Does Fear Drive Defensive Medicine?

A recent study published in the journal Health Affairs revealed that whether a physician practices defensive medicine may depend more on a doctor’s fear of being sued than the level of noneconomic damages caps and insurance premiums in that physician’s state. The research was conducted by the Center for Studying Health System Change, a policy research organization, examined responses from 3,469 physicians to questions about how concerned they were about medical liability lawsuits in the center’s 2008 Health Tracking Physician Survey. Then they compared the physicians’ concerns with actual Medicare claims for more than 1.9 million patients who came to their offices with headaches, chest pain or lower back pain from 2007 to 2009. Physicians who reported a high level of malpractice concern were most likely to engage in practices that would be considered defensive when diagnosing patients who visited their offices with new complaints of chest pain, headache, or lower back pain. Of the conditions studied, chest pain was the most common (n = 12,161), followed by lower back pain (n = 10,109) and headache (n = 6809). For patients with headache, the likelihood that a medium-concern physician would order advanced imaging was 8.5% compared with 6.4% for a low-concern physician (P ≤ .05). Similarly, the likelihood a high-concern physician would order advanced imaging was 11.5% (P ≤ .05 compared with physicians at both the low- and medium-concern levels). Similarly, if the patient had low back pain, the likelihood was 22.4% that a physician with a medium degree of concern would order conventional imaging compared with 17.6% for low-concern physicians (P ≤ .05) and 29.0% for high-concern physicians (P ≤ .05 when compared with physicians with low or medium levels of concern). High-concern physicians were also significantly more likely than low-concern physicians to order advanced imaging (6.1% vs 4.1%; P ≤ .05; no significant difference was seen for physicians with a medium degree of concern). However, there was a 1.6% likelihood that medium-concern physicians would order a trip to the ED compared with 1.0% for low-concern physicians (P ≤ 05) and 1.4% for high-concern physicians (difference not significant). The authors suggested that reducing defensive medicine may require approaches focused on physicians’ perceptions of legal risk and the underlying factors driving those perceptions. In my opinion we also should provide physicians the tools to provide defensible medicine by utilizing patient encounter documentation templates, evidence based treatment approaches and patient-centered outcome guidelines. All of these components are part of the Affordable Care Act and should be translated into practice sooner than later. Yours Bernd