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Year : 2018 | Volume : 6 | Issue : 3 | Page : 110 - 111  


Letter to the Editor
Defensive Medicine: Breaking the Code of Hippocratic Oath

Dear Editor,

Defensive medicine is the practice of recommending a diagnostic test or treatment that is not necessarily the best option for the patient, as a means to avoid medical negligence lawsuits. It is a growing threat to medical service and a common practice among physicians worldwide. It is one of the significant contributory factors for increasing health care cost. It accounts for 26 to 36% of annual health care cost in the United States. [1]

According to an estimate, about 200,000 deaths occur every year in United States because of mistakes by hospitals, doctors or other health care facilities. [2] Among high risk specialties like Obstetrician /gynecologists, surgeons, radiologists, emergency physicians, orthopedic surgeons and neurosurgeons in United States, 88% had been sued previously and 48% had been sued in the previous 3 years. Recent litigation experiences and longer duration of practice were independent predictors of an increased use of defensive practices. One another factor is consumers of health care services are conditioned in such a manner that more test should be ordered for better health care. [3]

According to Hippocratic Oath, “I will prescribe regimen for the good of my patients according to my ability and my judgment and never do harm to anyone”. [4] This oath implies the duty of the physician to do no harm to the patients. There are two types of defensive medicine practices: Assurance and Avoidance behaviour. Assurance behaviour means ordering unnecessary test, referral to other health care facility or doing non-essential procedures to protect the physicians from malpractice claims; to reduce adverse outcomes or to convince the legal network that the standard care was given. Avoidance behaviour refers to avoidance of certain high risk procedures or refusal of treating patients who are at high legal risk. [5]

Defensive medicine practices range from screening test to surgeries. It is estimated from a report that 35 percent of diagnostic tests, 29 percent of laboratory tests, 19 percent of hospitalizations, 14 percent of prescriptions and 8 percent of surgeries attributed by defensive medicine. [1] Among all health care providers, Obstetrician/gynecologists tops the list for practicing defensive medicine, followed by general surgeons, radiologists, emergency physicians, orthopedic surgeons and neurosurgeons. [5]

It not only accounts for unnecessary health care expenditure, but defensive imaging exposes a patient for radiation risk and non essential invasive procedures leads to physical and mental stress. Care of the patients is the primary responsibility of the physicians. Quaternary prevention is the concept of prevention of harm to the patient by avoiding over medicalization and defense medicine. Hellinger and Encinosa have revealed that laws limiting malpractice payment reduced the health care expenditure by 3 to 4%. [6]

A comprehensive solution has to be evolved that should involve all stakeholders through health care reforms, regular monitoring by government health authorities, formulation of ideal guidelines for common health issues that lead to defense medicine practices, educating patients, reforming medical curriculum, emphasizing the health care provider’s responsibility on ethically justified, scientifically proven and quality health care services.

References:

  1. Leigh D. Sub acute necrotizing encephalomyelopathy in an infant. J Neurol Neurosurg Psychiatry. 1951;14(3):216–21.
  2. Genetics Home Reference. Leigh syndrome. 2011. [Accessed: Jun 2014]. Available from: http://ghr.nlm.nih.gov/condition/leigh-syndrome.
  3. Carrozzo R, Dionisi-Vici C, Steuerwald U et al. SUCLA2 mutations are associated with mild methylmalonic aciduria, Leigh-like encephalomyopathy, dystonia and deafness. Brain. 2007;130(Pt 3):862–74.
  4. Darin N, Oldfors A, Moslemi AR et al. The incidence of mitochondrial encephalomyopathies in childhood: clinical features and morphological, biochemical, and DNA abnormalities. Ann Neurol 2001;49(3):377–83.
  5. Sofou K, De Coo IFM, Isohanni P et al. A multicenter study on Leigh syndrome: disease course and predictors of survival. Orphanet J Rare Dis. 2014;9(1):52.
  6. Saneto RP, Singh KK. Illness-induced exacerbation of Leigh syndrome in a patient with the MTATP6 mutation, m 9185 T.C. Mitochondrion. 2010;10(5):567–572
  7. Koene S, Rodenburg RJ, van der Knaap MS et al. Natural disease course and genotype-phenotype correlations in Complex I deficiency caused by nuclear gene defects: what we learned from 130 cases. J Inherit Metab Dis. 2012;35(5):737–747.
  8. Patel KP, O’Brien TW, Subramony SH, Shuster J, Stacpoole PW. The spectrum of pyruvate dehydrogenase complex deficiency: clinical, biochemical and genetic features in 371 patients. Mol Genet Metab. 2012;105(1):34–43
  9. Santorelli FM, Shanske S, Macaya A, DeVivo DC, DiMauro S. The mutation at nt 8993 of mitochondrial DNA is a common cause of Leigh’s syndrome. Ann Neurol. 1993;34(6):827–834.
  10. Chol M, Lebon S, Bnit P, et al. The mitochondrial DNA G13513A MELAS mutation in the NADH dehydrogenase 5 gene is a frequent cause of Leigh-like syndrome with isolated complex I deficiency. J Med Genet. 2003;40(3):188–191.
  11. Tsuji M, Kuroki S, Maeda H, et al. Leigh syndrome associated with West syndrome. Brain Dev. 2003;25(4):245–250.
  12. Rahman S, Blok RB, Dahl HHM, et al. Leigh syndrome: clinical features and biochemical and DNA abnormalities. Ann Neurol. 1996;39(3):343–351.
  13. Cavanagh JB, Harding BN. Pathogenic factors underlying the lesions in Leigh’s disease. Tissue responses to cellular energy deprivation and their clinico-pathological consequences. Brain 1994;117(Pt 6):1357–1376.
  14. Haack TB, Gorza M, Danhauser K, et al. Phenotypic spectrum of eleven patients and five novel MTFMT mutations identified by exome sequencing and candidate gene screening. Mol Genet Metab. 2014;111(3):342–352.
  15. Calvo SE, Compton AG, Hershman SG, et al. Molecular diagnosis of infantile mitochondrial disease with targeted next-generation sequencing. SciTransl Med. 2012;4(118)




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