Republicans, and now Democrats, proclaim that defensive medicine is a major factor in health care inflation. Defensive medicine is the practice by which physicians (and hospitals and other providers) order all of the tests and procedures required to meet the highest standards of professional (or institutional) practice in order to thwart malpractice accusations based on failure to consider, and test for, all of a patient's conditions which might give rise to a professional negligence lawsuit. Defensive medicine does not necessarily constitute high-quality care, but does reflect a rational fear of loss of a malpractice lawsuit and attendant consequences. Unfortunately, more tests and procedures may expose patients to increased false positive and false negative results and lead to inappropriate and unnecessary medical risk.
But fears of malpractice actions aren't the only cause of defensive medicine. Physicians are held to a local, and sometimes a national, standard of practice through a process called "Peer Review." If the practice in the community is to perform tests and evaluations and a physician chooses to do fewer tests, he may find himself in front of a medical group, hospital, county or other institutional review board (perhaps with some competitors as peer reviewers), defending himself against charges of failure to practice in accordance with applicable professional standards. Unlike some malpractice lawsuit results, a finding against the physician being reviewed (improper "competence or conduct") has an increased likelihood of resulting in her receiving a negative report to professional organizations and to the state and federal government, jeopardizing her family relationships, personal reputation, professional license, malpractice insurance, hospital privileges and medical staff membership, and provoking exclusion from state and federal health programs (Medicaid and Medicare). Defense of each such case at a hospital or local level may cost $100,000 or more in attorneys' fees for each side, and if the case escalates to an investigation and charges brought by a state or federal agency, the cost may substantially increase.
While defensive medicine related to malpractice is well-known and understood, defensive medicine related to peer review may be more subliminal and less appreciated. In either case, many physicians play it "safe." Faced with the dire consequences of a failure to comply with professional standards, they may notch-up their ordering of additional tests and procedures to test for unlikely, but not impossible diagnoses. You, or the insurer, get a bigger bill but the physician continues in practice, sleeps at night, and doesn't waste thousands of dollars on attorneys' fees.
If you were a physician, what would you do?
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In an Artificial Intelligence application, such as a chess playing computer program, the emphasis is on depth of search (and evaluation of positions) rather than breadth. Medical diagnostic techniques that might begin with a broad oral history taking and call for tests only as the diagnostician quickly burrows down a narrow decision tree will in the end lead to reduced costs (lab fees, return visits, etc.), and better patient care, I believe. More broadly, I feel the key to reducing mal practice is to sharpen our diagnostic methodologies (history taking, e.g.), tools (computer aided history taking with or without the doctor in attendance, e.g.) and training (n the lab and on rounds), not to encourage or enable more and more tests at the start of the doctor - patient dialogue.
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