Fear of lawsuits linked to MDs' decisions
Some tort reforms don't lessen worries
Executive Summary
Physicians' concern about malpractice risk is linked to ordering certain diagnostic tests, and tort reform had little effect on this, says a new study. To reduce risks, do the following:
Find out how your testing compares with peers.
Explain your reasoning to the patient.
Document the patient's response.
Physicians' anxiety over malpractice lawsuits drives defensive medicine moreso than other measures of risk, suggests a new survey of more than 3,500 physicians treating more than 29,079 Medicare patients with chest pain, headache, or lower back pain.1
Physicians who were very concerned about malpractice risk were significantly more likely to order certain diagnostic tests. For example, 11.5% of those with a high level of concern were more likely to order advanced imaging for a headache patient, compared with 8.5% of those with medium concern and 6.4% of those with a low level of concern. Doctors in states with laws capping damages in malpractice cases were not significantly less worried.
"Physicians and physician groups often assert that concerns about being sued play a large role in their medical decision-making," says Emily Carrier, MD, the study's lead author and a senior researcher at the Center for Studying Health System Change in Washington, DC. However, studies that compare states with and without common tort reforms, such as damages caps, have found only small effects on total medical spending.
"Our study suggests that these two findings don't actually contradict each other," says Carrier. "It's just that these tort reforms may not do as much as we had thought to make physicians less worried about malpractice suits." Consider these approaches to reduce defensive medicine while limiting legal risks:
• Find out how your testing behavior compares with that of peers.
"Typically, physicians are held to the prevailing standard of care in their community," says Carrier. "They may find that they could test fewer low-risk patients and still be in line with that standard."
• Develop strong, positive relationships with patients.
Patients who are questioning whether they got good care probably don't realize how thorough your workup was. "But most patients will have an opinion on whether you listened to their concerns, answered their questions, and seemed to be on their side," says Carrier.
• Explain your reasoning to the patient.
Physicians should do this step in cases in which someone might criticize them for not ordering a test which the physician doesn't feel is indicated, says Steven M. Levin, JD, founder and senior partner at Levin & Perconti in Chicago.
"For example, there are certain CT scans of the heart where studies show that ordering the test and responding to the results can be riskier than not performing the test," says Levin.2If the physician properly explains this issue to the patient, the patient might decide to opt out.
Physicians who are considering ordering a test or performing a procedure only because they fear legal repercussions should explain the risks and benefits, and let the patient decide, Levin advises.
"Then, the physician should thoroughly document the conversation and the patient's response," he says.
References
1. Carrier ER, Reschovsky JD, Katz DA, et al. High physician concern about malpractice risk predicts more aggressive diagnostic testing in office-based practice. Health Affairs 2013; doi: 10.1377/hlthaff.2013.0233.
2. Hoffmann U, Truong QA, Schoenfeld DA, et al. Coronary CT angiography versus standard evaluation in acute chest pain. NEJM 2012; 367:299-308.
