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Saturday
Jan152011

Defensive Medicine is a Symptom of a "Risk Society"

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By Amy Tuteur, MD


The conventional wisdom about defensive medicine is that it is caused by doctors and happens to patients. I’d like to propose an alternative view:  defensive medicine is “caused” by all of us and doctors are merely responding to our expectations.  Defensive medicine appears to be about protecting doctors from liability, but it’s really about protecting patients from any and all risk.

According to Wikipedia:

Defensive medicine is the practice of diagnostic or therapeutic measures conducted primarily not to ensure the health of the patient, but as a safeguard against possible malpractice liability. Fear of litigation has been cited as the driving force behind defensive medicine…

Defensive medicine takes two main forms: assurance behavior and avoidance behavior. Assurance behavior involves the charging of additional, unnecessary services in order to a) reduce adverse outcomes, b) deter patients from filing medical malpractice claims, or c) provide documented evidence that the practitioner is practicing according to the standard of care, so that if, in the future, legal action is initiated, liability can be pre-empted. Avoidance behavior occurs when providers refuse to participate in high risk procedures or circumstances.

What about defensive medicine in obstetrics?

Consider the explosion in the rate of C-sections and inductions. They satisfy the requirements of assurance behavior.

Reducing adverse outcomes? Check.

Deterring medical malpractice claims? Check.

Pre-empting liability? Check.

Consider the precipitous decline in the rate of VBAC. That’s avoidance behavior: malpractice insurers have forced providers and hospitals to refuse to participate in VBACs.

There’s an important subtext that undergirds defensive medicine that often goes unrecognized and therefore unanalyzed. Defensive medicine is driven by the fact that we live in a “risk society,” a society that is organized around a new understanding of risk.

There have always been risks, of course, but they have traditionally been viewed as outside the control of human beings. The risk society has arisen because of new beliefs that we can and (especially) that we should control every aspect of risk.

In our risk society, we are obsessed with the risk of auto accidents and outfit our cars with ever more airbags and safety features. We are obsessed with risks to our children, and restrict their play outdoors and their independence, and we are obsessed with illness and death, literally passing laws to control personal habits like smoking.

How does the “risk society” impact obstetrics? We have become obsessed with the perfect child, and we construct ever more elaborate requirements to ensure that everything we do contributes to the perfect outcome.

There have always been risks in childbirth. Indeed, it has traditionally been the leading cause of death of babies, and one of the leading causes of death of young women in every time, place and culture. The “risk society” demands that we do everything possible to reduce those risks to zero.

Lay people often conceptualize risk as a dichotomy: an individual is either low risk (it won’t happen) or high risk (it will happen). But that’s not how risk works. Risk exists on a continuum; the risk varies from individual depending on a complex interaction of numerous factors. What’s the risk that a baby will die of group B strep meningitis? That depends on the presence of GBS in the mother’s genital tract, the exposure of the baby when delivered, and the presence or absence of antibiotics. We can determine the risk of GBS meningitis in large populations, but for the individual woman who carries GBS, we cannot predict the risk that her infant will be infected.

What does this have to do with defensive medicine? Consider that in our risk society we are supposed to reduce our risk to zero. How do we do that? We do that by acting to reduce risk regardless of how small the risk might be.

That represents an entirely new approach. Until the advent of the risk society, we determined which tests and procedures to use by establishing a risk threshold. For example, we know that the risk of stillbirth begins to rise in the last weeks of pregnancy (from about 36 weeks onward). The risk of stillbirth begins to increase precipitous at 42 weeks. So we arbitrarilyestablished the risk threshold for postdates induction at 42 weeks.

Lay people, with their dichotomous view of risk, tend to imagine that there is no risk of stillbirth prior to 42 weeks, and there is a risk of stillbirth after 42 weeks. But the reality is that risk exists on a continuum. Defensive medicine can best be conceptualized at lowering the risk threshold. In the case of induction, the risk of stillbirth starts rising long before 42 weeks. Since the risk society mandates that we reduce risk to zero, doctors feel they have no choice, but to offer postdates induction to women by 41 weeks, or even 40 weeks. That’s really the only way to reduce the risk to zero.

This is a critical point. Lay people imagine that defensive medicine offers no benefits to patients and is undertaken solely to protect doctors, but that’s not a complete picture. Defensive medicine is simply lowering the risk threshold. It benefits patients in that the risk of a particular outcome (like postdates stillbirth) is reduced as far as it can be reduced.

So what’s wrong with defensive medicine? Defensive medicine rests on the premise that we must do things to reduce risk. It completely ignores the risks posed by doing things. But that’s not only a feature of defensive medicine, it is a feature of every aspect of a risk society.

Yes, we make cars safer by putting in more safety features, but we increase the price of cars. Yes, we reduce the risk of kidnapping if we don’t let our children play outdoors, but it’s not good for children to grow up cowering inside their houses. Yes, we reduce the risk of illness when we pass laws regulating private habits, but we also reduce freedom. And when we do more inductions for postdates we lower the risk of postdates stillbirth, but raise the risk of C-section.

In our risk society, though, we apparently don’t care. We consider ourselvesrequired to reduce risk to zero, regardless of the other risks or costs that increase as a result.

Where does that leave us in regard to defensive medicine?

First, we can see that defensive medicine is not the use of tests and procedures on people who don’t need them. It’s lowering the risk threshold for using tests and procedures that we previously reserved for higher risk individuals.

Second, defensive medicine is not really a medical issue, but rather a societal issue. As a society, we need to give up the idea that we can and should reduce all risk to zero. We need to recognize that there are negative consequences to reducing risk, as well as positive ones. Most important, we need to figure out how much risk we are willing to tolerate. Zero risk is not achievable, and the price for attempting to achieve it can be very high.

What does this mean for birth activists?

It means that blaming doctors for defensive medicine not only isn’t working, but it can’t work. It means recognizing that low risk is not no risk and that, therefore, doctors need guidance on what patients believe is acceptable risk. And most of all, it means deciding, as individuals in a risk society, what trade offs we are willing to accept in order to reduce risk.

 

 

Amy Tuteur, MD, is an obstetrician gynecologist. She received her undergraduate degree from Harvard College in 1979 and her medical degree from Boston University School of Medicine in 1984. Dr. Tuteur is a former clinical instructor at Harvard Medical School. She left the practice of medicine to raise her four children. skepticalob.blogspot.com

 

 

 

 


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Reader Comments (174)

You are blaming the victim. Stop it. If you truly believe that patients can force doctors into doing more caesareans than are necessary, then you must admit that obstetricians can be forced into doing home births by patient preference also. You are completely wrong.

Obstetricians are trained primarily in doing surgery. That is what they do best. That is what they like to do. That is their answer for all of women's problems. So if a woman does not want surgery, then she should stay away from surgeons.

January 15, 2011 | Unregistered Commentermo garcia

My three critiques with this post:

1) There is no substantiation of the claim that “lay people” have a dichotomous view of risk. The rest of the argument is predicated on this assumption.

2) The post flat out ignores that the “defensive medicine” is defined and self-reported as being practiced to protect the physician (or institution) from liability and this renders the tone of the post farcical.

3) The term “risk society” is attributed to German sociologist Ulrich Beck and the description and motivation of a risk society used here, namely about how a risk society wishes to reduce risk to zero, diverge from Beck’s work. In fact, Beck’s work more aptly reflects the views of a birth activist or critic of modern medicine in that a “risk society” engages in what he calls reflexive modernism—that is, continuously evaluating the latent side effects of this “modern” technology and managing and distributing the risks that result from its use.

Other than that, it’s spot on, in my opinion and an example of solid common ground.

January 15, 2011 | Registered CommenterJill

At first glance I thougth this article had a reasonable point of view. Then when I got to the bottom of it I saw who the author was. I changed my mind. Dr. Amy is wildly against home birth, natural birth, unmedicated birth. She only believes birth is a dangerous event to be managed as completely as possible. She posts on midwifery, childbirth and related sites all the time. Always, blaming women who want to have a triumphant birth for being irresponsible.

Though there is some truth in the article above, I now realize that it is just another in her long list of writings that try to expand medical involvement in birth, and make a case for banning women from choosing their own birth methods.

January 15, 2011 | Unregistered CommenterBonnie B Matheson

While I continue to despair in your tendency to define people as medical professionals (With Knowledge) or lay people (Without Knowledge), I'm going to actually have to agree with a lot of what you said here. Frankly, I wish you wrote like this more often. I do believe that a lot of defensive medicine originates with professionals promising more than they can truly promise, as Dr. Dorn described. However, I know that my partner and I had to decide what level of risk we were comfortable with in birthing our children. We, personally, feel the risks are higher at the hospital and were willing to accept the smaller risks of home birth. I think first, though, we had to accept that there are risks - everywhere. I don't think that they are generally as high or as many as often tossed about, but they do exist.

I do have a question, though. You state that the risks of stillbirth increase far before 40 weeks, but that induction at 41 or even 40 weeks is "the only way to reduce the risk to zero." May I assume that this is some license, as obviously the risk is not zero, even if all women were induced or sectioned at 40 weeks?

Also, how do you suggest that we begin? Would one way not be to change the way providers speak to patients? And do you not think that OBs-as-primary-maternity-providers encourages the idea we should reduce the risk to zero (by placing all pregnancies under the purview of a specialist)?

Bonnie: I understand that it may be difficult given her tendency towards inflammatory statements, but I think Jill was absolutely correct in bringing this post, because we can't move forward with reading and critiquing all viewpoints.

January 15, 2011 | Registered CommenterANaturalAdvocate

Bonnie, I was pleased to post this here, not because I agree with all of it but because I think it's worth judging on its own merit.

January 15, 2011 | Registered CommenterJill

This post ignores history. Obstetrics was built on the promise of a live and perfect baby, which they can't deliver (no one can, but no one makes promises like obstetricians, either), and are now crying Fred, as a trained-to-believe population now hold obstetricians accountable for their lack of purported divine powers.

OB's only started doing VBACs in the late 80's after Ester Zorn, Nancy Wainer, and numerous homebirth midwives, supported women who made the once-a-cesarean, always-a-cesarean, look like a fool's edict. Taken from midwives care and the home into the obstetrical/hospital institution, VBACs were tampered with and drugged, resulting in a few disasters--that is what caused ACOG to limit VBACs (never seeing that medical managing obstetrics was the inducing risk factor), and insurance and hospitals followed the trade Union. And most of the docs wanted to be home by 6 anyway.

January 15, 2011 | Unregistered CommenterBirthistorian

Interesting post!

I have thought for a while now that the (perhaps mythical, as we've seen in this series of posts) high rate of obstetrical malpractice suits and the resulting aggressively defensive medicine were a consequence of this story that we tell women: the story that the hospital is the only safe place to deliver your baby, and consequently, if you deliver in the hospital, it will be safe. It seems like part of this must have originated when doctors were initially working hard to discredit midwives and get all women into hospitals. But now we really believe that if anything goes wrong in a hospital, it must be the doctor's fault.

This post points out to me that this mindset doesn't exist in a vacuum. Yes, doctors may have pushed this view that nothing really awful (i.e. death of mom or baby) will happen in the hospital, but they have probably been pushed to that by a society that demands that doctors make birth risk-free!

I think that this post is good because it points out that there is an acceptable level of risk that we all can take on, and indeed do take on in our daily lives. Whether that's letting our children walk a few blocks by themselves, or making our own choices about birth, or even just going along with our doctor. We can accept that "yes, there is a small risk here, and I'm okay with that," and make those "risky" (oooh!) choices, and still be responsible people. And from the perspective of the defensive medicine issue, it would be good if (a) everyone accepted that there are risks inherent in birth and sometimes things just go wrong, awful as it is, and (b) if doctors could accept that a woman is truly conscious of the risks and let her make her own choices without harassment.

January 15, 2011 | Unregistered CommenterAmandaJean

"You are blaming the victim."

My whole point is that is the wrong way to look at this and it's wrong on several different levels. First, defensive medicine is not about performing random test and procedures. It's about performing specific tests and procedures that would have been used only for women at a high risk of a bad outcome, but now used for everyone.

Second, everybody's beliefs about risk has been transformed. This is particularly apparent in mothering where mothers are now responsible for monitoring all risks that might impact their children: What's in the food? Will they be kidnapped when they go outside? Will vaccines help them or hurt them?

As a society we have lowered our willingness to tolerate risks and doctors are affected by this change just like everyone else.

January 15, 2011 | Unregistered CommenterAmy Tuteur, MD

"1) There is no substantiation of the claim that “lay people” have a dichotomous view of risk. The rest of the argument is predicated on this assumption."

It's well described in the risk literature but I can provide cites if you'd like.

January 15, 2011 | Unregistered CommenterAmy Tuteur, MD

I, personally at least, would appreciate those citations regarding the dichotomous view of risk.

January 15, 2011 | Registered CommenterANaturalAdvocate
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