The doctor-patient relationship, defensive medicine and overprescription in Chinese public hospitals: evidence from a cross-sectional survey in Shenzhen city.

Defensive medicine describes physicians' behavioral response to threats from medical malpractice litigation. Previous studies have found widespread practice of defensive medicine that is responsible for the global escalation of health care costs. Defying the traditional explanations, this study, with a case of a Chinese city, reveals that in a country where medical malpractice lawsuits are rare, physicians' self-perceived threats from patients may constitute a major reason for defensive practices. Defensive behaviors in the Chinese context mainly take the form of overprescribing diagnostic tests, procedures and drugs. The existing literature tends to explain this in terms of Chinese doctors' desire to supplement their low incomes. Behind this is a series of misaligned incentives deeply embedded in the Chinese health system. Using a cross-sectional survey of physicians, this study shows that overprescription in Chinese hospitals is driven not only by hard economic incentives, but also by doctors' motive of avoiding disputes with patients. The survey was carried out in Shenzhen City, in December 2013. A sample containing 504 licensed physicians was drawn by random sampling. Descriptive analyses identified significant dissatisfaction with income and workload as well as severe tensions between doctors and patients. Drawing from the literature on defensive medicine, multivariate analysis revealed that physicians' previous experience of medical disputes is significantly associated with defensive behaviors, particularly overprescription. Low income continued to be a critical predictor, reinforcing the target income hypothesis and suggesting the resilience of perverse economic incentives. This study sheds fresh light on China's recent health policy reforms by highlighting the critical impact of the doctor-patient relationship. The effort to contain health care costs must progress on two fronts, mitigating the tensions between doctors and patients while still reforming the remuneration scheme cautiously to enable physicians to respond to right incentives.