Emergency physicians' fear of malpractice in evaluating patients with possible acute cardiac ischemia

A new survey of emergency physicians finds those most concerned about lawsuits are more likely to admit patients with cardiac symptoms and to order more tests. The results will be published by Annals of Emergency Medicine as an early online release July 13 (Emergency Physicians' Fear of Malpractice In Evaluating Patients With Possible Acute Cardiac Ischemia).

"Our research provides evidence that fear of lawsuits does drive health care providers to unnecessarily admit some patients, which increases health care costs," said David A. Katz, MD, with the University of Iowa Carver College of Medicine in Iowa City.

Of the 7 million people who seek emergency department care for chest pain or other symptoms of acute coronary syndrome, about 50 percent are hospitalized or admitted to chest pain observation units, and the majority of these patients are subsequently shown not to have acute coronary syndrome.

To determine the extent the practice of defensive medicine plays in emergency physicians admitting low-risk cardiac patients, researchers surveyed 33 emergency physicians at two university hospitals to gauge their fear of malpractice lawsuits and their impact on triage and workup patterns for patients with symptoms suggestive of heart disease.

To determine the relationship between emergency physicians' fear of lawsuits and their clinical decisionmaking, researchers ranked emergency physicians based on whether they had low, medium or high fear of malpractice. In addition, they prospectively examined the hospital records of 1,134 patients who sought emergency care for symptoms suggestive of heart disease and were treated by these physicians.

Overall, emergency physicians found to have the most fear of malpractice were less likely to discharge low-risk patients when compared with emergency physicians with the least fear. The "high fear" group also were more likely to admit chest pain patients to an intensive care unit or telemetry bed, and to order chest radiography (often a discretionary test) and a guideline-recommended laboratory test for heart muscle damage (cardiac troponin).

"Physicians respond to the perceived threat of litigation by ordering more referrals and more tests, some of which may be recommended by clinical guidelines and beneficial, but others might be wasteful and harmful," said Dr. Katz. "Our study suggests that interventions to lower emergency physicians' actual and perceived risk of lawsuits could be expected to reduce the practice of defensive medicine and its associated health care costs." Researchers caution that because only a small number of emergency physicians were surveyed, the results may not apply to all emergency physicians.

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