Defensive Medicine      The phrase "defensive medicine" is relatively new to the practice of medicine. When I began my practice in the early 1970s, I never heard these words being spoken, yet only a few decades later, they were on the lips of almost all my colleagues. But what do these words mean?      Defensive medicine has been defined in the medical literature as "A deviation from sound medical practice that is induced primarily by a threat of liability". In practice, defensive medicine is the ordering by doctors of supplemental care such as additional testing or treatments, avoiding risky procedures, referral to specialists for care or the refusal to take care of certain patients. Defensive medicine is considered by many as costly, as well as unnecessary for proper medical care of patients, while adding a dimension of mistrust between doctor and patient. The practice of defensive medical has been used as an argument for medical malpractice tort reform.        A 2005 study reported in the Journal of the American Medical Association, noted that of a survey of 824 Pennsylvania doctors, 93% stated that they sometimes or often practiced defensive medicine because of a fear of being accused of medical malpractice. Clearly this is a troublesome finding. While Pennsylvania is a state with a very high rate of malpractice problems, the practice of defensive medicine is considerable even in other states. It appears that a large percentage of physicians in this country are engaging in what they consider unsound practices that exposes patients and the insurers of health care to unnecessary costs, as well as, patients to potential harm.      Taken to the extreme, it is also a form of defensive medicine when young doctors in training decide not to go into a specialty of medicine because it is considered at a higher risk for malpractice claims; even though that is the specialty they most desire to practice. Or to refuse to care for patients who have complicated problems and therefore are at a somewhat higher risk for adverse outcomes, would truly represent the practice of defensive medicine.      However, defensive medicine could be looked at as a positive rather than negative medical practice because often time it may actually be beneficial to patients. Doctors have a duty to consider most, if not all possibilities that may be responsible for patient's symptoms, findings or complaints, which may mean ordering tests that could be considered by some as unnecessary and defensive. If, however, an unnecessary test yields a positive finding, the patient may benefit.      I am aware of many breast biopsies that were considered benign by doctors, but turned out to be malignant when an "unnecessary biopsy" was performed. I also know of instances where a symptom that appeared to be indigestion actually turned out to be a heart attack, and would not have been diagnosed had the patient not be admitted to an emergency room for a few "unnecessary tests".      Sending patients to other doctors for special care or just for a second opinion may sound like defensive medicine to some, but to me, simply represents good medical judgment. The very same kind of defensive medicine that the recently surveyed Pennsylvania doctors claimed to have practiced, could be considered comprehensive, thorough and caring. That is why I am bothered so much by the term defensive medicine.      The real medical malpractice problems confronting doctors today do not reside in the practice of defensive medicine. It resides primarily in analyzing and reducing medical errors, enhancing practices that assure patient safety, improving communication and trust between doctor and patient, and promoting team training as a model for health care systems.      Defensive medicine should perhaps be a term applied more to patients than physicians. Patients who refuse to live a healthy life style need to consider practicing defensive medicine by wearing seat belts, stopping smoking, reducing the amount of fried food in their diet, taking some time each week to exercise, beginning prenatal care early in pregnancy, reducing alcohol intake and seeking medical advice for recurrent problems. To me, that would be defensive medicine practices, and in the long run would prove to reduce morbidity, mortality and the cost of medical care.      Attempting to consider all possibilities by ordering additional tests and treatments or obtaining other opinions from specialist physicians should be labeled as comprehensive and thoughtful care by a physician and not the practice of defensive medicine. We need to rethink this issue.