Defensive Medicine Among High-Risk Specialist Physicians in a Volatile Malpractice Environment | Law and Medicine | JAMA | JAMA Network
[Skip to Navigation]
Access to paid content on this site is currently suspended due to excessive activity being detected from your IP address 35.170.64.36. Please contact the publisher to request reinstatement.
1.
Hershey N. The defensive practice of medicine: myth or reality.  Milbank Mem Fund Q. 1972;50:69-985060142Google ScholarCrossref
2.
Klingman D, Localio AR, Sugarman J.  et al.  Measuring defensive medicine using clinical scenario surveys.  J Health Polit Policy Law. 1996;21:185-2178723175Google ScholarCrossref
3.
US Congress; Office of Technology Assessment.  Defensive Medicine and Medical Malpractice. Washington, DC: US Government Printing Office; 1994. Publication OTA-H-602
4.
Veldhuis M. Defensive behavior of Dutch family physicians: widening the concept.  Fam Med. 1994;26:27-298132141Google Scholar
5.
Summerton N. Positive and negative factors in defensive medicine.  BMJ. 1995;310:27-29Google ScholarCrossref
6.
Coyte PC, Dewees DN, Trebilcock MJ. Medical malpractice.  N Engl J Med. 1991;324:89-931984189Google ScholarCrossref
7.
Mello MM, Brennan TA. Deterrence of medical errors.  Tex Law Rev. 2002;80:1595-1637Google Scholar
8.
Rosenblatt RA, Detering B. Changing patterns of obstetric practice in Washington State: the impact of tort reform.  Fam Med. 1988;20:101-1073282957Google Scholar
9.
Grumbach K, Vranizan K, Rennie D, Luft HS. Charges for Obstetric Liability Insurance and Discontinuation of Obstetric Practice in New York: Report to the Office of Technology AssessmentWashington, DC: Office of Technology Assessment; 1993
10.
Kessler D, McClellan M. Do doctors practice defensive medicine?  Q J Econ. 1996;111:353-390Google ScholarCrossref
11.
Reynolds RA, Rizzo JA, Gonzalez ML. The cost of medical professional liability.  JAMA. 1987;257:2776-27813573273Google ScholarCrossref
12.
 Medical Malpractice: Implications of Rising Premiums on Access to Health Care . Washington, DC: General Accounting Office; 2003. Publication GAO-03-836
13.
Bovbjerg RR, Bartow A. Understanding Pennsylvania’s medical malpractice crisis. Available at: http://www.medliabilitypa.org/research/report0603/UnderstandingReport.pdf. Accessibility verified April 4, 2005
14.
 2003 Rate Survey.  Med Liability Monitor. 2003;28:1-20Google Scholar
15.
Davies HT, Crombie IK, Tavakoli M. When can odds ratios mislead?  BMJ. 1998;316:989-9919550961Google ScholarCrossref
16.
Ballard DW, Li Y, Evans J.  et al.  Fear of litigation may increase resuscitation of infants born near the limits of viability.  J Pediatr. 2002;140:713-71812072875Google ScholarCrossref
17.
Swanson JW, Van McCrary S. Medical futility decisions and physicians’ legal defensiveness.  Soc Sci Med. 1996;42:125-1328745113Google ScholarCrossref
18.
Localio AR, Lawthers AG, Bengtson JM.  et al.  Relationship between malpractice claims and cesarean delivery.  JAMA. 1993;269:366-3738418343Google ScholarCrossref
19.
Cook WR, Neff C. Attitudes of physicians in northern Ontario to medical malpractice litigation.  Can Fam Physician. 1994;40:689-6988199521Google Scholar
20.
Passmore K, Leung WC. Defensive practice among psychiatrists.  Postgrad Med J. 2002;78:671-67312496324Google ScholarCrossref
21.
Woodward CA, Rosser W. Effect of medicolegal liability patterns of general and family practice in Canada.  CMAJ. 1989;141:291-2992766164Google Scholar
22.
Charles SC, Wilbert JR, Franke KJ. Sued and nonsued physicians' self-reported reactions to malpractice litigation.  Am J Psychiatry. 1985;142:437-4403976916Google Scholar
23.
Goold SD, Hofer T, Zimmerman M, Hayward RA. Measuring physician attitudes toward cost, uncertainty, malpractice, and utilization review.  J Gen Intern Med. 1994;9:544-5497823224Google ScholarCrossref
24.
Weisman CS, Morlock LL, Teitelbaum MA.  et al.  Practice changes in response to the malpractice litigation climate.  Med Care. 1989;27:16-242911218Google ScholarCrossref
25.
Vimercati A, Greco P, Kardashi A.  et al.  Choice of cesarean section and perception of legal pressure.  J Perinat Med. 2000;28:111-11710875095Google Scholar
26.
Griffin LP, Heland KV, Esser L, Jones S. Overview of the 1996 Professional Liability Survey.  Obstet Gynecol Surv. 1999;54:77-809950003Google ScholarCrossref
27.
Tussing AD, Wojtowcz MA. The cesarean decision in New York State, 1986: economic and noneconomic aspects.  Med Care. 1992;30:529-5401593918Google ScholarCrossref
28.
Baldwin L, Hart LG, Lloyd M, Fordyce M, Rosenblatt RA. Defensive medicine and obstetrics.  JAMA. 1995;274:1606-16107474245Google ScholarCrossref
29.
Ennis M, Clark A, Grudzinskas JG. Change in obstetric practice in response to fear of litigation in the British Isles.  Lancet. 1991;338:616-6181679160Google ScholarCrossref
30.
Sloan FA, Whetten-Goldstein K, Githens PB, Entman SE. Effects of the threat of medical malpractice litigation and other factors on birth outcomes.  Med Care. 1995;33:700-7147596209Google ScholarCrossref
31.
Glassman PA, Rolph JE, Petersen LP, Bradley MA, Kravitz RL. Physicians' personal malpractice experiences are not related to defensive clinical practices.  J Health Polit Policy Law. 1996;21:219-2418723176Google ScholarCrossref
32.
Goyert GL, Bottoms SF, Treadwell MC, Nehra PC. The physician factor in cesarean birth rates.  N Engl J Med. 1989;320:706-7092922015Google ScholarCrossref
33.
Weisman CS, Teitelbaum MA, Morlock LL. Malpractice claims experience associated with fertility-control services among young obstetrician-gynecologists.  Med Care. 1988;26:298-3063352326Google ScholarCrossref
34.
Sage WM. Understanding the first malpractice crisis of the 21st century. In: Gosfield AG, ed. Health Law Handbook. St Paul, Minn: West Group; 2003
35.
Blumenthal D. New steam from an old cauldron—the physician-supply debate.  N Engl J Med. 2004;350:1780-178715103006Google ScholarCrossref
36.
Tancredi LR, Barondess JA. The problem of defensive medicine.  Science. 1978;200:879-882644329Google ScholarCrossref
37.
Joint Commission on Accreditation of Healthcare Organizations.  Speak Up: help prevent errors in your care. Available at: http://www.jcaho.org/general+public/gp+speak+up/speakup.pdf. Accessibility verified May 5, 2005
38.
Mello MM, Studdert DM, DesRoches CM.  et al.  Caring for patients in a malpractice crisis.  Health Aff (Millwood). 2004;23:42-5315318566Google ScholarCrossref
39.
Eddy DM. Performance measurement: problems and solutions.  Health Aff (Millwood). 1998;17:7-259691542Google ScholarCrossref
40.
Bradley CP. Factors which influence the decision whether or not to prescribe: the dilemma facing general practitioners.  Br J Gen Pract. 1992;42:454-4581472390Google Scholar
Original Contribution
June 1, 2005

Defensive Medicine Among High-Risk Specialist Physicians in a Volatile Malpractice Environment

Author Affiliations
 

Author Affiliations: Department of Health Policy and Management, Harvard School of Public Health (Drs Studdert, Mello, DesRoches, and Brennan), Department of Medicine, Harvard Medical School (Dr Brennan), and Department of Medicine, Brigham and Women’s Hospital (Dr Brennan), Boston, Mass; Columbia Law School, New York, NY (Dr Sage); and Harris Interactive Inc, Rochester, NY (Mr Peugh and Dr Zapert).

JAMA. 2005;293(21):2609-2617. doi:10.1001/jama.293.21.2609
Abstract

Context How often physicians alter their clinical behavior because of the threat of malpractice liability, termed defensive medicine, and the consequences of those changes, are central questions in the ongoing medical malpractice reform debate.

Objective To study the prevalence and characteristics of defensive medicine among physicians practicing in high-liability specialties during a period of substantial instability in the malpractice environment.

Design, Setting, and Participants Mail survey of physicians in 6 specialties at high risk of litigation (emergency medicine, general surgery, orthopedic surgery, neurosurgery, obstetrics/gynecology, and radiology) in Pennsylvania in May 2003.

Main Outcome Measures Number of physicians in each specialty reporting defensive medicine or changes in scope of practice and characteristics of defensive medicine (assurance and avoidance behavior).

Results A total of 824 physicians (65%) completed the survey. Nearly all (93%) reported practicing defensive medicine. “Assurance behavior” such as ordering tests, performing diagnostic procedures, and referring patients for consultation, was very common (92%). Among practitioners of defensive medicine who detailed their most recent defensive act, 43% reported using imaging technology in clinically unnecessary circumstances. Avoidance of procedures and patients that were perceived to elevate the probability of litigation was also widespread. Forty-two percent of respondents reported that they had taken steps to restrict their practice in the previous 3 years, including eliminating procedures prone to complications, such as trauma surgery, and avoiding patients who had complex medical problems or were perceived as litigious. Defensive practice correlated strongly with respondents’ lack of confidence in their liability insurance and perceived burden of insurance premiums.

Conclusion Defensive medicine is highly prevalent among physicians in Pennsylvania who pay the most for liability insurance, with potentially serious implications for cost, access, and both technical and interpersonal quality of care.

×