Icy relationships with patients can increase your malpractice risk and cause you to practice defensive medicine.

Elaine: You are not going to believe what happened to me at the doctor's office today.
Jerry: Not the gown again.
Elaine: No, no. I was looking at my chart and it said I was difficult. Why would they write that?
Jerry: They have gotten to know you.

No doubt you have run into your share of "Elaines" over the years — difficult patients who, say, refuse to wear a gown (as Elaine did), or act in ways that seem in inappropriate, quirky, even scary.

Do you treat them differently, thinking they might sue you?

Maybe you do too much for them, or maybe you act in ways that you hope will prompt them to leave your practice. If so, you are practicing defensive medicine.

And you are not alone. Some 93 percent of physicians told researchers in a recent Columbia University-led study that they had practiced defensive medicine.

The study — one of the first to examine the impact of defensive medicine on clinical practice — revealed a little-known phenomenon: even as society is encouraging patients to be more assertive and involved in their care, patients who act this way may be receiving poorer care, as a result of defensive behaviors on the part of the physician.

Defensive medicine adds an estimated 10 percent to 20 percent of costs to the nation's already bloated healthcare system. But the problem is not purely financial. Access and quality of care are also compromised, and the doctor-patient relationship deteriorates.

Fear of malpractice litigation and spiraling malpractice insurance premiums contribute to this situation. You can't fix the malpractice crisis. But you can avoid being sucked into the defensive medicine trap.

Begin with a better understanding of what constitutes defensive medicine, learn what sort of patients may trigger you to overtreat or undertreat them, and increase your awareness of the reasons you are ordering those expensive, perhaps risky, tests. Ultimately you will strengthen your bond with your patients and reduce your chances of being sued.

Defining Defensive Medicine

The Columbia study defined defensive medicine as "a deviation from sound medical practice that is induced primarily by a threat of liability."

In May 2003, coauthor William M. Sage, a physician and law professor at Columbia, and his colleagues surveyed more than 800 Pennsylvania physicians who practiced emergency medicine, general surgery, orthopedic surgery, neurosurgery, obstetrics/gynecology, and radiology.

Defensive activities common across all specialties (except radiology) included ordering more tests or prescribing more medications than medically necessary; referring patients to specialists in inappropriate circumstances; suggesting invasive procedures to confirm diagnoses; avoiding certain procedures or interventions; and avoiding caring for "high-risk" patients.

Pennsylvania physicians were surveyed because their malpractice climate is particularly brutal: several insurers have left the state and premiums have tripled for some physicians. Sage thought the state would produce the most "dramatic" finding. Even so, he was shocked by the conclusions.