These days, a college student’s “simple stomachache” can generate thousands of dollars in health care costs. CBS News reported that a University of Richmond sophomore’s visit to the emergency room for abdominal pain resulted in an expensive computed tomographic (CT) scan that revealed nothing more than a “harmless” ovarian cyst. Her father was annoyed at the $8,500 bill. A physician, he claimed that her pain could have been diagnosed far more easily and cheaply with a “history, pelvic exam, and probably an ultrasound.” Similar situations arise in countless hospital emergency rooms around the country on a daily basis. Are physicians ordering too many tests, in part because they fear missing a diagnosis that could later result in a malpractice suit? How much does so-called “defensive medicine” cost the public? What can and should radiologists do about it?
Defensive medicine has been defined as the “ordering of treatments, tests, and procedures for the purpose of protecting the physician from criticism rather than diagnosing or treating the patient.” The Office of Technology Assessment has estimated that approximately 8% of diagnostic testing in the United States is consciously defensive. This figure amounts to tens of billions of dollars of health care spending. Other studies estimate that 5–9% of the annual US health care budget—which totals more than $2 trillion—is attributable to defensive medicine. Some observers of diagnostic practice have argued that ordering more tests when clinical suspicion is low or uncertain is merely likely to generate “pseudo-disease.” It has been estimated that 50% of women who will undergo mammography over the next decade will receive at least one false-positive mammography report, generating anxiety and possibly undermining patient confidence.
Defensive medicine in radiology may harm patients in other ways as well, by increasing cancer risk. Investigators have estimated that in years to come, 1.5–2% of all US cancers may be attributable to radiation from CT studies. To be sure, when a CT scan is medically justified, “the associated risk is small relative to the diagnostic information obtained.” Yet in such clinical situations as blunt trauma, seizures, and chronic headaches, researchers have suggested that physicians are ordering an excessive number of imaging tests. According to one poll of pediatric radiologists, perhaps a third of CT studies could be replaced by alternative approaches or not performed at all, leading to the widely quoted assertion that one-third of CT scans in the United States are “unnecessary.” Survey data suggest that defensive medicine may be very widespread. In Great Britain, 75% of psychiatrists reported instances of practicing defensively within the past month. A recent study of physicians practicing in Pennsylvania concluded that 93% of respondents practice defensive medicine. Among those who admitted to practicing defensively, 43% reported using imaging technology in situations where it was unnecessary.
What are the origins of defensive medicine? When the field of US medicine was in its infancy, a more paternalistic attitude pervaded medical culture, and physicians bore little financial liability for error. Physicians’ recommendations were seldom questioned, the profession of medicine was self-governed, and outcomes were not widely reported. In the current environment, society has become more risk-averse, a shift reflected in physician test-ordering patterns. As physician uncertainty increases, health care costs tend to rise. Of course, risk is both a scientific and a socially constructed concept, and we can legitimately question what level of risk aversion is appropriate. Studies have shown that changes in tort law coincide with changes in the behavior of health care providers. In one survey, more than 70% of radiologists reported that concerns about malpractice litigation led them to practice more defensively in such areas as mammography and ultrasound. There is evidence that radiologists’ assessments of future malpractice risk are probably inflated.
Aside from malpractice concerns, patient expectations are another factor underlying defensive medicine. Patients tend to want the best care available, and if they do not receive what they understand to be the latest and most technologically advanced option, such as digital mammography, they may feel that they are receiving substandard care. Ironically, the demand for the very best available care may be fueled in part by the rising cost of health care. When we take a loved one to the emergency department, we expect the physicians not to spare any expense. Adding to this tendency is the fact that out-of-pocket costs for insured patients are often low, decreasing the patient’s imperative to economize. Physicians may reason that adding one additional test will not make any substantial difference to a large health care insurer or government payer.
A related factor behind defensive medicine is the desire to be a hero. If physicians order a sufficient number of imaging studies in which the pretest probability of disease is low, they will inevitably pick up early-stage malignancies and other pathologies, earning them a reputation as a great doctor that a grateful patient may disseminate far and wide. Yet increasing the number of studies ordered, even if cost is not a factor, does not equate to an increase in the amount or quality of care. For one thing, it may overburden an already strained health care system and delay or even degrade diagnostic evaluations for patients whose needs are greater.
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