MEASURING DEFENSIVE MEDICINE USING CLINICAL SCENARIO SURVEYS

For more than two decades, advocates of malpractice system reform have claimed that the most damaging and costly result of the U.S. medical malpractice system is the practice of defensive medicine, in which phy sicians order tests and procedures primarily because of fear of malpra ctice liability. In this article, we discuss the issues raised by diff erent definitions of defensive medicine and propose a working definiti on to guide measurement of the concept. We also consider the strengths and weaknesses of available approaches for measuring defensive medici ne. Finally, we describe an empirical approach to measuring defensive medicine using clinical scenario surveys. The results suggest that,if physicians actually practice as they say they would in these surveys, defensive medicine does exist, although not to the extent suggested by anecdotal evidence or direct physician surveys. The results also sugg est that defensive medicine varies considerably across clinical situat ions. In all of the scenarios, many physicians chose aggressive patien t management styles even though conservative management was considered medically acceptable by the expert panels that developed the scenario s. In most cases, medical indications, not malpractice concerns, motiv ated clinical choices. Our results highlight the limitations of survey s as a method of measuring the extent of defensive medicine. The impli cations of managed care and health care reform for defensive medicine are also discussed.