As a result, physicians, hospitals and medical groups were struggling to find and retain coverage to

take cind of the worst casesin area. When we surveyed physicians in pennsylvania back in two thousand three, at the height of what people called a malpractised insurance crisis, 93 % of them said that they pracise defensive medicines, sometimes, are often. And forty two % of them said that they do these avoidance behaviors, which are the cutting back on risk procedures, refusing to see groups of patients that they perceive to be higher risk, pursuing them, those things that can really lead to patients having difficulty axcessing the care that they need.

When

you say assurance behaviour, can give me an example of the type of thing that a doctor might do to avoid the liability risk. Well,

the paradigmatic example is probably ordering expensive scans like a c t scan or an mri, when the doctor doesn't really think is indicated. But there are other forms as well. Physicians could prescribe more medications than they think are medically necessary, especially if the patient's asking for particular medicine, for example, antibiotics for an infection that the physician thinks doesn't require it. They suggest invasive procedures like biopses to confirm diagnoses that they already feel pretty comfetent about. And then again, on the avoidance behavior front, it's mostly cutting back on high risk procedures like delivering women who are at high risk for adverse pregnancy outcome, or avoiding caring for certain kinds of high risk patients. I've had physicians in this pennsylvania survey, for example, tell me they don't like to take care of lawyers. Interesting,

by the way, i have tried to look at whether ore not in large scale data where the doctors treat lawyers any differently. I haven't found any evidence of it yet, but not to say that it doesn't occur. I

have just another wrinkle at in addition to avoiding high risk patients who might be more likely to require high risk procedures, there is evidence that physicians will cortayl just doing whole categories of procedures that push them up into a higher bracket of libility insurance costs. Like if i'm an obe gon, maybe now i'm just going to do g and i'm not going to deliver babies any more.

So the paper that you describe, that was based on the survey of doctors in pennsylvania, basically found that everybody, or almost everybody, engaged in at least some form of defensive medicine. And to me, they almost suggests that defensive medicine is like innocense. It's medicine itself. It's so deeply ingrained that these doctors didn't know how to practise medicine without it.

Well, again, that survey is conducted in the high risk state at a high risk time. So, you know, hopefully in peace time it's a little bit less common than it was in this survey, but still, you knw, i think it's fair to say pretty woven into the fabric of medical practice for physicians to seek to protect themselves, and that's not surprising. Are

there any fields that are more likely to exhibit these behaviors, where the malpractice liability risk is particularly high, or your sense is that defensive medicine is just

much more common?