AAOS Bulletin - August, 2005

Orthopaedists, other specialists ‘on the defense’

Nine out of 10 high-risk specialists routinely practice defensive medicine to prevent lawsuits, study finds

By Carolyn Rogers

Although the prevalence and characteristics of “defensive medicine” remain controversial, a study published in the June 1, 2005, edition of the Journal of the American Medical Association suggests the practice is more widespread than previously believed.

The May 2003 survey of more than 800 Pennsylvania physicians in high-risk specialties found that 93 percent “sometimes” or “often” practice defensive medicine in an effort to shield themselves from potential lawsuits. Defensive behaviors included ordering unnecessary diagnostic tests, prescribing more drugs than medically indicated, avoiding risky procedures, referring high-risk patients to another physician or refusing to treat the patient at all.

The physicians surveyed were all in high-liability specialties, including orthopaedic surgery, emergency medicine, general surgery, neurosurgery, OB/GYN and radiology.

‘Assurance’ behaviors

More than nine out of 10 respondents (92 percent) reported that they practiced one or more “assurance” behaviors—such as ordering unneeded tests, performing unwarranted diagnostic procedures or referring patients for unnecessary consultations—for the purpose of deterring patients from filing liability claims, or persuading the legal system that the standard of care was met.

Imaging studies overused

Fifty-five percent of orthopaedic surgeons who reported their most recent act of defensive medicine described ordering computed tomography, magnetic resonance imaging (MRI) or radiography in clinically unnecessary circumstances. Excessive use of imaging technologies was also cited by more than half of emergency physicians and neurosurgeons who reported a recent act of defensive medicine.

Other specific “defensive acts” reported by orthopaedic surgeons included referring a patient to another physician (19 percent); ordering additional tests (14 percent); and prescribing additional drugs (6 percent).

Orthopaedists most likely to avoid high-risk procedures…

“Avoidance” behaviors—in which doctors avoid situations or patients that are perceived to carry a higher risk of litigation—were also widespread. One-third of specialist physicians reported frequently avoiding certain procedures or interventions. Orthopaedic surgeons were especially likely to report that they did so “often”—42 percent.

In fact, more than half of orthopaedists reported that they have stopped performing specific procedures altogether, or plan to stop within the next two years. These “high-risk” procedures include spine, neck or back surgery; revisions; joint surgery and other, unspecified surgeries. In addition, more than one-quarter of orthopaedists said they no longer perform emergency or trauma surgery, or plan to stop within the next two years.

…and patients

Patients are considered “high risk” either because of their clinical complexity or personal propensity for litigation—such as children and patients covered by workers’ compensation and medical assistance. Nearly 40 percent of all specialists reported that they “definitely will/already decided to” avoid caring for high-risk patients. This response was significantly more common among orthopaedic surgeons (57 percent) compared with other specialists.

In addition, 17 percent of orthopaedic surgeons reported that they have stopped practicing orthopaedics altogether because of liability concerns, or plan to stop practicing within the next two years.

Causes of defensive practices

Two subjective measures of liability experience—physicians’ confidence in the adequacy of their liability coverage, and their perceptions of premium burdens—were the strongest predictors of the defensive practices identified in the study.

Specialist physicians who lacked confidence in their coverage were more than twice as likely as other specialists to order unnecessary diagnostic tests, refer patients to another physician unnecessarily, suggest invasive procedures that in their clinical judgment were not needed, and avoid risky procedures and high-risk patients.

Those specialists who perceived their premium burden as extreme were 50 percent more likely than other specialists to over-prescribe medication, refer patients to another physician unnecessarily and order unnecessary diagnostic tests.


“The prevalence of assurance behavior, coupled with the unit of cost procedures typically ordered (eg, MRIs), lends weight to arguments that the total cost of defensive medicine is substantial,” wrote the researchers, who were from Harvard School of Public Health in Boston, and Columbia Law School in New York City.

Furthermore, defensive use of technology is self-reinforcing, they noted. The more physicians order tests or perform diagnostic procedures with low predictive values or provide aggressive treatment for low-risk conditions, the more likely such practices are to become the legal standard of care.

“Efforts to reduce defensive medicine should concentrate on educating patients and physicians regarding appropriate care in the clinical situations that most commonly prompt defensive medicine, developing and disseminating clinical guidelines that target common defensive practices, and reducing the financial and psychological vulnerability of individual physicians in high-risk specialties to shocks to the liability system,” the researchers concluded.

For more information visit JAMA's Web site and archives.

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