General Surgery Department, Faculty of Medicine, Al-Azhar University, Cairo, Egypt




Raouf Sallam


     Defensive medicine is -unfortunately- creeping into Egypt, slowly but progressively.

     In the management of a patient, medical decisions or actions should always be for the promotion of the health of the patient. Whether the decision or action be an investigation, a prescription, a referral or a procedure, it should always be solely for the good of the patient and no other reason. The same applies to any advice or instruction.

     But with such an ideal practice, doctors-not infrequently- find themselves in front  of the court of justice accused of malpractice inflicting an alleged harm to the patient, usually for not doing enough.

     When malpractice claims, against doctors, became a probability rather than a remote possibility, some doctors- gradually increasing in number- found it appropriate to include in patient management certain steps that are not meant for the promotion of the health of the patient, but rather as a precautionary protection in case of a malpractice suit. This is defensive medicine.

     Defensive medicine is when medical practice departs- in any step- from the medicine the patient needs for his health to the medicine the doctor may need for legal protection.

     Examples of defensive medicine are many:

● Excess investigations: brain c.t. or m.r.i. For a minor head injury with no symptoms or signs of brain involvement.

● Excess medications : antibiotics for an adult with flu when he is otherwise healthy.

● Unnecessary referrals: referring every patient with headache to a neurologist.

● Unnecessary procedures: stress e.c.g. or coronary angiogram for every chest pain. Or appendicectomy for anyone with vague right lower abdominal pain .

● Defensive medicine has also affected imaging and histopathology reports where we notice that most sonography reports recommend doing c.t. or m.r.i. and the other way round. The clinician may be held responsible if he neglects the advice of the radiologist he consulted.

● Many histopathology reports are now so indecisive, recommending almost always "correlation with the clinical,laboratory and radiological findings with close observation and follow up". Phrases that make the clinician suspicious about the diagnosis mentioned in the report

● And that is not all. An important technique in defensive medicine is avoidance. The clinician would avoid to be involved in 'difficult or complicated cases' or avoid to manage a patient who seems to be trouble maker.

    What is wrong in defensive medicine? :-

-  it increases the cost of health care, and with finite financial resources an increased spending in one area means, automatically, deprivation of another area. This practically means that an increased spending on one patient will ultimately deprive another patient.

-  It exposes the patient to the potential harm, side effects or complications of the unneeded test, drug or procedure .

-  A false positive result of an extra unnecessary test may derail the correct line of management .

-  It deviates the set of thoughts of the doctor from what is best for the patient to what is safer for the doctor.

-  worse of all , it shatters the doctor/patient relationship. Just imagine if the patient sitting in front of you doctor is not sure which of your recommendations is for him and which is for you. At the same time you as his doctor are not sure whether next time you will see him will be in your office or in the courtroom.

-  When patients know, and they already know, that some of the recommendations of their doctor are not for the sake of their own health, their compliance with the management advice will be reduced,  not being able to tell which is which.

     Defensive medicine is bad medicine, it is wrong, harmful and unethical. But to address the issue with fairness we must also address doctors concerns about legal actions taken against them if they do only the right thing without the protective extras.

     A comprehensive approach to combat and eventually eliminate defensive medicine must include:-

-  Guidelines for the management of common conditions must be available for doctors. It should be issued by specialist medical societies. Such guidelines will serve as a guide for the doctor to what to do and- equally important- as a reference to protect him from malpractice once he followed them.

-  A family doctor system must be established. When the patient and doctor know each other, the initial medical decision is more likely to be correct and satisfy the patient. Frequent visits, including home visits by the family doctor makes it easier to follow up and modify the initial decision if needed.

-  The medical syndicate representation in the jury is important, at least to make sure that a doctor's action presumed to be wrong and harmful is judged in the light of data available at the time of the action and not judged in retrospect as the tendency is today. We must remember that the retrospectoscope is an imaginary machine that has not yet been- and will never be- invented.

-  The syndicate should push for a swift end of any claim, considering the stress and disruption that prevails a doctor's life while under investigation.

-  The syndicate should help the doctor fight back if the claim is obviously false and financially motivated and innocence is established, the claimant should be accused of submitting a false claim and supplying wrong informations to the authorities.

-  Having said all of the above, I must stress that the syndicate- representing the medical profession- should always be on the side of the patient in case of misconduct, unexpected ignorance, or negligence from the side of the doctor, even when no harm has resulted.

    Other issues that need be mentioned in this context are:-

-  The medical community must work on improving the communication skills of its members. Misunderstandings between doctors and patients are due at least in part to inadequate attitudes and improper communication from the doctors.

-  The medical community and the media should cooperate to promote the overall health and medical knowledge of the public.

-  An informed consent for each step of the management is one of the essential rights of the patient. It also confers protection for the doctor if such protection be needed. Sufficient informations about the patient's condition, plan of management, alternative lines of treatment and prognosis, should be supplied to the patient. 

     The consent should be detailed but not scary. Side effects and complications of a probability of 1% or more should be included in the consent. Adverse effects that are less common need not be mentioned unless the patient enquirers about them.

     When doctors feel that they are reasonably protected from false allegations and lengthy stressful investigations that affect their bodies, souls, reputation, practice and career, they will not seek to practice the tactics of defensive medicine.

     We must realise that defensive medicine once incorporated in the medical practice will be very difficult to eradicate since beneficiaries from compensation lawyers, greedy patients and may be malingerers will make sure to keep it running.

      Something wrong, bad and harmful is creeping into our medical practice, shouldn't we stop before it holds ground in our system?.


Prof. Raouf Sallam F.R.C.S.