The role of dysfunctional physician-patient relationships in generating lawsuits is unquestionable, and the elegant article, "Reducing Legal Risks by Practicing Patient-Centered Medicine,"1 focuses on defensive medicine as a manifestation of such dysfunction and hence a marker of increased legal exposure. However, the issue is complex in that the universe of malpractice contains subsets in which rather different factors are at play. Over the last 30 years, I have reviewed more than 200 legal files of missed myocardial infarction that led to death and litigation. Typically, these consisted of cases seen in the emergency department where the patient was sent home as having "indigestion." Communication with the patient was not the issue. Reliance on tests was not necessarily defensive but rather reflected a culture in which tests constitute the only valid reality and provide professional confidence and security to the physician. Hence, dependence on normal electrocardiograms and enzyme levels, for example, led to erroneous decisions. Often, when I question my residents regarding an inappropriate or redundant test, they raise the excuse of legal risks to cover their immature clinical skill and lack of confidence. In short, excessive testing does not always reflect interpersonal problems but may indicate poor clinical skills, and it is this that leads to increased legal exposure.
Brachfeld J. "Defensive Medicine" and Malpractice Suits. Arch Intern Med. 2002;162(22):2631. doi: