Risk Management _ __________________________________________________________________________
with emergency department claims, with fractures (6%), acute myocardial infarction (5%), and appendicitis (2%) topping the list [70]. In a review of 307 claims of diagnosis error in an ambulatory setting, cancer accounted for 59% of the missed or delayed diagnoses; breast cancer was the leading type of cancer (24%), followed by colorectal cancer (7%), and skin, gynecologic, and hematologic cancers (4% each) [57]. Other diagnoses frequently missed or delayed according to that review were infection (5%), myocardial infarction (4%), and fractures (4%) [57]. Patient Motivations Given that a high number of malpractice claims do not involve a medical injury, other factors must motivate patients and families to sue [18; 71]. Patient motivations for malpractice have been extensively studied, and a wide variety of motivations have been identified ( Table 2 ) [18; 58; 71; 72]. In general, these motivations are not related to financial need but rather to problems with patient-physician communication or the patient-physician relationship and unmet expectations of the patient [71]. The overwhelming majority of patients and families say they just want information about what happened, and many wish to prevent the situation from happening again [18; 71; 73]. CONSEQUENCES OF MALPRACTICE Malpractice exacts a substantial cost on healthcare delivery, physicians, and patients. The fear of litigation alone (real or perceived) has led many physicians to reconsider their profession. For example, the risk of litigation has prompted one-third of radiologists to consider leaving the field of breast imaging [15]. Fear of malpractice also influences physicians’ practice behaviors, primarily through the use of defensive medicine. The legal process involved with a malpractice claim takes physicians away from patient care and their families, a burden that is heightened by the amount of time required for resolution of a case. Defensive Medicine The threat of malpractice—real or perceived—has been shown to affect clinical decision making, prompting many physicians to practice so-called defensive medicine, or care based primarily on avoidance of litigation rather than on defined clinical need [4; 16; 74; 75]. Defensive medicine has been defined in two categories: “assurance behavior” or “avoidance behavior” [8; 16]. Assurance behavior, referred to as “positive defensive medicine,” involves excessive ordering of tests and hospitalization of patients and referrals for consultations; avoidance behavior, referred to as “negative defensive medicine,” involves decreasing the delivery of high- risk services or declining to treat high-risk patients [8; 16; 17; 25; 74; 76; 77].
SPECIFIC REASONS INDIVIDUALS GIVE FOR FILING A MALPRACTICE CLAIM Problems with patient-physician communication Poor relationship with the healthcare provider Desire for information about what happened Feeling of not being informed Desire to prevent situation from happening to another person Unmet expectations or unwanted outcomes Desire for accountability/revenge Suspicion of cover-up Feeling of not being appropriately referred Financial need Pain and suffering Advice from another (knowledgeable friend or acquaintance or healthcare provider)
Television ad for law firm Source: [18; 58; 71; 72; 73]
Table 2
The use of defensive medicine has been evaluated among general practitioners as well as several physician specialties and has been found to be widely prevalent [25]. Surveys of urologists have shown that 77% have practiced defensive medicine, with 58% to 60% saying they had considered referring difficult cases and/or limiting the scope of their practice because of the threat of malpractice [8]. Neurologists with higher malpractice concerns were found to order more tests in clinical scenarios related to seizures and Alzheimer disease [17]. A survey of defensive practices among 1,028 neurosurgeons found that 72% ordered additional imaging studies, 67% ordered additional laboratory tests, 66% referred patients to consultants, and 40% prescribed medication. Forty-five percent of respondents reported eliminating high-risk procedures from their practices [78]. Among emergency physicians, the fear of malpractice accounted for significant variability in decision making, especially with regard to individuals with chest pain, and was associated with the increased use of diagnostic tests and the increased hospitalization of low-risk patients [76]. These findings are consistent with those from broad samples of physicians. In a survey of 824 physicians in six high-risk specialties (i.e., emergency medicine, general surgery, orthopedic surgery, neurosurgery, obstetrics/gynecology, radiology), 93% of respondents reported practicing defensive medicine, and a survey of 2,416 physicians, conducted by Mount Sinai School of Researchers, found that 91% of physicians said they practiced defensive medicine [77; 79]. A national survey of 1,214 orthopedic surgeons showed that 96% reported having practiced defensive medicine by ordering imaging, laboratory tests, specialist referrals, or hospital admissions to avoid potential malpractice liability [80].
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MDMI1826
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