Defensive Medicine vs. Cost Consciousness: How Doctors Actually Make Decisions

Last Updated May 5, 2010 6:00 AM EDT

Under prodding from accreditation organizations, U.S. medical schools are finally starting to teach future physicians about the cost consequences of their medical decisions. But medical students and resident doctors are also being taught to practice "defensive medicine" to avoid malpractice suits. The conflict between those two directives says a lot about why costs are out of control and why the efforts of medical schools to change doctors' attitudes may not bear much fruit.

In a recent poll, 83 percent of doctors aged 25-34 said that, in medical school or residency, a physician or mentor had advised them to order tests and prescribe treatments that might be unnecessary to protect themselves from being sued. In contrast, only 63 percent of doctors aged 35-44 gave that response, and the numbers declined with age, dropping to 19 percent for practitioners 65 or older. What this seems to indicate is that, even as the pressure on doctors to contain costs grows, the countervailing pressure to do everything that might be of any value is increasing even faster.

Of course, liability fears aren't the only reason for the overuse of healthcare resources. Patients want the moon, and it's an easy call for doctors to maximize their income by doing more for them. In a recent New England Journal of Medicine essay, Molly Cooke also points out that the culture of medicine emphasizes the need to focus on whatever might benefit the patient, regardless of cost. But this is a false dichotomy, she notes, because physicians are always making cost-benefit decisions, with or without patient participation.

We makeall kinds of choices in caring for patients; some involve denyingcare that patients perceive as -- and that might actuallybe -- beneficial. Given that we make value-based decisionsabout the deployment of other finite resources, such as ourtime and the use of beds in the intensive care unit, why notabout costly treatments? In fact, numerous studies in the UnitedStates and Europe confirm that bedside rationing of care iscommon practice.

Good, compassionate physicians also consider the cost of care when they prescribe drugs or order tests in non-life-threatening situations. For one thing, they know that generic drugs are usually as good as brand-name medications; for another, they realize that if patients can't afford a drug or a test, they'll pass, and may not return for a follow-up visit.

But in the course of my healthcare reporting, I've run across doctors who had no idea what anything cost. Sure, they realized that an MRI was more expensive than an x-ray; but what it might cost a patient with skimpy or no insurance just wasn't on their radar screens. In fact, they were often unaware of what kind of coverage a patient had when they walked into an exam room.

Unfortunately, even if medical schools try to change this dynamic, their students are likely to forget that lesson and remember the story about the physician who got sued because he didn't run the fifth test on the patient who seem to have diagnosis X but actually had Y. For a generation raised on the TV show House, the moral is that it's always better to do more than to miss something in one out of 1,000 cases.

Reform of the malpractice laws -- which are more punitive to American doctors than to their counterparts in other countries -- would undoubtedly dampen the urge to practice defensively. But the real game changer would be a realization by both doctors and patients that we simply can no longer afford low-value medicine.

Image supplied courtesy of Periodic Table, Too.

  • Ken Terry

    Ken Terry, a former senior editor at Medical Economics Magazine, is the author of the book Rx For Health Care Reform.