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The Art of Defensive Medicine

Modern times have brought with it a wave of technological advancements that have strongly influenced art, science and the practice of medicine. The current trends in medical care, combined with medical sophistication and improved patient awareness have changed the clinical approach to treatment of patients.

Clinicians often combine their clinical acumen with biochemical investigations, radiological imaging or procedure to improve the certainty ofa diagnosis or for carving a comprehensive treatment plan. However, sometimes, clinicians may need to rely on specific investigations or procedures, which may override their clinical judgment. A simple metaphor is MRI of spine requested for a patient who comes with history of backache to your OPD or a CT scan of chest for a patient who has recurrent sore throat to rule out malignancy, TB or other less common disorders. This approach may be accepted as part of clinical algorithm. This is now common in the current practice of medicine in West, and is slowly creeping into global medical practices, including practices in India.

The question that merits consideration is, whether this approach is a paradigm shift in clinical practice for better diagnostic/therapeutic accuracy or an attempt to heed to current trends in litigation in medical practice. Interventions or modifications in clinical practice aimed to preventsuch potential litigationcan be aptly called as‘Defensive Medicine’.

Most clinicians would agree that access to advanced medical care is now well within reach and may want to use current available technologies to benefit the patients. Nonetheless, in doing so,they exercise great caution as there is obvious evidence that reflects that the practice of ‘Defensive Medicine’ is consistently on the rise. Often, clinical judgments taken in good faith may turn counter-intuitive to the clinician. This may sometimes result in delayed diagnosis, affect clinical outcomes through sub-optimal treatment or in rare cases, may even be fatal. In such circumstances, it makes the clinician vulnerable to litigation or more often, the clinicianapprehends such a possibility. Thus, to protect themselves from the potential hazard of litigation, clinicians may resort to practice of ‘Defensive Medicine’ by exceeding or limiting certain clinical requisites.

In India, the more serious issue thatis emerging is the threat from assaults on medical establishments, destruction of property and attacks on doctors and hospital staff. This societal approach in dealing with alleged medical negligence without any proof may have deeper ramifications and may entrench the practice of ‘Defensive Medicine’even further into clinical diagnosis. The current trend of ‘trial by media’ is adding to this problem. Practicing medicine in a potentially hostile environment may result in reluctance on the part of medical care providers to treat patients with complex clinical conditions or handle emergencies, as these often require spontaneous and bold decision-making. This may also result in an over-cautious approach, leading to over-investigations (which are then termed as ‘un-indicated diagnostics interventions’) and may affect free doctor-patient communication. This sometimes casts undue doubt on the credibility of the medical practitioner.

From the patient’s perspective, the most common impact of ‘Defensive Medicine’is increasing cost of healthcare. Often, patients complain that the tests asked for were not really necessary. Such additional interventions not only increase the cost but also result in mental agony to the patient and family. Further, as already highlighted,‘Defensive Medicine’may also lead to delayed decision making on the part of the treating clinician, which could have a negative impact on patient recovery.

Hence, both the clinician and the patient stand to lose in this bargain for over cautions approach. The question is – “Is Defensive Medicine here to stay?”

While a shift from the ‘Caveat Emptor’model in the form of consumer rights is welcome, the medical world should not be burdened with the ‘Caveat Venditor’approach.With current commercial trends inmedicaleducation, increasing malpractice, and lack of evidence based practice of medicine – the integrity of medical community has been questioned globally.  Medical litigation is steeply on the rise, and so are assaults on medical establishments and attacks on doctors. In such a hostile situation, the ambient clinical attitude of clinicians is changing, to primarily protect their interests and safeguard themselves from potential lawsuits or physical threats. These potentially pose to mar the very reputation the clinicians aims to achieve through his lifetime of clinical practice.

Better patient-physician communication, shared and informed decision making between patients and doctors, and adhering to evidence based guidelines holds the key to minimizing both patient related litigations and reduce the practice of ‘Defensive Medicine’.

The writer is Dr.Vishal Rao U.S, Consultant – Head& Neck Surgeon, Department of Surgical Oncology,HealthCare Global Enterprises Limited, Bengaluru.

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