Malpractice Concerns Drive Aggressive Care, Say Physicians

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Defensive Medicine is a Dead-End

"Implicit in these findings is a kind of trained helplessness – it seems that physicians know they are practicing aggressively but feel they have no recourse," Dr. Calvin Chou wrote in an invited commentary.

Dr. Chou suggests that defensive medicine is a dead-end; it is not a sustainable practice and there is no evidence that it actually prevents malpractice suits.

Instead, studies have shown that physicians sued the least are the ones who connect more with patients by actively listening and including them in their own care.

"Patients tend to define quality of care in terms of the quality of communication with members of their health care team," Dr. Chou wrote.

Dr. Chou is a professor of medicine at the University of California, San Francisco. These comments were adapted from a commentary accompanying the report (Arch. Intl. Med. 2011;171:1585-6). He reported no relevant financial conflicts of interest.



Forty-two percent of physicians admit that patients in their practices receive too much treatment, which was described as "aggressive" care, according to a survey of general internists and family doctors. Fifty-two percent said that they thought the amount of care they provided was just right, and 6% said their patients received too little care.

When asked about their own practice style, 28% of respondents said they were too aggressive, ordering more tests and referrals than necessary. Just under 20% said they were practicing more conservatively than their ideal (Arch Intern Med. 2011;171:1582-5).

The doctors were also asked to describe practice styles among other health care providers and reported that they believed they saw too much testing and ordering of referrals by nurse practitioners, physician assistants, and specialists.

Twenty-nine percent said other primary care physicians were practicing too aggressively, while 61% said they believed that specialists are too aggressive in their practice and 47% said mid-level providers overtreat patients.

Malpractice concerns were cited by 76% of the survey respondents as a reason for their more aggressive practice style. Eighty-three percent of the physicians said that they feared being sued if they did not order an indicated test.

About half of those surveyed said that clinical performance measures led to more care, and 40% said that not having enough time with patients translated into a more aggressive practice. Instead of thinking through an issue, they order tests or make referrals.

Few physicians (3%) said that they believed financial considerations influenced how they personally practiced medicine. But 39% said they thought other primary care doctors would order fewer tests if there was no incentive. Sixty-two percent said that specialists would likely perform fewer procedures if they did not generate extra revenue.

The survey authors, led by Dr. Brenda E. Sirovich of the VA Outcomes Group, White River Junction, Vt., said that while many have debated just how much the fear of malpractice leads to more aggressive care, "based on our findings, we believe it is not a small effect."

The survey respondents acknowledged that there is a huge variation in care. They said that they’d like to know where they stand when compared with other physicians.

This indicates a willingness to learn more conservative practice, said Dr. Sirovich and colleagues. "Our work shows that primary care physicians recognize the excesses of our health care system, can point clearly to some of the causes, and may be open to changing their own practices to address them," concluded the authors.

The authors mailed a nine-page survey to primary care physicians, asking them to describe how they and their colleagues practiced medicine. A total of 627 physicians were randomly sampled from the American Medical Association’s Physician Masterfile; 70% responded. Most survey respondents were male, board certified, and reported a median of 24 years in practice. Surveyed physicians were provided with an honorarium of $20-$100 for their participation.

The study was supported by grants from the Department of Veterans Affairs and the National Institute of Aging. The authors reported no relevant financial conflicts of interest.

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