The effect of defensive medicine in plastic surgery.

Defensive medicine (DM) is defined as medical practices carried out primarily to avoid malpractice liability rather than to benefit the patient 

A recent study from Israel has highlighted the increasing trend for DM that seems to be dictated geographically by litigation prevalence. 

This study states that “DM entails referring patients for superfluous consultations or tests, performing unnecessary medical procedures or treatments, avoiding patients who are considered high risk, and refusing to perform procedures that may increase the chance of litigation.” 

Clinicians may be pressurized by the threat of personal litigation but also by provider regulation and the possible implications of not conforming to provider and regulatory guidance. The motivation to avoid litigation however is difficult to separate from the desire to enhance patient safety. Enhancing patient safety and creating optimised results undoubtedly will lead to a reduction in litigation. 


The practice of DM in relation to additional referrals / tests can only be addressed through the patient / doctor consultation and can only be circumnavigated by the patient having been given sufficient information to make an empowered decision. 

Often unnecessary treatments / referrals and tests are performed as screening tools. Patients need to understand the reason for these tests and be able to make a decision to have these tests. A clinician can only decrease the practice of DM by engaging the patients in this decision making process.

Interestingly this study has highlighted an increasing trend towards a more robust consent process. This is undoubtedly a great benefit of DM for both patients and clinicians and is imperative for patient safety. This in Mr Ross’s eyes does not demonstrate a practice of DM. 

In this study clinicians in private practice, where the litiginous risk is higher, the consent process was more robust with 43% of clinicians in private practice obtaining written consent twice before surgery compared with 24% in public practice. 

Additional visits / additional time to develop a doctor/patient relationship is in Mr Ross’s opinion the most important aspect of delivering high quality patient care. Mr Ross provides all patients with detailed information during the initial consultation, a detailed consent information sheet at a second visit and reconfirms this consent for patients preoperatively. All patients are given the opportunity to discuss the pros and cons of additional referrals / tests that could be considered necessary by protocols and regulatory guidance and given sufficient information to be empowered to make a decision as to whether to proceed or not.

Patient derived empowered care is essential in optimizing results. Although Mr Ross does not actively practice DM he does spend significant time informing and empowering patients. Allowing patients to determine their own preoperative and postoperative regimes delivers individualized care. Although time consuming the benefits for patients and doctors alike are essential in optimizing care and enhancing patient safety.

Clinicians need to be aware that standards of care are continually changing and that the evidence to support change in practice is also changing. All advice given to patients to empower them to make decisions needs to be supported by evidence based medicine.  

Reference  Silberstein E, Shir-Az O, Reuveni H, Krieger Y, Shoham Y, Silberstein T, Bogdanov-Berezovsky A. Defensive Medicine Among Plastic and Aesthetic Surgeons in Israel. Aesthet Surg J. 2016 Nov;36(10):NP299-NP304.

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