AIM: To clarify the prevalence of defensive medicine and the specific defensive medicine practices among gastroenterologists in Japan.

METHODS: A survey of gastroenterologists in Hiroshima, Japan, was conducted by mail in March 2006. The number of gastroenterologists reporting defensive medicine behaviors or changes in their scope of practice and the reported defensive medicine practices, i.e., assurance and avoidance behaviors, were examined.

RESULTS: A total of 131 (77%) out of 171 gastroenterologists completed the survey. Three (2%) respondents were sued, and most respondents (96%) had liability insurance. Nearly all respondents (98%) reported practicing defensive medicine. Avoidance behaviors, such as avoiding certain procedures or interventions and avoiding caring for high-risk patients, were very common (96%). Seventy-five percent of respondents reported often avoiding certain procedures or interventions. However, seasoned gastroenterologists (those in practice for more than 20 years) adopted avoidance behaviors significantly less often than those in practice for less than 10 years. Assurance behaviors, i.e., supplying additional services of marginal or no medical value, were also widespread (91%). Sixty-eight percent of respondents reported that they sometimes or often referred patients to other specialists unnecessarily.

CONCLUSION: Defensive medicine may be highly prevalent among gastroenterologists throughout Japan, with potentially serious implications regarding costs, access, and both technical and interpersonal quality of care.

The number of negligence claims against physicians is increasing continuously, not only in Western countries but also in Japan[1-9], where a 10-fold increase in malpractice litigations, from 102 to 1019 cases per year, was observed between 1960 and 2003[7]. Although the number of medical lawsuits in Japan is relatively small in comparison to that in the United States of America (USA), the situation in Japan is gradually becoming more like that in the USA[10,11].

Defensive medicine is a deviation from sound medical practice that is induced primarily by the threat of liability claims[12,13]. Defensive medicine consists of two general behaviors. One is assurance behavior (sometimes called “positive” defensive medicine), which involves supplying additional services of marginal or no medical value with the aim of reducing adverse outcomes, deterring patients from filing malpractice claims, or persuading the legal system that the standard of care is met. The other is avoidance behavior (sometimes called “negative” defensive medicine), which refers to physicians’ efforts to distance themselves from sources of legal risk. It was recently reported that nearly all (93%) physicians in the USA practice defensive medicine[12]. Defensive medicine has been reported in other countries[14,15], but the prevalence and specific behaviors of defensive medicine in Japan, particularly among gastroenterologists, remain unclear. Therefore, we studied the prevalence of defensive medicine and specific defensive behaviors in a proportion of gastroenterologists in Japan.

We found that defensive medicine practices were as widespread among the gastroenterologists we surveyed in Japan as they are among physicians in the USA. In the USA, 88% of physicians have a lawsuit filed against them, reflecting the high rate of litigation in that country[12]. Studdert et al[12] reported that 93% of physicians in the USA practice defensive medicine, and that assurance behaviors, such as ordering tests, performing diagnostic procedures, and referring patients for consultation, are very common (92%). In Japan, the number of negligence claims against gastroenterologists is still very limited. Only 2% of our respondents have been sued, a finding similar to that reported by the Hiroshima Prefectural Medical Association from a survey of all its members[16]. Despite the relatively low frequency of lawsuits, nearly all (98%) gastroenterologists we surveyed reported practicing defensive medicine, and both assurance and avoidance behaviors were very common (91% and 96%, respectively). This may be due to the continuous increase in the number of litigations. With sensational mass media reporting on medical malpractice in Japan, gastroenterologists in Japan have begun to focus on risk management activities, leading them to practice defensive medicine[7,17]. These findings support the idea that individual physicians’ propensity to practice defensive medicine is not associated with objective measures of physicians’ exposure to and experience with liability claims[18-20]. It has been suggested that the signal to practice defensive medicine may have been broadcasted so widely that individual experience is overshadowed by collective anxiety[18].

Although the prevalence of defensive medicine in Japan is similar to that in the USA, individual components of this trend differ between the two countries. In a USA study of physicians in 6 specialties (not including gastroenterology)[12], almost one-third of respondents reported that they often describe more medications than medically indicated, whereas only 16% of our survey respondents, all gastroenterologists, reported doing so. In addition, 32% of physicians in the USA often suggest invasive procedures to confirm diagnoses, whereas only 16% of gastroenterologists we surveyed did so. Our findings suggest that assurance behavior is less prevalent among gastroenterologists in Japan than among physicians in the USA. In contrast, our findings suggest that the prevalence of avoidance behavior among gastroenterologists in Japan is similar to that among physicians in the USA. This may be due to differences in the structure of the medical economic system between the two countries[21]. In Japan, medical examination fees are considerably lower than those in the USA. Therefore, physicians in Japan may be more apt to suggest invasive procedures to confirm diagnoses.

Avoidance behaviors we surveyed were significantly less common among seasoned gastroenterologists than among those in practice less than 10 years. It is not surprising that less experienced physicians tend to avoid difficult procedures and interventions and caring for high-risk patients. It is reasonable that high-risk patients should be treated by fully experienced doctors.

Respondents who worked in hospital clinics ordered more tests than medically indicated significantly more often than respondents in solo practices. In Japan, patients desiring a thorough examination tend to visit a hospital clinic. To meet patients’ expectations, doctors in hospital clinics may order more tests than medically indicated. However, doctors in hospital clinics reported referring patients to other specialists unnecessarily less frequently than doctors in solo practices. Doctors in hospital clinics may refer less frequently because of easy access to specialized examinations or to other specialists, especially in general hospitals.

Our study was limited in several ways. First, measurement and identification of defensive medicine by the physicians themselves are difficult because distinctions between inappropriate and appropriate care are not clear in many clinical situations[22]. Moreover, it can be difficult to disentangle liability-related motivational factors from other factors that influence clinical decision-making, such as physicians’ general desire to meet patients’ expectations, preserve trust, and avoid conflict[23,24]. To the extent that the responding gastroenterologists attributed their decisions to liability concerns when in fact they were driven primarily by other considerations, our results are exaggerated. Second, the gastroenterologists’ self-reports of defensive medicine may have been biased toward giving a socially desirable response or achieving political goals. This may have led respondents to overestimate the frequency of their adoption of forms of defensive medicine.

An increased incidence of defensive medical practices is part of the social cost of a health-care system. The most frequent form of defensive medicine we found is suggestion of invasive procedures to confirm diagnoses, which seems not only wasteful but also likely to increase the risks of medical complications. Efforts to reduce the practice of defensive medicine in Japan should focus both on educating patients and gastroenterologists regarding appropriate care in the gastroenterological context that most commonly prompts defensive medicine, and on developing and disseminating clinical guidelines that target common defensive practices.