Defensive medicine is widely practiced and may lead to higher costs, lower quality of care and less access to services, according to a new study from the Journal of the American Medical Association.
But since this was something many observers already knew, some experts said it's doubtful the report will create much movement in the state's medical liability reform efforts."What kind of reform could you adopt at this point to make it go away?" asked Steve Foreman, an attorney and associate professor of economics and allied health at Robert Morris University in Moon Township, Pa. "You can't go to the Legislature and say, `If you cap liability, defensive medicine will go away.' "
Policy consultant Atul Grover with the Pittsburgh Regional Healthcare Initiative, a healthcare consortium pushing for better patient-centered care, agreed with Foreman. But Grover, who is also affiliated with the Lewin Group, said the report was helpful because it raised the profile of defensive medicine as a side effect of the medical liability crisis.
"It doesn't jump out and tell me we need to do X, Y or Z in terms of tort reform, but it says something's wrong," Grover said. "That's what the strength of the study is3/4it says, `Look closer at what's going on.' "
For the report, published in the June 1 JAMA, researchers surveyed 824 Pennsylvania physicians in the specialties most frequently involved in litigation: emergency medicine, general surgery, neurosurgery, obstetrics and gynecology, orthopedic surgery and radiology. Some 93% of the doctors reported sometimes or often engaging in defensive medicine. The survey was conducted by mail (See chart).
Practices meant to protect against oversights by physicians, such as performing extra diagnostic tests or referring patients for consultation, were about twice as common as avoidance practices, such as refusing to perform certain procedures or treat certain patients.
More than 59% of all respondents said they often ordered more tests than medically indicated. That figure was 70% among emergency physicians.
By comparison, some 32% of respondents said they had limited their practice or avoided procedures as a defensive step.
Physicians said they ordered extra tests not only out of legal concerns but also to pacify demanding patients, feel more confident in their decisions and create a paper trail indicating they had tested patients for particular conditions.
The irony is that defensive medicine can potentially lead to more lawsuits because performing more tests and procedures exposes patients to more risks, study co-author William Sage said at a May 31 news conference.
"I think he's right on that," said Foreman, a former director of the Pennsylvania Medical Society's Health Services Research Institute. "And it's not just risk but also time and hassle3/4and for what purpose?"
Sage, a professor at Columbia University Law School in New York and director of the Project on Medical Liability in Pennsylvania, added that there's also a negative side to recent efforts that promote getting patients involved in their own care.
"Assertive patients do not, in the current malpractice climate, always get the right care," Sage said. He explained that because doctors are so apprehensive about being sued, patients who insist on certain tests "may be indulged," even if the test is not in their best interest.
The researchers did not calculate the added cost of defensive medicine but noted that more than 90% of respondents had ordered unnecessary tests and more than 60% of specialists, excluding only neurosurgeons, had performed or requested unnecessary procedures, such as biopsies.
Researchers said the high degree of avoidance behavior indicated defensive medicine not only raises costs but also limits access to services.
The effect is particularly strong on women. Some 46% of OB/GYNs reported reducing their obstetric practices, while 54% of radiologists said they avoided interpreting mammograms.
Foreman said these findings show how the state's medical service network is unraveling and adds to a growing body of evidence that "Pennsylvania is not a good place to practice medicine."
"Intelligent, well-trained physicians know this and they are not coming here," he said.