From divine profession to defensive medicine

The ongoing transition in the medical industry from the Divine Profession to Defensive Medicine is somewhat akin to sacrilege. Unfortunately, though, there is no denying that we are in this dark age wherein medical professionals often order tests or procedures to shield themselves from litigations.[1] In a survey[2] conducted with doctors, 91% agreed that excess tests and procedures are ordered as a means of self-protection against the looming threat of litigation. However, there lies another significant finding in this study that sheds light on the root cause of why Defensive Medicine encroached its way into this noble profession. A total of 90.7% of the medical professionals believed that being safeguarded from unwarranted lawsuits could decrease unnecessary recommendations of tests and procedures. It is food for thought: are medical professionals losing their integrity by indulging in this practice or are they simply overcompensating in an attempt to survive in the litigation-driven, new-age healthcare system? Decoding Defensive Medicine The term “Defensive Medicine” was first introduced in USA medical research literature during the late 1960s, and it has acquired numerous definitions over time. The common essence among all these is that the physician’s thought process while prescribing treatment or diagnostics is more geared toward the prevention of malpractice claims than patient care. It has further been bifurcated into two extremities, and both these adversely impact patients in their way. Negative Defensive Medicine is characterized by high-risk (such as multi-trauma roadside accidents) patients and procedures being avoided or transferred to other facilities.[3] At the other end is Positive Defensive Medicine, which has an overuse of resources and excessive diagnostics. An argument of ambiguity could be made here, for it is difficult to accurately categorize when resources are being smartly used or overused. However, the distinguishing line here is the mindset. If resources are not used to increase benefits for the patient and simply as the doctor’s safety measure, it becomes an instance of positive defensive medicine. However, is it possible to encompass such a broad concept with limitless implications into a concise definition? A study[4] confirmed the fluidity of this terminology, wherein European healthcare professionals had a different concept of defensive medicine. Along with avoidance of litigation, they engaged in this practice out of fear of overlooking a serious diagnosis, dissatisfying patients, and negative rumors or publicity that could ruin their careers. So far, the perception of defensive medicine has been developed based on a one-dimensional view. It was thought that avoidance of litigation was the sole determining factor for a doctor’s recommendations, however, the fact that they may be truly concerned with overlooking something or worried about failing their patients was overlooked. We also need to be cautious about this vicious cycle comprising the increasing number of lawsuits and instances of defensive medicine stems from a mistrust generated in patients against the medical industry at large. The Varied Reasons for Defensive Medicine It has been established that the primary reason for this practice is the avoidance of malpractice and negligence suits. Numerous statistics emphasize the magnanimity of this problem, and why it has become a leading trigger for defensive medicine. India has roughly 5.2 million cases of medical errors filed yearly,[5] whereas, in the United States of America, 34% of medical professionals[6] have been sued at some point in their careers. While many of these cases are undeniably in favor of the aggrieved patients, many others are frivolous and achieve nothing more than to malign the doctors and instill a fierce instinct of self-protection in them which drives them towards defensive practices in their subsequent cases. Doctors working in the emergency department refer the patient to a higher center to minimize the possibility of litigation but also to minimize the possibility of violence against doctors. More than 75% of doctors across the country have faced at least some form of violence according to a study done by the Indian Medical Association (IMA).[7] The Victims of Defensive Medicine Patients undeniably are the largest impacted victims of this practice. One of the defining criteria for it implies that the patient’s best interest is not the driving factor for medical decisions. This approach in itself defies the sanctity of the profession and fails to uphold the fundamental principles of healthcare, which dictate that patient care should be valued above all. If we consider positive defensive medicine, patients are forced to undertake unnecessary procedures and tests that greatly increase the financial burden on them. Cesarean deliveries are blatantly preferred over vaginal deliveries[8] and women are operated on even when it is not always required. Overprescribing of antibiotics has led to resistance development,[9] which reduces the efficacy of this treatment over time. There are also cases of harmful overexposure to radiation[10] due to incessant diagnostic imaging. All these are instances of positive defensive medicine, and its counterpart is equally damaging. When patients are simply refused admission or treatment due to complexities, they are denied their basic right to healthcare and this undermines the entire medical profession. However, the ill effects of defensive medicine plague more than just patients. The healthcare system at large suffers monetary losses owing to the incessant testing and procedures. A country like Italy places these costs in the primary category of healthcare waste, whereas the USA estimates that they account for 80% of the total annual costs for medical liabilities.[11] Healthcare institutions also face resource shortages and allocation problems, and they are compelled to hire more trained personnel or acquire more equipment and other materials in response to the higher number of tests and procedures being conducted. Ironically, physicians/medical professionals also attract the negative effects of defensive medicine. They are the perpetrators of it and not victims, however, they too stand a lot to lose because of it. They are at risk of intensifying the problem that they want to solve with this practice. There is much higher accountability placed on them to justify the extra tests and procedures, and they are also exposed to potential lawsuits regarding misdiagnosis. Ridding the System from Defensive Medicine It is evident now that defensive medicine is a blot on the honorable name that the medical field has rightfully earned. It compromises patient care and safety and intensifies the mistrust that has developed of late in their minds against physicians/medical professionals. The financial damage that it inflicts on hospitals due to the onslaught of tests and procedures threatens to cripple the system. Physicians are unknowingly making themselves more vulnerable to legal action by engaging in defensive medicine. It is the need of the hour to eradicate this practice and restore faith and honor in the industry. We have seen how the current structure of medical education contributes to this problem, and hence a possible solution can be found there too: Awareness about the practice needs to be generated for physicians to be more aware and conscious of when their acts might fall under this category. Medical legalities should also be taught in medical curriculums to clarify when and how physicians may be brought under legal scrutiny. Greater emphasis on developing practical, problem-solving skills. Training and mock sessions may be introduced that test medical students’ or resident’s abilities to analyze facts, understand the patient history, and make recommendations accordingly. The practice of keeping meticulous records and documents should be inculcated in all medical students/resident doctors to help validate their actions and offer insights into their thought processes while making decisions. This may also help doctors tackle the questions of patients or their family members and allow them to prove the authenticity of their work. If medical professionals know that they are backed by the system and organizations in case they are wrongfully blamed, this confidence will reflect in their work too. System and procedural reforms may achieve this: Better ways for medical complaints to be addressed and decided upon that do not entail doctors having to face courts for even frivolous matters. Internal committees or separate legal bodies with industry experts can be set up for a more streamlined process and to allow only valid and serious complaints to be turned into lawsuits. Protection and active representation for medical professionals against violence and overbearing patient demands. Widespread attempts should be made to establish the trust of patients in physicians and the healthcare system by promoting ethical practices and showcasing the good that comes from it instead of only representing the negative side. Additionally, eliminating ambiguity from laws will make a big difference. They should be drafted in a way that serves the best interest of every stakeholder. Patients should have strong remedies available for cases of genuine malpractice, and medical professionals/healthcare establishments should be protected from having baseless cases filed against them. The law needs to go deeper into the nuances of medical care and put down some clear clauses and guidelines. The legislature should closely work with professionals and experts who can ensure that fair, just, and sound laws are put in place. This will eventually be beneficial for the legal system since resources and manpower will not have to be directed toward cases filed out of anger or contempt that have no true validity. Conclusion In conclusion, to minimize defensive medicine, doctors, and medical organizations can adopt several strategies. Firstly, uninterrupted listening to patients and fostering open communication with patients is crucial; this builds trust and helps in managing patient expectations. Informed consent should be emphasized, ensuring patients are fully aware of the benefits, risks, and alternatives to treatments. Additionally, maintaining thorough and accurate medical records is essential for legal protection and continuity of medical care. Continuous medical education and training in the latest medical practices and awareness about legal requirements, legal issues can also help in reducing medical errors and improving patient outcomes. Implementing evidence-based guidelines and protocols ensures consistency and standardization in medical practice, which can help in reducing the incidence of medical errors. Peer reviews and audits can help identify areas for improvement and reinforce adherence to best clinical practices. Creating a supportive environment that encourages reporting and discussing near misses and errors without fear of punitive actions can lead to systemic improvements and enhanced patient safety. To keep the medical profession out of the Consumer Protection Act (CPA), it is important to engage in advocacy and policy-making processes. Medical organizations and professional medical bodies (such as Indian Medical Association, Association of Physicians of India, etc.) should work closely with legislators to develop regulations that recognize the unique nature of medical practice and provide adequate protections for healthcare providers. Establishing dedicated medical tribunals for handling malpractice claims, rather than subjecting them to consumer courts, can also help in addressing grievances more appropriately. By focusing on these strategies, the practice of defensive medicine can be minimized, leading to better healthcare outcomes and reduced legal pressures on medical professionals and these steps would help strengthening the doctor-patient trust and help improve image of medical profession among public and society. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.