___________________________________________________________________________ Risk Management
All of these studies and surveys have shown that assurance behaviors are more common than avoidance behaviors, with the most frequent practice being the excessive ordering of tests, especially imaging studies [17; 76; 77]. For example, in the survey of physicians in high-risk specialties, 92% of respondents reported ordering more tests, performing more diagnostic procedures, and referring more patients for consultation [77]. Approximately 42% of the respondents said they had recently limited their practice to eliminate procedures with a high risk of complications or had avoided patients with complex medical problems or who were perceived as litigious [77]. A 2015 study that included more than 24,000 physicians, evaluated data from acute care hospital admissions in Florida from 2000 to 2009 [81]. Across specialties, greater average spending by physicians was associated with reduced risk of incurring a malpractice claim. For example, among internists, the probability of an alleged malpractice incident ranged from 1.5% with spending at $19,725 to 0.3% with spending at $39,379. In six of the specialties evaluated, a greater use of resources was associated with a statistically significantly lower subsequent rate of alleged malpractice incidents [81]. Both types of defensive medicine have several important implications for health care and healthcare costs. Unneeded testing may be associated with false-positive results and treatment complications, and limitations in physician services can lead to unmet care needs [17; 75]. The financial cost of defensive medicine is difficult to quantify, primarily because of the challenges in identifying and measuring assurance and avoidance behaviors. Physician expectations about the benefits and harms of interventions also may be a contributing factor. One systematic review sought to assess clinicians’ expectations of the benefits and/or harms of any treatment, test, or screening test [82]. Following a comprehensive search of four well-known databases, the authors included a total of 48 articles in their review: 20 focused on treatment, 20 on medical imaging, and 8 on screening. Of these, the majority (67%) assessed only harm expectations. Among the studies that compared benefit expectations with a correct answer (total of 28 outcomes), most participants provided correct estimation for only 3 outcomes (11%). Among the studies that compared expectations of harm with a correct answer (total of 69 outcomes), most participants correctly estimated harm for only 9 outcomes (13%) [82]. Inaccurate perceptions about the benefits and/or harms of interventions contribute to suboptimal clinical management choices and increased costs. A 1994 study estimated the cost of defensive medicine to be between $5 and $15 billion in 1991 U.S. dollars [74]. A study published in 2010 found that annual overall medical liability costs are an estimated $55.6 billion, or 2.4% of total healthcare spending [82]. Personal and Professional Effects A malpractice claim has a profound impact on a physician in terms of time, psychologic effects, and reputation. The average length of time between the date of an incident and closure of the claim is approximately four to five years [1; 2; 4; 72]. During
this time, the physician is distracted with the malpractice defense and the legal process robs time from personal and professional activities. Malpractice litigation has a negative psychologic effect on a physician because of its threat to personal integrity and honor. In general, physicians share personality traits that render them particularly vulnerable to malpractice litigation in which fault must be established [83]. These traits include self-criticism, exaggerated sense of responsibility, and vulnerability to guilt [84]. Physicians may experience loss of self-esteem and engage in self-questioning (e.g., “What did I do wrong?” or “What could I have done better?”) [72; 85]. In addition, the adversarial nature of litigation contradicts the normal work environment of a physician. As a result, approximately 80% to 95% of physicians have reported emotional distress during the process of malpractice litigation [86; 87]. This distress affects not only the physician but also his or her family and office staff [72]. A physician’s reaction to a malpractice claim has been described as beginning with a sense of shock, outrage, or dread, followed by feelings of intense anger, frustration, isolation, and inner tension [83]. In a study of physicians with a malpractice claim, 54% indicated that they were very surprised by the claim, 32% were somewhat surprised, and 14% were not surprised [4]. In cases in which there is clearly a negative outcome, the physician may also feel a substantial amount of guilt. Among the most common reactions to malpractice are [87; 88]: • Adjustment disorder symptoms (20% to 50%) • Major depressive disorder symptoms (27% to 39%) • Onset or exacerbation of physical illness (2% to 15%) A malpractice suit may also cause negative professional effects. In addition to the time spent away from the practice to defend a claim, a physician’s and/or practice’s reputation can be damaged by a claim, regardless of the outcome of the litigation [85]. In a 2021 survey of physicians who have had a malpractice lawsuit, 48% indicated changes to their practice. Among these changes were lack of trust in patients or treating them differently (24%); leaving the practice setting (7%); changing insurer (3%); and/or purchasing more insurance (2%) [4]. In addition, 29% of physicians surveyed felt that the lawsuit negatively affected their medical career [4]. A malpractice suit may also have implications on licensing and credentialing [72]. In general, patterns in the type of adverse events and the severity (amount) of payment to resolve the claim are the focal points for licensing boards and credentialing bodies [6]. Availability and cost of liability insurance may also be concerns; the frequency and severity of claims influence insurance underwriting, but a favorable settlement will weigh positively in the risk evaluation of the insurer [6]. The risk of negative physical and psychologic outcomes during and after a medical malpractice claim has been termed medical malpractice stress syndrome; it presents similarity to post- traumatic stress disorder. Strategies to ensure emotional and physical health due to the consequences of medical malpractice
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MDMI1826
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