A new study finds a lot of orthopedic surgeons playing defense. In terms of cost, it says, nearly 35 percent of all imaging ordered in 2,068 Pennsylvania orthopedic cases was for defensive purposes.

John Flynn, MD, associate trauma director of orthopedic surgery at The Children’s Hospital of Philadelphia, was to present the study today at the annual meeting of the American Academy of Orthopaedic Surgeons (AAOS) in San Diego. An AAOS news release quoted him as saying, “This is the first study we know of that looked at the actual practice decisions of physicians regarding defensive imaging in real time—prospectively done.”

Dr. Flynn said 72 orthopedic surgeons, members of the Pennsylvania Orthopaedic Society, volunteered to participate in the study, which encompassed 2,068 patient encounters throughout the state. Most of the patients were adults.

According to the study, the participating doctors said 19 percent of the imaging tests they ordered were for defensive purposes. Because MRI, the most commonly ordered defensive test, is relatively expensive, the defensive tests accounted for $113,369 of the total imaging charges of $325,309 (in Medicare dollars). That’s 34.8 percent.

Dr. Flynn said many lawsuits involve a plaintiff’s claim that the doctor should have ordered more diagnostic testing. “And such a claim may be the driving force of so much of the defensive test ordering,” he said.

The study found that surgeons in practice for more than 15 years ordered more defensive tests than their less-experienced counterparts.

“That was counterintuitive,” Dr. Flynn said. “I thought that young doctors would come out of medical school immediately after training, be less confident because they weren’t experienced, and order more defensive tests. Then, as they became more comfortable and confident after 10 or 20 years in practice, they would order many fewer tests.

“In fact, the opposite was true. We found that, in Pennsylvania at least, a surgeon’s defensive nature gets worse over time.”

Dr. Flynn added:

In this legal environment, orthopedic surgeons order more imaging tests of a defensive nature because over time they become more concerned that someone is going to second-guess or sue them.

He pointed out that the added burden of defensive tests isn’t just financial. Patients endure inconvenience, discomfort or pain, and loss of valuable time.