Running head: McVeigh– Defensive Medicine Essay 1 1 It has been said that the fear of medical liability drives healthcare providers, particularly physicians, to unnecessarily order diagnostic tests and to perform treatments and procedures that may not be necessary, simply to ensure that nothing is left undone. Is this in fact the case? Defend position on this premise using literature. Langley McVeigh, MHA, FACHE May 23, 2017 McVeigh - Defensive Medicine 2 Yes, defensive medicine is practiced in the United States. However, it is important to understand: (1) what impact it has on healthcare expenditures (2) to what degree does it occur (prevalence) and (3) if so, what can be done to prevent it? As an emergency services administrator for a Level 1 trauma center, experience has led me to understand the dynamic influencing physicians in their clinical decision making process. Ideally, this process should be void of non-clinical bias or influence. However, this is not the case in many circumstances. Physicians are considering risk and liability when ordering tests and procedures. This risk management, or risk mis-management, phenomenon is called defensive medicine. By definition, these occurrences are medical practices intended to exonerate practitioners from liability with limited or without medical benefit to the patient (Sethi et al, 2012). Physicians have been directed by health policy to provide value based care, but defensive medicine practice works against this care model. There have been studies conducted measuring physician attitudes towards tort reform and defensive medicine practices. While studies show physicians, especially high risk medical specialists, regularly practicing defensive medicine, the cost implications are unclear. Furthermore, proposed reforms to the medical tort system must be investigated. Some have proposed to completely do away with the medical tort litigation and insurance system, replacing it with a system similar to workman’s compensation models. While it may be a reflex mechanism to use cost as a metric to measure results of defensive medicine practices, patient outcomes and quality of life implications must also be measured. The patient is the one who is being subjected to additional and unwarranted procedures. McVeigh - Defensive Medicince 3 According to a survey of 2000 orthopedic surgeons in 2010 (Sethi et al, 2012), of the 1214 respondents, 96% admitted to have practiced defensive medicine by ordering labs, imaging studies, specialist referrals, and inpatient admissions. Many surgeons confided this was done to avoid malpractice claims. These prescriptions offered little no benefit to patient outcomes, and contrary to the current posture of value based practice in our health care system. This additional intervention is costly, at an inconvenience to the patient, and may carry additional health risk. As a reflex, one may think of ...

1. Running head: McVeigh– Defensive Medicine Essay 1
1
It has been said that the fear of medical liability drives
healthcare providers, particularly
physicians, to unnecessarily order diagnostic tests and to
perform treatments and procedures
that may not be necessary, simply to ensure that nothing is left
undone. Is this in fact the case?
Defend position on this premise using literature.
Langley McVeigh, MHA, FACHE
May 23, 2017
McVeigh - Defensive Medicine 2
Yes, defensive medicine is practiced in the United States.
However, it is important to
understand: (1) what impact it has on healthcare expenditures
(2) to what degree does it occur
(prevalence) and (3) if so, what can be done to prevent it?

2. As an emergency services administrator for a Level 1 trauma
center, experience has led
me to understand the dynamic influencing physicians in their
clinical decision making process.
Ideally, this process should be void of non-clinical bias or
influence. However, this is not the
case in many circumstances. Physicians are considering risk and
liability when ordering tests
and procedures. This risk management, or risk mis-management,
phenomenon is called
defensive medicine. By definition, these occurrences are
medical practices intended to
exonerate practitioners from liability with limited or without
medical benefit to the patient
(Sethi et al, 2012). Physicians have been directed by health
policy to provide value based care,
but defensive medicine practice works against this care model.
There have been studies conducted measuring physician
attitudes towards tort reform
and defensive medicine practices. While studies show
physicians, especially high risk medical
specialists, regularly practicing defensive medicine, the cost
implications are unclear.

3. Furthermore, proposed reforms to the medical tort system must
be investigated. Some have
proposed to completely do away with the medical tort litigation
and insurance system,
replacing it with a system similar to workman’s compensation
models. While it may be a reflex
mechanism to use cost as a metric to measure results of
defensive medicine practices, patient
outcomes and quality of life implications must also be
measured. The patient is the one who is
being subjected to additional and unwarranted procedures.
McVeigh - Defensive Medicince 3
According to a survey of 2000 orthopedic surgeons in 2010
(Sethi et al, 2012), of the
1214 respondents, 96% admitted to have practiced defensive
medicine by ordering labs,
imaging studies, specialist referrals, and inpatient admissions.
Many surgeons confided this was
done to avoid malpractice claims. These prescriptions offered
little no benefit to patient
outcomes, and contrary to the current posture of value based
practice in our health care

4. system. This additional intervention is costly, at an
inconvenience to the patient, and may carry
additional health risk. As a reflex, one may think of the
additional testing or care as a good thing
because of the abundance of caution, but carries additional
implications for the health care
system in that now risks from these procedures must also be
managed.
A similar survey was conducted of neurosurgeons in 2011
(Nahed, Babu, Smith, & Heary,
2012). 76% of members of the American Association of
Neurological Surgeons responded to the
survey. Of these respondents, 64% considered malpractice
premium costs as a “major or
extreme” burden, consequently influencing 45% of the
respondents to eliminate high risk
procedures from their medical practice because of this concern.
The study broke down
defensive medicine practice into distinct categories: imaging
studies – 72%; lab tests – 67%;
specialist consultation referrals – 66%; and prescribing
medication – 64%. These practices were
done solely to avoid a perceived legal risk at a financial cost to
the system and at an expense of

5. patients’ health. This study concluded with two alarming
advices: this phenomenon (1)
increases costs; and (2) limits access to care of high risk
procedures. Cost and access (& quality)
issues are plaguing our health care system, begging for reform.
So not only are we seeing
physicians ordering additional procedures, but we also have
physicians avoiding procedures
that may be beneficial for patients because they carry
significant risk. Defensive medicine is
McVeigh - Defensive Medicine 4
usually perceived as practices that add additional interventions.
Fact is, access to valuable, but
risky, interventions are being limited too. Physicians are
thinking twice in prescribing or
operating on procedures that carry a risk of future litigation.
Defensive medicine may be
hindering clinical outcomes.
How much is the does the medical liability system cost the
nation? According to an
assessment conducted in 2008 (Mello, Chandra, Gawande, and
Studder, 2010), only $55.6

6. billion annually or 2.4% of total health care expenditures were
attributed to medical liability. In
absolute dollars, this may not seem like a minimal amount,
however, the actual percentage is
not as high as some political voices have expressed in the health
care debate. The authors of
this study concluded that measures to reduce these costs have
minimal impact on overall
health spending and recommended efforts placed on reforming
financing and reimbursement
methods to curb the overuse of ineffective procedures. A
continuation of a move away from a
fee-for-service system should help. If payments are bundled into
outcomes-based-best-
practices, additional utilization should be curbed. This still does
not address the psychological
and financial stresses physicians face by risk of litigation in the
current medical tort system.
Another study published around the same time (Thomas, Ziller,
and Thayer, 2010)
concluded from their analyses of the Congressional Budget
Office’s reporting on medical
specialty practices that the impact of defensive medicine on
health care costs are little. Savings

7. estimations predict that a 10% decrease in malpractice
premiums would result less than 1% in
total health care costs. While the phenomenon exists, the
significance of impact is
questionable. The authors of this study opined physician’s
perception of medical liability and
management of risk was more of a concern rather than the
actually statistics illustrating cost.
McVeigh - Defensive Medicine 5
Tort reform intends on lowering expenditures by controlling the
cost of malpractice
insurance (insurance covering indemnity payments of claims
plus legal costs). Reforms changing
the current medical tort systems could have an indirect affect on
healthcare spending by
removing the incentive to providers to order additional tests,
medications or procedures to
avoid litigation. If physicians do not have pressure to manage
legal risk in practicing medicine,
they would be free to practice as they are trained to as
clinicians.
The question then arises: what is going to prevent physicians
from being reckless or

8. malicious? If the pressure of litigation is stressing some
physicians to dot I’s and cross T’s, how
should the system continue to encourage and support physicians
to always do right by their
patients if there are changes to the risk management dynamic?
Also, what about patients that
are harmed by some practices. How can these victims be fairly
compensated for their losses?
There is a definite need for additional applied research studies
and policy discussions to explore
strategies to manage risk and ensure quality and accountability
of physicians.
The professional goal or objective of a physician is to heal
patients and not cause harm.
Technology and human practice have flaws and are not perfect.
These imperfections can cause
mistakes or even deliberate harm. The medical tort system may
have been well intended on
holding physicians accountable of their practices. However, the
system has shown to influence
them into exposing patients to additional risk, limiting access to
complex or risky care
interventions, and in the lease additional financial costs or
logistical inconvenience to the

9. patients. The health care delivery system must always strive to
do better and solve problems
that need resolving. We must explore reforms of our medical
tort system, not necessarily for
the financial cost implications, but also for quality
considerations.
McVeigh - Defensive Medicine 6
Medical liability drives physicians to practice defensive
medicine. These practices add
cost, add medical risk, and limit access. The delivery system
must always consider the Iron
Triangle of Health Care - cost, access and quality in deciding
the future of health care delivery.
Defensive medicine practices must be addressed in this pursuit.
Quddus - DHA Admission Essay 7
References
Mello, M. M., Chandra, A., Gawande, A. A., & Studdert, D. M.
(2010). National costs of the

10. medical liability system. Health Affairs, 29(9), 1569-1576.
https://doi.org/10.1377/hlthaff.2009.0807
Nahed, B. V., Babu, M. A., Smith, T. R., & Heary, R. F. (2012).
Malpractice liability and defensive
medicine: A national survey of neurosurgons. PLoS ONE, 7(6),
1-7.
https://doi.org/10.1371/journal.pone.0039237
Sathiyakumar, V., Jahangir, A. A., Obremsky, O. T., Lee, Y.
M., Apfeld, J. C., & Sethi, M. K. (2013).
The prevalence and costs of defensive medicine among
orthogpaedic trauma surgeons:
A national survey. Journal of Orthopedic Trauma, 27(10).
https://doi.org/10.1097/BOT.0b013e31828b7ab4
Sethi, M. K., Obremskey, W. T., Natividad, H., Mir, H. R., &
Jahangir, A. A. (2012). Incidence and
costs of defensive medicine among orthopedic surgeons inthe
united states: A national
survey study. American Journal of Orthopedics, 41(2), 69-73.
Thomas, J. W., Ziller, E. C., & Thayer, D. A. (2010). Low costs
of defensive medicine, small
savings from tort reform. Health Affairs, 29(9), 1578-1584.
https://doi.org/10.1377/hlthaff.2010.0146