A common belief among doctors and healthcare economists is that "defensive medicine," which means ordering superfluous lab and imaging tests to protect against future lawsuits, rather than to advance patient diagnosis and treatment, contributes substantially to healthcare spending.
Now, a uniquely designed study appearing in the current issue of BMJ seems to indicate that doctors might actually reduce their malpractice lawsuit exposure by ordering more expensive tests and studies on their hospitalized patients.
This potential support for the defensive-medicine hypothesis comes from four researchers, and is entitled "Physician spending and subsequent risk of malpractice claims." The lead author is Dr. Anupam B. Jena of Harvard's Department of Health Care Policy. He and his colleagues analyzed data from 19 million hospitalizations in Florida between 2000 and 2009, and linked various parameters, including malpractice suit frequency, to the records of over 24,000 physicians in seven specialty practice areas.
Here are the key findings:
Across all specialties, greater average spending by physicians was associated with reduced risk of incurring a malpractice claim. Among internists, the probability of being accused of malpractice in the following year ranged from 1.5 percent in the bottom-spending fifth ($19,725 per hospital admission) to 0.3% in the top fifth ($39,379 per hospital admission). In other words, the internists making up the lowest-spending fifth have five times the risk of being sued than the the highest-spending internists.
Similar associations were seen among pediatricians, surgeons, and obstetricians. Family medicine physicians were the only physicians where this association was not observed, which may reflect a combination of relatively low malpractice claim rates overall and relatively fewer physicians compared with other specialties.
The authors' own conclusion is that they did, indeed, find evidence: the more spent on patient "care," the lower the likelihood of subsequent (within one year) malpractice suit being filed.
"We investigated the association between average resource use by physicians and subsequent malpractice claims. In six of seven specialties, we found that greater resource use was associated with statistically significantly lower subsequent rates of alleged malpractice incidents," the authors wrote. "For example, internists in the highest fifth of patient risk adjusted resource use were less than half as likely to face a future malpractice claim compared with those in the lowest fifth.
"Among obstetricians, those with higher caesarean rates a procedure sometimes considered to be defensively motivated had lower subsequent rates of alleged malpractice," they continued. "These relations held even when we adjusted for patient characteristics and accounted for time invariant physician characteristics such as patient mix, clinical skills, or communication skills."
An editorial in the same journal points out some weaknesses in the study, one of which is that the patient population studied was all in-hospital, such that the relevance to the more typical out-patient clinic experience is limited. Further, the editorialists ask if "those doctors in the highest spending categories had been named in a malpractice claim before the study period. If, in fact, those in the highest spending categories had been sued before the study, they may be more acutely aware of the risk of malpractice claims and may be employing targeted defensive practice ... to reduce the risk."
In any event, let's hope that this study does not provoke physicians to even more eagerly take up the approach of more and more tests defensive medicine as a shield against litigation. Far better would it be for doctors to pay more careful attention to their patients and avoid departures from clinical standards of care. In other words, practice better medicine to avoid malpractice, and lawsuits arising from it.