Malpractice fears may make ED docs defensive

Study shows unnecessary tests may be ordered

ED physicians who have the greatest fear of malpractice suits are more likely than their colleagues to admit and order tests for patients with chest pain or other heart symptoms, even if those patients are at low risk for actual problems, according to a study led by David Katz, MD, associate professor of internal medicine in the Roy J. and Lucille A. Carver College of Medicine at the University of Iowa in Iowa City. Those admissions and tests, in turn, lead to what Katz considers to be unnecessarily high costs in the ED.

Those findings were based on surveys of 33 emergency doctors who participated in a prospective study of 1,134 patients at two teaching hospitals. The results appear in the July 13 on-line issue of the Annals of Emergency Medicine.1

Through a survey of the emergency physicians, the researchers used a "malpractice fear scale" to rank the doctors into high-, medium-, and low-fear groups. Then, by analyzing patient records, the team determined that physicians with the greatest fear of malpractice were less likely to discharge low-risk patients compared with physicians with low malpractice fear. Instead, these high-fear doctors were more likely to admit low-risk patients and to order chest X-rays and troponin tests, which can measure heart damage.

They looked at patients who presented to the ED with symptoms of acute coronary syndrome: chest pain, shortness of breath, and so forth, Katz says. "The specific behaviors we were able to measure were triage decisions — whether or not the patient was discharged from the ED or admitted to a monitored bed — as well as the diagnostic tests ordered," he explains.

They found that the fear of malpractice was associated with a significantly lower chance of discharging the patient, even for physicians who thought themselves to be at low-risk of malpractice, Katz says.

"One could easily speculate that overall costs for those patients would be higher," he says. For example, Katz points out, while plain chest X-rays at $150 and troponin at $44 are relatively inexpensive health care costs, the volume of patients receiving one or both can raise the overall price tag on patient care. Then, of course, there’s the cost of admission, which can be as high as $1,200 per patient for a brief hospitalization, according to Katz.

The findings make sense to Andrew Nugent, MD, vice chair of emergency medicine at University of Iowa Healthcare in Iowa City. "I think it’s certainly possible that fear of malpractice can lead to more conservative decisions," Nugent says.

Katz notes that since emergency physicians must see all patients, regardless of how risky a patient’s case may be, one way physicians may respond to fear of malpractice is by seeking consultations and admitting patients about whom they are uncertain. "If they have a greater concern, they may have a lower threshold for seeking a consult," he asserts.

Since the possibility of a malpractice suit is a reality that cannot be changed, what can ED managers do to help allay staff fears and thus contain some of those unnecessary costs?

Katz says there are several ways to reduce fears of malpractice in EDs, including developing systems to improve patient safety and to reduce risk of medical errors. "One approach that has been proposed is to use chest pain observation units, where patients can be monitored for a longer period of time in the ED," he suggests.

There is a small chest pain observation unit at the University of Iowa Healthcare, where Nugent practices. "It’s a two-bed unit, which we keep full all the time," he notes. The unit is located immediately off the ED and is monitored by nurses and overseen by an emergency physician. "I think it does make us feel more at ease," Nugent adds. "We not only can rule out ACS [acute coronary syndrome], but we give the patients a definitive test, like a stress treadmill or an echocardiogram, before they go home, which does lead to increasing the doctor’s peace of mind."

Another approach with the potential to reduce physician fears is the use of computerized decision aids that more accurately can predict who will develop signs of ischemia or who has true ischemia, Katz says. "Rapid exercise testing and other noninvasive imaging tests can further lower the risk of missing cardiac ischemia," he adds.

Finally, Katz notes, though it is beyond the purview of his paper, creating a culture of safety in the ED, which makes it easier for physicians and nurses and other ED personnel to report errors when they occur, can go a long way toward mitigating fears. "Create a true, living and breathing quality improvement system in your ED," he recommends.

That’s a strategy Nugent totally endorses. "In our ED, we very much encourage our nurses and docs to point out when something’s wrong — at any time," he asserts.


  1. Katz DA, Williams GC, Brown RL, et al. Emergency physicians’ fear of malpractice in evaluating patients with possible acute cardiac ischemia. Ann Emerg Med — on-line publication. Web:


For more information, contact:

  • David Katz, MD, Associate Professor of Internal Medicine, Roy J. and Lucille A. Carver College of Medicine, University of Iowa, 200 CMAB, Iowa City, IA 52242. Phone: (319) 356-1141. E-mail:
  • Andrew Nugent, MD, Vice Chair of Emergency Medicine, University of Iowa Healthcare, Department of Emergency Medicine, 200 Hawkins Drive, Iowa City, IA 52242. Phone: (319) 353-7946. E-mail: