___________________________________________________________________________ Risk Management
urologists have shown that 77% have practiced defensive medicine, with 58% to 60% saying they had considered refer- ring 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 per- cent 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, ortho- pedic 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 poten- tial malpractice liability [80]. 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 sur- vey 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 medi- cal 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 prob- ability 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 impli- cations 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
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
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 primar- ily 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 hospital- ization 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]. 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
79
MDAZ2326
Powered by FlippingBook