Unconscious defensive medicine: The case of erythrocyte sedimentation rate

Background: We investigated physician rationale for and against performing routine erythrocyte sedimentation rate (ESR) tests during hospital admissions. Methods: A comparative, descriptive, prospective study among 82 physicians in 15 departments of internal medicine from two University Medical Centers - A and B - in Israel was conducted between July and August 2004. Reasons for physicians' use of ESR were examined using a confidential questionnaire. A panel of four experts reviewed the need to perform an ESR test in 100 patients' files from center B. The main outcome measures were the use of ESR in routine hospital admissions and reasons for use. Results: Forty-four vs. zero physicians from medical centers B and A, respectively, routinely perform ESR tests for all admitted patients (p < 0.001). According to the experts, in only 10-30% of the 67 new patients could ESR tests have been of some value. Reasons for performing ESR routinely were as follows: to identify severe and "hidden" diseases (21/44, 47.7%); because it is crucial for all patients, both new and returning (10/44, 22.7%); because it is a guideline from department head (6/44, 13.6%); it is recommended in the literature (5/44, 11.4%); don't know why (2/44, 4.5%); defensive medicine (1/44, 2.3%); and other (6/44, 13.6%). Conclusion: Routine use of ESR tests on admission can be explained by old habits and by an unconscious concern about liability, i.e., unconscious defensive medicine.