Practice of defensive medicine widespread among physicians in specialties at high risk of lawsuits

More than 90 percent of surveyed physicians in Pennsylvania reported defensive medicine practices such as over-ordering of diagnostic tests, unnecessary referrals and avoidance of high-risk patients, according to a study in the June 1 issue of JAMA.

Defensive medicine is a deviation from sound medical practice that is induced primarily by a threat of malpractice suits, according to background information in the article. Defensive medicine has been reported widely in the United States and abroad. However, its prevalence and characteristics remain controversial.

According to the article, defensive medicine may supplement care (e.g., additional testing or treatment), replace care (e.g., referral to another physician or health facility), or reduce care (e.g., refusal to treat particular patients). Some practices, described as "assurance behavior" (sometimes called "positive" defensive medicine), involve supplying additional services of marginal or no medical value with the aim of reducing adverse outcomes, deterring patients from filing malpractice claims, or persuading the legal system that the standard of care was met. Other practices, described as "avoidance behavior" (sometimes called "negative" defensive medicine), reflect physicians' efforts to distance themselves from sources of legal risk. Defensive medicine, particularly avoidance behavior, encompasses both day-to-day clinical decisions affecting individual patients and more systematic alterations of scope and style of practice.

David M. Studdert, L.L.B., Sc.D., M.P.H., of the Harvard School of Public Health, Boston, and colleagues conducted a study to determine whether during a more volatile period in malpractice insurance markets, physicians' uncertainty about the costs and availability of coverage may induce a wider array of defensive practices, affecting not only the cost of health care but also its accessibility and quality. In May 2003, the researchers surveyed Pennsylvania physicians in six specialties at high risk of malpractice claims about the frequency and nature of their defensive practices. The specialties were emergency medicine, general surgery, orthopedic surgery, neurosurgery, obstetrics/gynecology, and radiology.

A total of 824 physicians (65 percent) completed the survey. Nearly all (93 percent) reported practicing defensive medicine. "Assurance behavior" such as ordering tests, performing diagnostic procedures, and referring patients for consultation was very common (92 percent). Among practitioners of defensive medicine who detailed their most recent defensive act, 43 percent reported using imaging technology in clinically unnecessary circumstances. Avoidance of procedures and patients that were perceived to elevate the probability of litigation was also widespread. Forty-two percent of respondents reported that they had taken steps to restrict their practice in the previous 3 years, including eliminating procedures prone to complications, such as trauma surgery, and avoiding patients who had complex medical problems or were perceived as litigious. Defensive practice correlated strongly with respondents' lack of confidence in their malpractice insurance and perceived burden of insurance premiums.

"Higher levels of defensive medicine are part of the social costs of instability in the malpractice system. The most frequent form of defensive medicine, ordering costly imaging studies, seems merely wasteful, but other defensive behaviors may reduce access to care and even pose risks of physical harm. Because both obstetrics and breast cancer detection are high-liability fields, women's health may be particularly affected," the authors write.

"Efforts to reduce defensive medicine should concentrate on educating patients and physicians regarding appropriate care in the clinical situations that most commonly prompt defensive medicine, developing and disseminating clinical guidelines that target common defensive practices, and reducing the financial and psychological vulnerability of individual physicians in high-risk specialties to shocks to the liability system," the researchers conclude.


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