Defensive Medicine Practices in Pennsylvania are Common

Abstract & Commentary

Dr. Chan reports no relationships with companies having ties to this field of study.

Source: Studdert DM et al. Defensive medicine among high-risk specialist physicians in a volatile malpractice environment. JAMA 2005; 293:2609-2617.

Defensive medicine has been defined as clinical care that deviates from sound medical practice primarily as a result of medicolegal liability concerns. In this study, investigators conducted a mail survey in Pennsylvania of 824 physicians from six high-risk specialties including emergency medicine. (The other specialties included general surgery, orthopedics, neurosurgery, obstetrics/gynecology, and radiology.) The survey asked respondents about their frequency of defensive medicine practices, including assurance behaviors (so-called "positive" defensive medicine), which involve supplying additional services of marginal or no medical value with the aim of reducing adverse outcomes (e.g., additional tests, procedures, prescriptions), as well as avoidance behaviors (so-called "negative" defensive medicine), which involve physician efforts to distance themselves from liability risks (e.g., refusing to perform certain procedures or care for certain types of patients). The investigators also asked respondents about any specific instances of defensive medicine practices in which they had engaged recently.

Nearly all survey respondents (93%) reported practicing defensive medicine. Assurance behaviors were more frequent than avoidance behaviors. In particular, the use of imaging technology in clinically unnecessary circumstances was common and reported by 43% of all physician respondents. Of the 148 emergency physicians (EPs) surveyed, 70% reported "often" ordering more tests than medically indicated as the most common form of defensive medicine practice, a rate that was statistically higher than all other specialties (59%). More than half of EPs who reported specific instances of defensive practices cited the use of imaging studies when not clinically necessary. Other assurance behaviors reported being used "often" by EPs included prescribing more medications than indicated (30%), unnecessarily referring to specialists (52%), and suggesting invasive procedures (19%).

Specific examples cited by EP respondents included the evaluation and hospitalization of chest pain patients, abdominal computed tomography (CT) scan for abdominal symptoms, and head CT scans for minor trauma or questionable indications. EPs were less likely to report avoidance behaviors than the other specialties, including avoiding caring for high-risk patients such as trauma patients (13% vs 39%) and avoiding certain procedures or interventions (21% vs 32%).

The investigators also collected information from each respondent on individual malpractice experiences and ability to obtain liability coverage. Interestingly, they found no correlation between level of defense medicine practice and prior individual malpractice experience or expense. In summary, the authors concluded that the prevalence of defensive medicine is widespread and has important implications for health care quality and access, as well as societal costs.

Commentary

There are a number of limitations to this study. First, as a survey, the results incorporated potential biases of the respondents regarding defensive medicine and the malpractice liability system in this country. Second, the survey was conducted in Pennsylvania at a time when that state was experiencing a malpractice crisis, which may have affected the physician responses. Nonetheless, this study is remarkable in demonstrating the pervasive practice of defensive medicine in response to the medicolegal liability system in this country. The irony is that defensive medicine practices—particularly assurance behaviors—ultimately may be counterproductive. As the authors pointed out: The more that physicians order tests or treatments that are only marginally or not indicated, the more likely such practices are to become the legal standard of care.