Medical students are navigating two competing curricula: the evidence-based algorithms taught in textbooks and the liability-driven decisions they witness daily on clinical rotations. In a new opinion piece, two medical students describe how defensive medicine — ordering unnecessary tests or avoiding high-risk procedures to shield physicians from lawsuits — has become a de facto "hidden curriculum" in medical training, one that is never formally acknowledged or taught.

The authors recount a telling example: a 12-year-old with a clear-cut appendicitis diagnosis who received an unnecessary CT scan at the family's request, adding thousands of dollars in costs without changing the treatment plan. When the students later answered a similar case question on an exam by choosing "order CT" (as they'd observed in practice), the correct answer was "admit for surgery." The gap between what they saw and what they studied created real confusion.

Key Takeaways:

• Defensive medicine has roots in the 1970s malpractice crisis; a 2014 JAMA Internal Medicine study estimated 28% of hospital orders and 13% of costs at one large medical center were at least partially defensive
• Unnecessary testing can expose patients to excess radiation, false positives, higher bills, and longer ED wait times
• High-value care initiatives in hospitals show promise but face an inherent limitation: the institution doesn't bear the same personal legal risk as the individual clinician

Why it matters: If future physicians can't distinguish evidence-based decisions from liability-driven ones, patient care and healthcare costs both suffer. The authors call for open conversations — and eventually formal curriculum changes — to help trainees navigate this tension early in their careers.