By Stacey Kusterbeck
A common belief is defensive medicine is to blame for the large increase of healthcare spending. “There is a long-standing narrative going back years on how if we could only eliminate defensive medicine, we would save a lot of wasted resources,” says Bruce E. Landon, MD, MBA, MSc, professor of healthcare policy at Harvard and professor of medicine at the Beth Israel Deaconess Medical Center.
Landon and colleagues wanted to challenge this assumption, to see what actual ED clinicians really thought.1 “Is it really defensive medicine that’s front and center of people’s minds? Or are physicians concerned about something different but probably much more important — the chance of patients being harmed or having poor outcomes?” Landon asks.
Landon and colleagues surveyed 1,222 ED attending physicians and advanced practice clinicians in Massachusetts acute care hospitals in 2020. Respondents were asked to rate how strongly they agreed or disagreed with the statements: “In my day-to-day practice, I am fearful of making a mistake that results in harm to the patient” and “In my day-to-day practice, I am fearful of making a mistake that results in being sued.”
The clinicians feared harming patients to a greater degree than they feared legal action.
“As a physician, that strikes me as being right,” Landon offers. “The thing that would keep you up at night is: I really should have ordered that test. What if something happens to the patient?”
Concurrently, many EDs are trying to cut back on unnecessary testing and low-value care. Focusing solely on emergency physician concerns about liability when making decisions on test ordering is ineffective, according to Landon.
“The whole narrative that by fixing the legal system, that’s going to get rid of overuse — that’s probably not a true narrative,” Landon asserts.
The results of the study by Landon and colleagues suggests focusing on patients is a more effective way to stop overuse of diagnostic testing in the ED.
“Keeping the focus on improving patient outcomes is the place where we should be,” Landon says.
For instance, EDs could share data with physicians on how well the department is performing in terms of eliminating care that is not helping patients. EDs could track adherence to accepted protocols or use of low-value services for which evidence suggests are overused, such as MRIs for routine low back pain. “Doing yet another CT scan when there’s a very low chance of finding anything isn’t in the best interest of patients,” Landon argues.
Any test ordered in the ED carries risks — radiation risks and incidental findings on CT scans that cause additional workups that have nothing to do with why the patient came to the ED. “The few cases that are found earlier are far offset by the harm and costs of following things that are unimportant, which could continue for years,” Landon says. n
REFERENCE
1. Ostrovsky D, Novack V, Smulowitz PB, et al. Perspectives of emergency clinicians about medical errors resulting in patient harm or malpractice litigation. JAMA Netw Open 2022;5:e2241461.
In a survey of more than 1,200 ED attending physicians and advanced practice clinicians, respondents indicated they are more concerned about doing what is right for their patients (i.e., shielding them from harm and preventing poor outcomes) as opposed to focusing only on defensive medicine to prevent future litigation.
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