A malpractice fear scale quantifies defensive medicine

Quantifying defensive medicine: Now we have the “malpractice fear scale”
“In evaluating patients who have chest pain, some emergency room physicians too often order unnecessary tests and hospitalizations out of fear of malpractice lawsuits, according to a new study. ‘Concern about malpractice has a formidable effect on physician decision making,’ particularly in the scenario of a possible heart attack or unstable angina, collectively referred to as acute coronary syndrome, Dr. David A. Katz told Reuters Health.

Katz, from University of Iowa, Iowa City, and colleagues developed a malpractice fear scale and used it to evaluate the association between emergency physicians’ fear of malpractice and the evaluation and treatment of patients with symptoms suggestive of an acute coronary syndrome.

The findings are reported in the online issue of Annals of Emergency Medicine.

Patients seen by ER doctors with the highest scores on the malpractice fear scale were significantly less likely to be discharged from the emergency room than were patients seen by ER doctors with the lowest scores, the authors report. The trend persisted when only low-risk patients were included in the analysis.

Physicians with the highest malpractice fear scores were also more likely to admit patients to monitored beds and to order laboratory tests and chest X-rays in the emergency room, the report indicates . . .

. . . ‘Our findings that high-fear physicians are more likely to admit patients with symptoms of possible acute coronary syndrome (including low-risk patients) and to obtain more diagnostic tests in these patients suggest that the initial costs of care are quite a bit higher for this group of physicians.’”

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  • Anonymous

    :…for this group of physicians…”, which is pretty much any reasonable physician

  • drdarcy

    Hey Kevin,
    Interesting link … the paper’s not actually out yet, just corrected proofs. I downloaded the pdf, which you can also do if you have access to that journal, or if not, I’m happy to send it to you. It’s a six-item measure, scored with a five-point Likerty scale.

    A couple interesting points about their small sample (N = 33 ER docs, 2 teaching hospitals). They didn’t gather data on who (if anyone) had actually been sued, and there appears to be a trend towards older MDs being more likely to be in the low fear group.

    Raises some interesting possibilities: have the older MDs already been sued, and so they know what to expect? Have the older MDs not been sued, and therefore become more confident they will not be? Are they just more confident in general?

  • chucky

    I am an ER doc. I feel that I practice in the middle range of the bell shaped curve as far as risk tolerance is concerned. There is no reward or glory for trying to discharge every “soft” chest pain.

    I have estimated that each shift I admit one person, order 3-4 CT or ultrasounds, and order 10 plus blood tests that are purely defensive. I estimate this daily cost at 10-15 thousand dollars X 15-20shifts/month = 1.8 to 3.6 million dollars annually!!

    I scoff at those who argue that defensive medicine does not significantly raise medical expenditures.

  • Anonymous

    “I scoff at those who argue that defensive medicine does not significantly raise medical expenditures.”

    The only people that claim this are not doctors – usually they’re people who have a vested interest in convincing the public otherwise (read: lawyers). Think about it.

  • Elliott

    This looks like the same survey or at least sample reported earlier regarding admission for chest pain. I wonder how many papers will come out of the same group?

  • Anonymous

    “I scoff at those who argue that defensive medicine does not significantly raise medical expenditures.”

    Let’s say you’re right. Got a suggestion for reducing it?

  • Anonymous

    They should do a study to see if Homeless patients or patients whose charts read “none” for next of kin (read: less litigators)get less tests and are admitted less often. It’s hard not to look at demographics when you’re thinking of admitting someone purely to cover your ass and you know there’s nothing wrong with them.

  • Elliott

    mbu, the issue with defensive medicine is that it is a meaningless term in the sense that it reframes what is simply stupid with a rationale. I don’t see any evidence that “defensive” medicine defends the patients. Outcomes are no better. I don’t see any evidence that “defensive” medicine defends the doctor.

    Are doctors with low c-section rates sued more often than doctors with high c-section rates? I don’t know the answer but I extend a proposition of an even money bet to all comers with me taking the side that low c-section rates get sued less.

  • Rich, MD

    Elliott –

    You make good points. Similarly, there is no evidence that total body CT scans save lives or improve outcomes, and yet patients ask for them, and can get them on demand. Outcomes are no better.

    Performing a higher proportion of C-sections may not reduce the risk of being sued. Performing a single c-section in a given case will certainly prevent one from being sued in that case for failing to perform one. In a certain situation, an OB has to decide, is there enough distress to proceed to C-section? Can I wait and perhaps the delivery will progress smoothly? These are judgement calls, in under a threat of potential litigation, the doctor may consciously or sub-cousciuously tip the scales in favor of a c-section.

  • Anonymous

    Obviously, the answer for most OB_GYNS is to not perform ANY C-sections, or vaginal deliveries, for that matter. A high number of OB-GYN Docs in high-risk states are getting out of the OB portion of their jobs. Anyone who advises med students needs to warn them to stay away from this specialty for now. I have a friend who got out after his INTERN year and he’s had to defend 2 lawsuits just from that one year.

  • Elliott

    Most tudies show that malpractice pressure characterized by premiums or number of claims or other proxies tends to increase the number of c-sections in a region. The funny thing is that the studies I have read which pay lip service to the correlation is not causation axiom then go on to implicitly buy in to the higher malpractice pressure leads to more c-sections without even considering the possibility that the greater number of c-sections might be leading to higher malpractice pressure.

  • Curious JD

    “A high number of OB-GYN Docs in high-risk states are getting out of the OB portion of their jobs. “

    Of course, you have a source for this claim other than what a friend of a friend told you, correct?

  • Anonymous

    Yes, in the hospital I work in I can’t spit without hitting a former OB-GYN who is now doing ER, Medicine, or some other speciaty. If you check with NRMP (National Resident Matching Program) you’ll find that although OB_GYN used to be a highly sought after residency position, programs are now having trouble finding new victims, I mean applicants. They now have to reach out to foreign trained grads to fill spots. At least it’ll be easier to sue OB-Gyns, since one effect of the asssault on the profession by lawyers is to lower the quality of victim (applicant) going into the profession.

  • Curious JD

    Well clearly, your anecdotes are evidence of a nationwide trend. That statistics degree is really coming in handy!

    Now you can even judge the quality of applicants into a specialty even though you’ve never seen them. A first rate statistician AND a psychic.

    I bet your resume kicks butt!

  • chucky

    Elliot, Yes I agree defensive medicine is largely “stupid” and does little for the patient and can be harmful. Example: finding an incidental finding that should have not been looked for anyway, that leads to more invasive testing, that leads to a complication.

    Does it help the physician? I don’t know of any data. Distinctions between “good”, “defensive”, and “bad” medicine are often difficult, especially when made in real time while managing a department full of patients. Psychologically, I will feel a lot better if that “soft” chest pain patient rules in with a heart attack while in the hospital rather than at home. Then there is the annoying customer service aspect. If a patient requests a test/admission that I don’t think is indicated, patient complaints are filed, and Hospital administration wants the doc to shoulder the problem. Who wants to be annoyed with that all of time?

    What I do know is that it costs a lot of money despite the naysayers. I can estimate cost, and I am sure other physicians in different specialties can as well.

  • Curious JD


    It seems like you want to practice in a vacuum where your decisions never have to be explained or questioned, and you can never be held responsible if they are wrong.

    Sounds nice. But that’s not how the world works.

    I don’t think anyone disputes that there is a cost to “defensive medicine”, however you define it. What the dispute is over is what to do about it. Or if there is anything you can do about it.

  • chucky

    No suggestions. The waters are too poisoned. I need to go on mission trips to practice with reasonable judgement.

  • chucky

    curious JD,

    Thanks for the brilliant lesson on how the world works.

    I don’t think any doc expects to practice in a “vacuum” resistant to criticism and responsibility. Is that your prejudicial view?

    On the other end of the spectrum I would doubt that you hold the view that every bad outcome is the direct result of “bad” medicine.

    I would favor a system like New Zealand where there is review and restitution to the victims of malpractice. Other than the big awards that lawyers are aiming for, most victims in this country get very little restitution. It is all eaten up by the legal process.

  • Anonymous

    “Now you can even judge the quality of applicants into a specialty even though you’ve never seen them. A first rate statistician AND a psychic.”

    I apologize. You wouldn’t know that the quality of applicants applying to a specialty are rated by the NRMP (matching service) and RRC (residency review committee) through Board Scores, class rank, etc. Psychic? What does being a psychic have to do with the fact that when a specialty becomes less popular (ie OB-GYN) programs are forced to fill it with Foreign Grads who statistically have much greater difficulty passsing the specialty Boards? Am I psychic because the average Board scores and class rank for high risk specialties has gone down in the last five years? I thought lawyers don’t insult those they debate with anyway?

  • Anonymous

    Got any links? Here’s the thing anonymous, your stats are pretty suspect because you routinely throw out stuff you have literally no basis for.

    I was being sarcastic, but I didn’t realize you would be so sensitive. I figured since you’ve got no problem dishing it, that you might be OK with taking it. Forgive me if I was mistaken.

  • Anonymous




  • Anonymous
  • Anonymous


    Malpractice crisis blamed; Fewer U.S. seniors match to ob.gyn. residency slots: the fill rate for this group falls to 65.1%
    OB/GYN News, April 1, 2004 by Jennifer Silverman
    Fewer U.S. medical students matched to ob.gyn. residency positions again this year, renewing concerns that the medical liability crisis is driving students away from the profession.

    A total of 1,142 ob.gyn. positions were offered this year, 9 fewer than in 2003. Graduating seniors filled 1,066 of those positions, an overall fill rate of 93.3% that marks an increase of 2.1% from last year, according to statistics released by the National Resident Matching Program (NRMP).

    The number of ob.gyn. residency slots filled by students graduating from U.S. medical schools dropped more dramatically, however. Only 743 U.S. seniors matched to ob.gyn. this year, 43 fewer than in 2003, and 219 fewer than in 1994. The fill rate for U.S. seniors fell again this year, to 65.1%.

    The drop in U.S. seniors “is not unexpected,” considering that medical students have major trepidations about the medical liability crisis, Dr. John M. Gibbons Jr., president of the American College of Obstetricians and Gynecologists, told this newspaper.

    The medical liability premium crisis “has gone from number two to number one in terms of the most serious concern prompting people not to go into ob.gyn.,” Dr. Gibbons said.

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