Building Rapport Can Ease Reliance on Defensive Medicine

In sports, a great defense can help win championships. Just ask the 2016 Super Bowl champ Denver Broncos.

In communication, however, getting defensive hinders relationships by impeding our ability to truly listen to what another person is saying.

But in healthcare, defensive medicine is not only costly to the healthcare system, it can be harmful to patients. And yet, the fear of missing something in a diagnosis leading to malpractice lawsuits is sufficient impetus for physicians to over-prescribe tests and procedures.

That fear is magnified among specialists, such as oncologists.

“You’re dealing with the life and death of the patient,” explains Larry Altshuler, MD, a board-certified internist and director of Oncology Intake at Cancer Treatment Centers of America in Tulsa, OK. “With PCPs, their concerns are more of the diagnostic misses. For specialists, a mistake can be deadly.”

Statistical Support

Altshuler’s thesis is supported by results of a survey on defensive medicine in radiation oncology. The survey, published in Radiol Med Journal found a “widespread use” of defensive medicine tactics in daily practice among radiation oncologists. Survey results were based on responses to a three-page questionnaire sent to members of the Italian Association of Radiation Oncology. Nearly 70% said one of the major reasons for practicing defensive medicine is the “climate of opinion that exists towards doctors.”

The costs of defensive medicine are considerable. A study published in JAMA Internal Medicine examined the cost of defensive medicine at three different hospitals. The study “hypothesized that physicians who were concerned about being targeted by litigation would practice more defensively and have higher overall costs.” The study found that 28% of orders and 13% of costs were judged to be “at least” partially defensive.

“I think the majority of physicians practice defensive medicine,” Altshuler says. “The latest statistics I saw was that almost 11% of healthcare costs are attributed to defensive medicine. That’s quite significant.”

Jay Woody, MD, FACEP, co-founder and chief medical officer at Legacy ER & Urgent Care, a stand-alone healthcare facility offering urgent care and emergency room treatment options under one roof, agrees with Altshuler’s assessment.

“I think there has been some improvement in trying to be better stewards of the healthcare dollar,” Woody says. “But there is no doubt that doctors are still nervous and may be doing more than they would for be best outcomes.”

A litigious environment is certainly one of the main culprits contributing to the practice of defensive medicine, but social media plays a role as well. Woody believes that when rational patients visit reputable websites and come armed to physician visits with good information, it may be easier to avoid extra tests and studies “because the patient gets it.”

But then there’s the other side of the camp.

“People fall into reading all this stuff, don’t really understand it all, and are a little confused, and then come in with a stubbed toe thinking they need a full body MRI to rule out malignant melanoma,” Woody explains. “And then you’re set up as a physician for failure, or at least a big battle to convince them otherwise.”

Communication and Education

Altshuler believes that communication is the primary tool physicians can use to avoid practicing defensive medicine. He encourages physicians to take the time to sit with patients and answer all their questions—but to do so in layman’s terms.

“A lot of patients, when they get with the doctor, the doctor may explain things in medical terms, and the patients will just kind of sit there and nod their heads, but they don’t understand it,” Altshuler says. “But the doctor thinks they understand it, because they’re just nodding their heads and not asking other questions. So physicians really need to communicate in layman’s terms and make sure the patient understands that, and maybe even repeats it back to them.”

Woody echoes those thoughts. He says that where a working relationship between patient and physician already exists, the physician will have a great deal more flexibility in terms of what tests they have to do and what they can omit.

“I don't think [communication and education] completely mitigates the practices of defensive medicine, because even if you can convince them otherwise you can still in the back of your mind be like, well, what if it is this bigger problem and I’m blowing it off?” he says. “But I do think communication and education and building a rapport would allow you and the patient to perhaps become more comfortable with doing less testing, if it’s medically appropriate.”

Do No Harm

In addition to the monetary costs that defensive medicine can accrue, the practice can be harmful to patients. Woody recalls a time about 15 years ago when full body CTs were becoming popular following an early cancer detection “that had saved somebody’s life.” But that’s not always the case.

“I cared for a patient who had one of them done,” he recalls. “They found this spot, and so they went in and did this biopsy and it turns out it was just some calcium which is totally normal. But in doing the biopsy they punctured the lung, and then when they were fixing the punctured lung an artery got damaged. And so this healthy guy who had no cancer growing in him had to spend half a year in the hospital from complications due to that full body scan he got.”

Woody acknowledges the case as an extreme example, but says that once you start doing more testing you might find more noise, and the more noise you have the more testing you do, and it becomes a propagating circle that could hurt a patient by having something done that didn’t necessarily need to be done.

While there is no complete fail-safe system for avoiding the practice of defensive medicine, Woody reiterates the importance of the patient having confidence in the doctor to make the right decisions.

“Because as confidence in the physician on the part of the patient goes down, the number of tests and studies to satisfy the needs and wants of both the physician and the patient tend to go up,” he says. “So that’s really the ground floor.”