A 12-year-old boy arrives in the pediatric emergency department with right lower quadrant pain. A bedside ultrasound confirms uncomplicated appendicitis, and surgery is booked for the next morning. His worried parents ask for an abdominal CT to confirm. The diagnosis is already clear, yet the CT is ordered anyway — a classic case of defensive medicine. It changes nothing, and the family gets a several-thousand-dollar bill a month later.
This is the opening scene of a recent opinion piece in MedPage Today by medical students Henry Diamond-Pott and Manav Midha, published on 26 September 2026. The test was ordered for protection, not because it would change management. That is defensive medicine: the lesson medical school never formally teaches.
What defensive medicine actually is
Defensive medicine is clinical decision-making driven by the fear of legal liability rather than by patient benefit. Positive defensive medicine means ordering extra tests or imaging “just to be safe.” Negative defensive medicine means avoiding high-risk patients or procedures, for example steering a patient toward palliative care when a risk score looks slightly too high.
This pattern took root after the malpractice crisis of the 1970s, when claims, awards, and premiums all climbed sharply. As the authors put it, medicine is practiced for two audiences: the patient in front of you and the hypothetical lawyer who might one day cross-examine you.
How common is defensive medicine?
Trainees see it constantly: a 2014 JAMA Internal Medicine estimate found 28% of orders and 13% of costs at a large hospital system were at least partially defensive. A survey of 202 fourth-year medical students and third-year residents at Northwestern University’s Feinberg School of Medicine, published in Academic Medicine, found that 94% of students and 96% of residents had witnessed defensive medicine during clinical training, most often “assurance behaviors” such as ordering extra services of little clinical value.
The price tag is large: a widely cited 2010 Health Affairs analysis conservatively estimated $45.6 billion a year in the United States. The cost is not only financial.
Why junior doctors fall into defensive medicine
The core problem is what educators call the hidden curriculum. By day, students memorize evidence-based algorithms. On the wards, they absorb a second syllabus: order the CT, because nobody wants to be the one who missed something. Diamond-Pott and Midha recall a teaching vignette modeled on their appendicitis case. Both answered “order CT,” as seen on rotations. The correct answer was “admit for surgery.” Studying two syllabi like this creates hesitation at the bedside.
Behavioral economists call this impulse anticipated regret: ordering the test to dodge the emotional burden of wishing, later, that one more test had been done. Long before any claim is filed, physicians are already weighing that regret. Defensive medicine is not just a reaction to the legal system; it is human nature responding to asymmetric incentives.
What defensive medicine costs patients and the system
The harm of defensive medicine’s “just one more test” is real: unnecessary testing exposes patients to radiation, false-positive results, and incidentalomas that trigger cascades of further procedures, plus longer emergency department stays, bigger bills, and real psychological distress. Hospitals under financial pressure absorb slower workflows, lower-value care, and longer waits for everyone.
There is a subtler cost for trainees too: when every uncertain case defaults to imaging, history-taking, examination, and clinical judgment get less exercise. Ordering becomes a substitute for deciding, and that habit follows doctors into practice.
Five ways to resist defensive medicine and practice confidently
The goal is not gambling with patient safety. It is replacing defensive medicine with reasoned, defensible decision-making:
1. Anchor your decisions in guidelines and decision rules
When an evidence-based rule supports your plan, say so in your note. Documenting that a validated decision rule recommended against imaging is itself protection, built on patient benefit rather than defensive medicine.
2. Document your reasoning, especially when you do not order
A note saying “CT not ordered: diagnosis confirmed on ultrasound, no red flags, plan discussed with parents” tells any future reader that a decision was made deliberately. Good documentation protects the careful doctor as much as any scan.
3. Share the decision with the patient
Most patients accept a recommendation against extra testing when the reasoning is explained: the diagnosis is clear, the test adds radiation and cost, and it will not change the plan. Shared decision-making turns a unilateral order into a documented conversation.
4. Escalate to a senior instead of hedging with a test
When uncertainty tempts you toward the order button, call the registrar first. A second clinical brain is cheaper, faster, and safer than a scan ordered for reassurance.
5. Learn which uncertainty you can tolerate
Senior clinicians carry a mental list of red flags for common presentations. Build yours for the conditions you see most: tolerating residual uncertainty is a clinical skill, trained like any other.
A conversation worth starting early
The MedPage Today authors do not claim to have solved defensive medicine. But they make a strong case for naming it early: through informal discussion on rotations first, and eventually through changes to how trainees are tested.
For junior doctors, the practical takeaway is simple: ask whether the test serves the patient or the fear. Evidence, documentation, conversation, and senior backup answer most of those moments. For more on the training years, see My First Year as a Doctor: 7 Lessons Nobody Taught Me in Medical School. The white coat carries responsibility, and responsibility deserves better than reflex ordering.
Sources: Diamond-Pott H, Midha M. “We’ve Seen Defensive Medicine, but It Was Never Taught.” MedPage Today. September 26, 2026; American Medical News; Fierce Healthcare.