Defensive medicine, defined as recommending and ordering tests and or treatments for the sole purpose of avoiding or mitigating potential litigation, has been vigorously examined. This approach to the practice of medicine has been heightened by the increasingly technologically sophisticated tests currently available, the medical information being generated by complex imaging, and information coming to patients on smartphones that exacerbates physicians’ defensive instincts. Defensive medicine may be driven by a host of variables, including generalized risk aversion, financial incentives, and an explosion of exponentials evolving in our world of artificial intelligence, robotics, quantum computing, nanotechnology, and robotics, but available data suggest the chief driver is a desire to avoid litigation.(1)
The Intersection of Medicine, Law, and Technology
Physicians are acutely aware of the menace of medical negligence. Medical malpractice occurs when a hospital, doctor, or other healthcare professional, through a negligent act or omission, causes an injury to a patient. The negligence might be the result of errors in diagnosis, treatment, aftercare, or health management. The patient must prove that the negligence caused the injury.(2)
Why are physicians so attuned to the negligence issue? A few obvious and simple answers include personal reputation, peer review, hospital privileges, National Practitioner Data Base, and malpractice premiums. The importance of reputation is obvious. The physician’s pocketbook also is a major factor through increased insurance premiums and loss of ability to practice medicine. Malpractice insurance premiums are shocking, with the yearly cost approaching $100,000, but that huge expenditure is dwarfed by the cost of a physician defending a lawsuit and by the healthcare system in general. The annual costs of defensive medicine in the United States exceed $46 billion.(3)
We live in the post–information age, in an age of information overload.
The power of the Internet has allowed the public access to a huge amount of information, but that does not ensure that the information is interpreted correctly or used intelligently. Such information may cause the overzealous patient to demand a wide array of tests in search of a diagnosis for a perceived medical disorder. This becomes almost inevitable as advances in software and hardware supporting medical practices seemingly reduce the likelihood of a missed diagnosis. This new paradigm also encourages physicians to become overly reliant on automated systems such as those that read ECGs and imaging modalities, because deviating from these increasingly accurate algorithms could result in a judgment of negligence in a courtroom. The impact of the use of artificial intelligence, quantum computing, and robotics in medicine has made the standard of care a moving target.
We are left at the crossroads where the increasing financial strain on the healthcare system and the well-being of physicians practicing medicine and attempting to avoid liability intersect. Certainly, any technological advance that increases the likelihood of making an accurate diagnosis and increases the legal standard for diagnostic accuracy should be welcomed from a patient-centric standpoint. That distinction is a real grey zone in the day-to-day practice of medicine, however, where we work in a world of uncertainty and exponential change. Often we hear we live in the information age. More accurately, we live in the post–information age, in an age of information overload. Most of the data available today have been created in the last three to five years. That figure will shrink to the last six months and soon to the last six days. A singularity is when there is so much knowledge that the world collapses upon itself. Physicians can feel the convergence of the exponentially growing available medical data on their daily practice life.
The question that we are left to solve is how do we figure out how to separate developments that are net benefit to our healthcare system from those that just add financial strain. That answer will reduce the need for defensive medicine.
There are things in life that incubate, and when they reach their tipping points, big changes occur. In medicine, physicians face those incubation and tipping points with the rapidly expanding technology that impacts the practice of medicine. The tipping points of artificial intelligence, nanotechnology, quantum computing, and robotics can be overwhelming as the field evolves, and all play a role in the increasing magnitude of defensive medicine. Until we identify how to address the issues of technology’s impact, the practice of defensive medicine will persist because of its burden on the finances of the healthcare system and the stress on physicians’ daily practice.
Sekhar MS, Vyas N. Defensive medicine: a bane to healthcare. Ann Med Health Sci Res. 2013;3:295-296.
Paterick TJ, Carson GV, Allen MC, Paterick TE. Medical informed consent: general considerations for physicians. Mayo Clin Proc 2008;83:313-319.
Rothberg MB, Class J, Bishop TF, et al. The cost of defensive medicine on three hospital services. JAMA Intern Med. 2014;174:1867-1868.