Then, in the mid-1970s, things changed, and we became enlightened. Third parties, typically the insurance companies, were interpolated between the physician and the patient. Some of the consequences were unfortunate.

Patients knew that any suggestions I might make would have negligible consequences for their own budgets, so “more” became the expectation. A sense of entitlement developed. Why would the doctor hesitate to do some procedure, or hesitate to request a test? Everything was already paid for. If I was reluctant, perhaps weighing the cost to them, patients speculated there must be some hidden reason. Perhaps I was, in some obscure way, feathering my own nest. Misgivings arose.

This mistrust heightened—and became rational—when “prepaid” group practices became more prevalent. Physician compensation is tied to “efficiencies,” which means reducing the outlays and costs to the group (translation: skimp where possible) and thus generating for internal distribution a larger share of the prepaid premiums.

Second opinions proliferated, upping the costs. Patients could get two opinions for the same price: near zero. I could acquire additional knowledge from the feedback of the consultant and was better positioned should some legal controversy arise. One underexamined aspect of defensive medicine is those excessive referrals to diminish responsibility.