Choosing Wisely and Defensive Medicine

The Choosing Wisely campaign was launched in 2012 by the American Board of Internal Medicine Foundation to identify commonly used medical interventions where evidence shows they provide no benefit or, in some cases, lead to harm. Choosing Wisely aims to help the community, including doctors and their patients, to start a conversation about improving the quality of health care by eliminating unnecessary and sometimes harmful tests, treatments and procedures.

Initially, nine US medical societies created “Top Five” lists of tests, treatments and procedures in their discipline for which there was strong scientific evidence of overuse and significant potential harm. The US campaign now involves 70 societies. Thirteen countries have subsequently adopted and implemented Choosing Wisely.

The five principles underlying Choosing Wisely are:

• physician led
• patient focused
• evidence based
• multi-professional
• transparent.

Choosing Wisely focuses on professional values and doctor-patient interactions and, importantly, includes a community education component. Ultimately, the goal is to reduce low or no value care, avoid harm and decrease waste in health care. 

Choosing Wisely Australia

Choosing Wisely Australia was launched in 2015.²

To date, 23 colleges and societies have developed “Top Five” lists which provide recommendations of the tests, treatments and procedures that clinicians and consumers should question:

Why do doctors order unnecessary tests?

The underlying factors are complex and often intertwined:

• patient expectations – the majority of patients overestimate the benefits of interventions and underestimate their harm³ 
• doctors’ estimation of patient risk with interventions – consent discussions may include overstatements about the benefits and minimisation of the risks⁴ 
• tension between a doctor’s obligations to the individual patient (especially if there is no potential harm to the patient from the intervention) and obligations to society to use resources appropriately, saving unnecessary costs of health care
• fragmentation and lack of continuity of care – e.g. re-ordering tests on admission to hospital
• cognitive biases:
• anticipated regret about missing a diagnosis – regret about a patient experiencing an adverse event if an investigation or procedure is not performed
• commission bias – tendency towards action/intervention, rather than inaction
• fear of reputational damage for the doctor if a diagnosis is missed
• doctors’ training – new evidence on safety, effectiveness and/or cost effectiveness may have come to light since training; resistance to “de-innovation” (stopping the use of older, less effective tests or treatments); or tendency for “indication creep” (using new technologies for indications where effectiveness has not yet been proven)
• time limitations – easier to order the intervention than to discuss benefits and risks
• financial – including fee-for-service for procedures
• fear of being sued.

Defensive medicine

Defensive medicine can be defined as the ordering of tests, treatments and procedures primarily to help protect the doctor from liability, rather than to substantially further the patient’s diagnosis or treatment.⁵

While the fear of litigation is not the sole reason for ordering unnecessary interventions, it is a potential barrier to the implementation of Choosing Wisely.

In a 2005 survey of US specialists at high risk of litigation, 96% reported practising defensively.⁵

A 2013 survey of UK hospital doctors revealed that 78% reported practising defensive medicine, including:

• 59% ordering unnecessary tests
• 55% making unnecessary referrals.⁶

A survey of Australian doctors in 2007 reported changes in behaviour due to medico-legal concerns, with:

• 55% of doctors ordering more tests than usual
• 43% referring patients more than usual.⁷

Of note, doctors who had experienced a medico-legal matter were significantly more likely to perceive they had changed their practice in response to medico-legal concerns.

Does practising defensively actually reduce your risk of being sued?

The short answer to this question is we do not know.

A recent study explored whether hospital doctors in the US who provided more costly care were less likely to be sued.⁸ The study found that those doctors who were in the highest fifth of spending had the lowest rates of malpractice claims. For example, physicians in the highest spending fifth were five times less likely to be sued than their colleagues in the lowest spending fifth. Obstetricians who had the highest rate of caesarean sections had almost half the rate of claims, compared to those who had the lowest rate. Of note, family medicine physicians were the only clinicians in the study in whom this association was not observed.

This study suggests that if doctors spend more per patient, and use more resources, they are less likely to be sued. However, there are a number of limitations to this study. It is not possible to determine if the increased spending and procedure rates actually represent defensive medicine or if it represents additional, appropriate care that led to fewer adverse events. It would also be interesting to know if the doctors in the highest spending categories had been involved in a claim before the study period. If so, these doctors are likely to be more alert to the risk of claims and may also be employing other strategies to reduce their medico-legal risk.

The future

In the future, will we see claims arising out of an allegation that an intervention, although performed appropriately, was unnecessary and therefore any adverse outcome is negligent? There is no doubt that when an intervention is not clinically indicated and leads to patient injury, any claim arising out of the injury will be indefensible.

Dr Sara Bird
Manager, Medico-legal and Advisory Services
MDA National

Article update 17 August 2017

References

1. Berwick DM, Hackbarth AD. Eliminating Waste in US Health Care. JAMA 2012;307:1513-1516.
2. Choosing Wisely Australia. Available at: choosingwisely.org.au
3. Hoffman TC, Del Mar C. Patients’ Expectations of the Benefits and Harms of Treatments, Screening, and Tests: A Systematic Review. JAMA Intern Med 2015;175(2):274-286.
4. Lin GA, Redberg RF. Addressing Overuse of Medical Services One Decision at a Time. JAMA Internal Med 2015:175(2):274-86.
5. Studdert DM, Mello MM, Sage WM et al. Defensive Medicine Among High-Risk Specialist Physicians in a Volatile Malpractice Environment. JAMA 2005;293:2607-2617.
6. Ortashi O, Virdee J, Hassan R et al. The Practice of Defensive Medicine Among Hospital Doctors in the UK. BMC Medical Ethics 2013;14:42.
7. Nash LM, Walton MM, Daly MG et al. Perceived Practice Change in Australian Doctors as a Result of Medicolegal Concerns. Med J Aust 2010;193(10):579-583.
8. Jena AB, Schoemaker L, Bhattacharya J, Seabury SA. Physician Spending and Subsequent Risk of Malpractice Claims: Observational Study. BMJ 2015;351:h5516/doi:10.1136/bmj.h5516. Available at: bmj.com/content/351/bmj.h5516