Original article Unconscious defensive medicine: The case of erythrocyte sedimentation rate Elad Asher a,b, ⁎ , Yoav Parag b , Lior Zeller c , Ronit Yerushalmi d , Haim Reuveni a,e a Department of Health Systems Management, Faculty of Health Sciences, Ben-Gurion University of the Negev, PO Box 653, Beer-Sheva, 84105 Israel b Tel-Aviv Medical Center, Department of Internal Medicine E, Tel-Aviv, 64239 Israel c Soroka University Medical Center, Internal Medicine D, PO Box 151, Beer-Sheva, 84101 Israel d Soroka University Medical Center, Hematology Department, PO Box 151, Beer-Sheva, 84101 Israel e Soroka University Medical Center, Pediatrics Division, PO Box 151, Beer-Sheva, 84101 Israel Received 20 November 2005; received in revised form 26 May 2006; accepted 11 July 2006 Abstract 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 b 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. © 2006 European Federation of Internal Medicine. Published by Elsevier B.V. All rights reserved. Keywords: Defensive medicine; Routine tests; Unconscious behavior; Liability 1. Introduction Erythrocyte sedimentation rate (ESR) is one of the oldest laboratory tests. It is simple, inexpensive, and easy to obtain [1]. ESR is the rate at which erythrocytes settle, as measured by the distance that red blood cells fall in a tube within a specific amount of time (usually 1 h) [2]. An elevated ESR is a non-specific response to the presence of inflammation, although it has also been found to be of clinical significance in the follow-up and prognosis of non-inflammatory condi- tions such as prostate cancer [3], coronary artery disease [4], stroke paraproteinemia, and anemia [5]. ESR is not an appropriate screening test in asymptomatic individuals [1,2,6,7,] and is of little value as a screening test for serious disease in patients who have non-specific symptoms [8]. Defensive medicine is defined as ordering tests, proce- dures, or visits, or avoiding high-risk patients or procedures primarily, but not necessarily solely, to reduce exposure to malpractice liability [9]. In the U.S., defensive medicine is estimated to cost $50 billion annually, more than the costs of treatment for hypertension and chronic obstructive pulmo- nary disease together [10]. European Journal of Internal Medicine 18 (2007) 35 – 38 www.elsevier.com/locate/ejim ⁎ Corresponding author. Soroka University Medical Center, PO Box 151, Beer-Sheva 84101 Israel. Tel: +972 8 640 3405. E-mail address: ashere@bgu.ac.il (E. Asher). 0953-6205/$ - see front matter © 2006 European Federation of Internal Medicine. Published by Elsevier B.V. All rights reserved. doi:10.1016/j.ejim.2006.07.021