Examples of Risk Externalisation in Medical Practice

Examples of Risk Externalisation in Medical Practice

The existence of "defensive medicine" is disputed by many lawyers. Many doctors perceive that the threat of being sued makes them so risk averse as to practise bad medicine. Lawyers argue that the legal system tackles only medical negligence, and so good medicine is the only means to prevent law suits. Regardless of whether or not the legal system should have this effect, most doctors are convinced that the threat of legal action affects medical practice in a negative way in some circumstances. 

Defensive medicine can be divided into positive and negative effects. Positive defensive medicine means doing more - more tests or treatments. Negative defensive medicine means doing less treatments - for example, a surgeon not performing an operation on a high-risk patient. In the NHS, the hospital is sued rather than the doctor so a successful law suit has no financial consequences typically for the clinician. However, there are other issues such as media attention, reputational damage, disciplinary or GMC proceedings. 

Positive defensive medicine can be part of a process of "risk externalisation" - the doctor by ordering more tests or treatments reduces his risks, but may increase the patient's risks. I came across an interesting and stark example of this.

A patient who has been diagnosed clinically with confidence as having typical migraine has a 1 in 4,000 chance of having an otherwise "silent" brain tumour. Thus a clinician might order a CT scan of the brain for all his migraine patients because if he missed one brain tumour it would end his medical career (his perception). 

Given the known risks from the radiation associated with CT scanning, is it the correct approach? That is the big question