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How can we differentiate between defensive medicine and “good” medicine?

By Anupam B. Jena, MD, PhD to Defensive Medicine


How can we differentiate between defensive medicine and “good” medicine?

Our guest on Healthcare Matters is Anupam B. Jena, MD, PhD, one of the authors of the study Physician spending and subsequent risks of malpractice claims: an observational study, which was published in The BMJ in November 2015. Dr. Jena sat down with Healthcare Matters to discuss the study's results, methods and limitations as well as its implications for research on defensive medicine and healthcare spending. Dr. Jena details how the study shows a correlation between increases in physician spending and a lower likelihood for that physician to be subsequently sued for malpractice. Though the study has several limitations which are addressed during the interview, it helps to shed light on important aspects of healthcare spending, the doctor-patient relationship and the difference between appropriate healthcare spending and defensive medicine. In Part VI of our interview, we discuss how we can begin to parse out the difference between defensive medicine and "good" medicine. This is the sixth part of our interview with Dr. Jena. To see the full interview, click here. To view each portion of the interview separately, please use the links below.

  1. Does Defensive Medicine "Work"?
  2. Greater use of Resources vs. Defensive Medicine: What's the Difference?
  3. The Link between Physician Spending and Medical Malpractice Claims
  4. Medical Malpractice Claims and the Doctor-Patient Relationship
  5. Physician Spending, Patient Outcomes and Future Research
  6. How can we differentiate between defensive medicine and “good” medicine?
  7. Fee-for-Service vs. Outcome-Based Models and the Effect on Healthcare Costs
  8. Could Defensive Medicine Actually Lower Medical Malpractice Claims?
This interview is brought to you by Cunningham Group, the Medical Malpractice Insurance Specialists.


Mike Matray: I had the opportunity to interview Dr. Richard Anderson on this program. Dr. Anderson is the CEO of the medical malpractice insurer The Doctors Company, and considered a foremost authority on defensive medicine. We discussed your study, and he had the following to say:

“Using a very sophisticated statistical analysis, the authors found data that they believe supports the notion that defensive medicine does reduce liability. And here I’m not so sure that that’s true. Again, if you take my definition of defensive medicine, a test, procedure or therapy that is ordered by the physician primarily to protect themselves from liability rather than because of its diagnostic or therapeutic utility, it can’t be true. In other words, if it is the right test or therapy to order in the first place, then it wasn’t defensive. Then ordering a test that isn’t the right treatment is not going to reduce your liability. So almost by definition, what they say can’t be true, but it shows how difficult it is to separate all of these factors out.”

Would you agree with that statement?

Dr. Jena: So actually, I couldn’t agree more. I think he hit the nail on the head. Dr. Anderson’s definition of defensive medicine is I would say, is the widespread definition of defensive medicine. Defensive medicine, again, is additional spending that delivers no benefit to patients, but just cost to healthcare system money. And all we see in our study is that physicians who do cost the healthcare system more money get sued less often. And without, unfortunately, looking at outcomes, and that is something that we’re doing right now in subsequent work, without actually measuring whether or not the outcomes of these patients was better or not, it’s really impossible to say whether or not this is truly defensive or not.

But that being said, I don’t want to sell our results too short. What we do find is that doctors who spend more get sued less often. And from an individual practitioner’s perspective, if you actually believe the results, it’s not entirely clear to me that they should be worried about whether or not it’s good medicine that’s driving this relationship, or whether it’s defensive medicine that’s driving the relationship. From the point of care perspective of a doctor, if you believe these results, then their only decision is that at the margin, “Should I order this test or not?” Not only could it give you more information that helps them make a better clinical decision, that’s possible, but there’s also this possibility that irrespective of whatever clinical insight I might get from this decision, it might actually be more reassuring to the patient that this test was appropriately done.

And so at the end of the day, I think it’s important to parse out these differences, whether or not this is wasteful spending/defensive medicine, or whether or not this is good medicine. But again, I think, what I take from this paper is that this is really the first attempt to do this, and to highlight how these two different databases can be used to answer a question I think is really a fundamental importance to medical malpractice.