The relationship between healthcare providers and patients has become increasingly shaped by awareness of legal risk. In South Africa and many other jurisdictions, the marked rise in medical malpractice claims has influenced clinical decision-making, explains Michael-John Damant, Managing Director, Genoa Underwriting Managers.
Doctors no longer combat only disease; they must also manage legal risk. This self-protective response is commonly described as defensive medicine – ordering tests, performing procedures, making referrals or avoiding higher-risk patients primarily to reduce perceived liability rather than to achieve a clinical benefit.
Genoa’s role and interaction with practitioners
As an underwriting manager specialising in medical malpractice cover and supporting thousands of healthcare practitioners, my team has witnessed how deeply this anxiety runs. While diagnostic thoroughness is commendable, a fine line separates prudent risk management from clinical over-engineering. When defensive actions eclipse evidence-based medicine, the healthcare system suffers.
Toolset of fear: what tests are actually called for?
The anxiety regarding litigation typically manifests in the over-ordering of diagnostic tools. Doctors feel compelled to cover each conceivable, albeit mathematically improbable, differential diagnosis to protect themselves from allegations of delayed diagnosis or misdiagnosis.
In daily practice, this can result in an escalation of specific diagnostic requests, including:
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Advanced neuroimaging: Ordering brain MRI or CT imaging for routine tension-type headaches, where the neurological examination is normal and no red flags are present – solely to exclude unlikely intracranial pathology;
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Redundant cardiac biomarkers: Repeating cardiac biomarkers beyond the requirements of a validated chest-pain pathway, or ordering echocardiography in a patient assessed as low risk without another clinical indication;
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Extensive laboratory profiles: Ordering broad autoimmune panels or other extensive laboratory profiles during routine examinations, without symptoms, clinical signs, or risk factors to justify them;
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Over-reliance on radiography: Requesting lumbar spine X-rays or MRI for acute, uncomplicated lower back pain, where no red flags or progressive neurological deficits are present – despite guidelines generally advising against initial imaging.
In many cases, the motivation is to create a medical record demonstrating that serious conditions were considered. However, a negative test result records only the outcome of that investigation. It does not, on its own, prove that the clinician’s reasoning was sound, or that the condition was conclusively excluded.
When are you going one step too far?
Defensive medicine moves from reasonable caution towards potential harm, when the risks and burdens of further testing begin to outweigh its likely clinical benefit. Three important warning signs may indicate that this balance has shifted:
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Physical and biological harm: Unindicated CT scans expose patients to avoidable ionising radiation, with repeated exposure adding to their cumulative dose. Over-testing may also uncover benign incidental findings, commonly called “incidentalomas”. These can lead to further investigations and, in some cases, invasive procedures that carry risks such as infection, bleeding, or surgical complications;
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Financial exhaustion: Unnecessary investigations increase healthcare expenditure, can deplete patients’ medical savings accounts, and place further pressure on public health resources. At scale, low-value testing diverts limited resources away from patients who are more likely to benefit;
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Erosion of the doctor-patient bond: When anxiety about litigation begins to overshadow the needs of the individual patient, trust can be undermined. Over-reliance on testing may displace clinical examination, professional judgement, and shared decision-making, making care feel increasingly transactional.
Finding the balance: charting a way forward
The solution is not to tell doctors to ignore risk. The industry’s legal reality does not allow for this. Instead, we must reshape how risk is managed.
The most effective approach to reducing medico-legal risk is not excessive diagnostic testing, but clinically appropriate care supported by sound reasoning, a strong clinical relationship, and comprehensive documentation.
Malpractice claims arise from a range of factors, including clinical or diagnostic errors, communication failures, inadequate follow-up, and poor documentation. An unexpected outcome may prompt a patient to question the care they received – particularly where they feel dismissed or unheard – but it does not in itself establish negligence.
Clear, contemporaneous notes that record the doctor’s clinical reasoning, together with an honest discussion explaining why certain tests are not currently indicated, can materially strengthen patient care and the practitioner’s ability to respond to a complaint or claim. These discussions should also explain what warning signs to watch for, and when the patient should return for reassessment.
At Genoa, we emphasise supporting practitioners through targeted education and patient relationship training. After all, effective risk mitigation requires clinically appropriate care, open communication, informed decision-making, dependable follow-up and test-result management, and meticulous record-keeping.
By prioritising clinically appropriate care and clear communication over redundant testing, South African doctors can step away from defensive patterns and confidently return to practising precise, patient-centred medicine in their speciality areas.
