You may have missed this when it first appeared. Experts from Harvard and the University of Southern California say assumptions made by some analysts that defensive medicine is not an important facet of the high cost of healthcare may be wrong.

Those assumptions were based on data showing that malpractice reforms instituted in some states did little to reduce healthcare spending.

According to the report from the National Center for Policy Analysis (NCPA) about an article in the Wall Street Journal, defensive medicine (“ordering some tests or consultations simply to avoid the appearance of malpractice”) is just as common in states with both low and high malpractice risk. In fact, about 2/3 of doctors in both the low- and high-risk states admitted to practicing defensive medicine.

My experience is that the 2/3 figure is probably a very low estimate. Just about every physician I know has ordered a test or consult strictly to “cover his/her/their asses” if something were to go wrong. I am certain it happens tens of thousands of times per day in the US.

I can cite many examples of defensive medicine:

A young man with chest pain arrives in the ED. After taking a history and examining the patient, the ED MD is 99.95% certain that the patient did not have a heart attack or a pulmonary embolus. But he’s a little short of breath. He remembers a case of a fatal PE with only minimal shortness of breath, orders a blood gas and CT angiogram of the chest.

A young girl comes in with lower abdominal pain, no GI symptoms, no fever. The pain improves over a couple of hours. Could she have appendicitis? Very doubtful —but yes, it is possible. Will she get a CT scan? Yes. People who get sent home from EDs and return with appendicitis often have complications. Complications = lawsuit (delay in diagnosis).

A surgeon readmits a patient with a wound infection after a colon resection. The wound is opened widely and packed. The culture comes back “E. coli sensitive to every antibiotic.” The surgeon knows that the treatment of a wound infection is drainage without antibiotics unless there are systemic signs of infection (fever, elevated WBC, tachycardia). Just “to be safe” he asks an infectious disease doctor to see the patient.

In my opinion, defensive medicine is ubiquitous and not going to go away soon. Healthcare costs will continue to rise.

What can be done about it? If you believe the NCPA article, tort reform is not the answer. Then what is the answer?

I think reducing defensive medicine would take a massive culture shift that is unlikely to happen any time soon. Patients would have to be educated about expectations. For example, despite what the so-called “never events” list says, some complications are not 100% preventable.

And it might require a whole new generation of physicians with a different outlook before meaningful change could occur.

Skeptical Scalpel is a recently retired surgeon and was a surgical department chairman and residency program director for many years. He is board-certified in general surgery and a surgical sub-specialty and has re-certified in both several times. For the last two years, he has been blogging at SkepticalScalpel.blogspot.com and tweeting as @SkepticScalpel. His blog averages over 900 page views per day, and he has over 5,900 followers on Twitter.

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