals are ransacked by patients, relatives, and the mob. The media shows such events in a bad light. As a result, the doctors fear loss of their reputation. These are also the main reasons in India for the practice of defensive medicine.
TYPE OF PATIENTS WHO FACE PRACTICE OF DEFENSIVE MEDICINE
High-risk cases, operations, litigant-mindedness, argumentativeness, indecisiveness, emotionally unstable, bargaining, high-profile patients, suspicious/not trusting, and demanding patients are vulnerable to the defensive medical practice. But in practice, almost all patients bear the effects of defensive medicine.
Methods of Defensive Medicine
1. Over investigating the patients is the commonest method. Imaging tests like CT and MRI are the commonest among them. Electrocardiography (ECG), Echocardiography (ECHO), and treadmill test (TMT) have become routine preoperative investigations in many hospitals. Doctors justify them by saying they don’t want to miss anything/they are looking for some rare diseases. E.g., asking for a CT for a minor headache. CT for a clear-cut case of acute appendicitis. Magnetic resonance cholangiopancreatography (MRCP) for cholelithiasis, mammography for fibroadenoma, etc.
Advocates are fond of asking why something was not done, ignoring many things which are done. The law looks for errors of omission.
Clinical medicine, having taken a back seat in recent times, is another reason for such tests. Investigations are done to make up the lacunae in the clinical examination, hoping to detect something which may have been missed in the cursory clinical examinations.
2. Multiple cross-references: Referring the patients to multiple specialists is another common method of defensive medicine. This happens very frequently in the tertiary care multispeciality hospitals. Minor complaints - refer-cough pulmonologist, chest pain to a cardiologist, urinary complaint to an urologist, diabetes to an endocrinologist, and wax in the ear to an ear nose throat (ENT). References are made even before clinical examination. Our postgraduate residents pick up this practice during their residency.
3. Over prescription of medication: Overprescribing the medicines is a very common example of defensive medicine. E.g., broad spectrum expensive antibiotics for simple infections; postoperative antibiotic courses for simple surgery, e.g., excision of lipoma. General tonics for obese patients. Ignorance also may be the reason for this practice.
4. Undertaking invasive procedures without proper indication: Asking for colonoscopy for all haemorrhoids. Fine needle aspiration cytology (FNAC) for fibroadenoma and lipoma. Coronary angiography for nonspecific chest pain. These are some examples of invasive procedures of defensive medicine.
5. Hospitalization/intensive care unit (ICU) admission of patients who don’t need admission; this is happening very frequently.
6. Avoid high-risk cases: Many a high-risk cases are referred to the government. hospitals or tertiary care private hospitals. In the US, the malpractice insurance premium depends on the procedures one agrees to undertake. If a neurosurgeon agrees to take up all types of cases, his premium is very high. If he excludes some risky procedures, the premium is less. As a result, many surgeons are choosing safe procedures so that they pay less premium and are happy with the stress-free practice. The doctors don’t mind losing out on some of their income. Some doctors opt out and change their careers, while others take premature retirement.
ADVERSE EFFECTS OF DEFENSIVE MEDICINE -HEALTH ECONOMICS AND QUALITY OF CARE
The practice of defensive medicine has adverse effects on the health economics and quality of health care. In India, the patients who take treatment at government hospitals and those having health insurance don’t feel the pinch of defensive medicine. But it is a wasteful expenditure for the government. The others have to bear the expenses out of their pockets for defensive medicine.
As a result of defensive medicine, there is wasteful usage of health care resources. In the US, defensive medicine results in 60.2 billion dollars’ worth of wasteful expenditure every year.
Another important adverse effect of defensive medicine is reduced quality of health care. As a result of time spent in investigations and cross-references the initiation of treatment gets delayed. Invasive investigations can be injurious to some patients. Excessive medication has its own adverse reactions. Doctors refusing critically ill patients and risky operations also result in reduced quality of health care. This is the irony of defensive medicine: many years of rigorous training to acquire skills but unable to use the skills and knowledge.
REMEDY
Educate the public about the limitations of medical science. Medicine is an inaccurate science. Everything is not diagnosable, and everything is not curable. Complications are a part of the disease process. Death in certain situations is not preventable.
Formulate practice guidelines - everybody should follow the guidelines so that there is no variation in the management between the doctors and the hospitals. Everywhere, patients will be getting the same treatment for the same disease.
Clinical medicine needs to be strengthened at the UG and PG teachings and the CMEs and conferences.
Improve cost consciousness in the clinicians.
Reforms in the consumer protection act (COPRA): Decriminalise minor medical errors. Doctors should be members of consumer forums. Make a pretrial screening panel. Exonerated doctors are to be adequately compensated.
TORT REFORMS IN THE US
In many states of the US, there is legislation against frivolous lawsuits against medical practitioners. The TORT reform includes a cap on the claim amount ($100,000-250,000) and a cap on the advocates’ fees. This has resulted in a reduced number of lawsuits against doctors, reduced malpractice premiums and reduced ambulance chasers.
FUTURE CONSEQUENCES OF DEFENSIVE MEDICINE IN INDIA
If unchecked, less number of bright students are likely to take medicine and high risk medical specialities; quality of health care is likely to deteriorate; and insurance premiums will escalate. Only beneficiaries will be the labs, imaging and the pharma industry.
Doctors in India have to defend themselves not only from lawsuits but also from the media and, more importantly, from the unruly public. Video recording of counselling can protect doctors from lawsuits. Sensitive areas in the hospitals should be under CCTV surveillance. The gates of the casualty and ICUs need to be guarded by bouncers.
One has to wait and see whether the doctors in India will need personal bodyguards to protect from physical assaults. Of course they do not come under the definition of defensive medicine.
CONCLUSION
Defensive medicine is increasingly practised. It results in adverse effects like wasteful expenses, increasing health care costs, waste of health care resources, reduced access to health care, and reduced quality of health care. Educating the public and reforms in COPRA are needed to address the issue.
Ethical approval:
Institutional Review Board approval is not required.
Declaration of patient consent:
Patient’s consent not required as there are no patients in this study.
Conflicts of interest:
Ashok Godhi is on the Editorial Board of the Journal .
Use of artificial intelligence (AI)-assisted technology for manuscript preparation:
The author confirms that there was no use of artificial intelligence (AI)-assisted technology for assisting in the writing or editing of the manuscript and no images were manipulated using AI.
Financial support and sponsorship: Nil.
References
- Defensive Medicine in Neurosurgery: Does State-Level Liability Risk Matter? Neurosurgery. 2015;76:105-114.
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