The idea of defensive medicine is that ordering lots of tests, admitting patients and making referrals will reduce the risk of being sued, even when there is a low probability that the activity will be beneficial. In obstetrics it is well known that the clinician is much more likely to be sued for not doing, than for doing, a Caesarean section.
But what about general medicine – is it true that defensive medicine works in its own terms, i.e. that it will reduce the risk of medical litigation? Resource use by physicians is a proxy for defensive medicine. So, is there a correlation between physician spending and litigation risk?
STOP AND THINK – WHAT IS YOUR GUESS?
NOW READ ON.
Well, the answer (and it was not what the CLAHRC WM Director guessed) is that there is a strong negative correlation between spending on extra activities and the risk of litigation.
This is a spectacular record linkage study – in this case data from Florida hospitals and data from the Florida Office of Insurance Regulation. Doctors were compared within speciality after risk-adjustment for patient severity. To avoid the possibility of reverse causality, expenditure in one calendar year was correlated with incidence of litigation in the following year, it having been established that expenditure patterns within clinicians are highly correlated across time epochs. The study also replicated the well-known negative correlation between Caesarean section rate and risk of a malpractice claim.
So it’s not just how well you communicate with patients that determines your litigation risk, but how defensive your practice is. Why is this? Do patients get a sense that you have taken the complaint seriously when you have done the things that consume the resources? Or do they sense that their chances of successful litigations are reduced? Or is the extra-expenditure effective in reducing adverse events? The policy implications turn on the mechanisms by which higher expenditure translates to lower claims. For instance, if activity reduces the probability of a misdiagnosis, then defensive practice is not really defensive – it is clinically effective and quite possibly cost-effective because it has the potential to reduce the costs of both adverse events and litigation. On the other hand, if the (negative) correlation is an artefact of patient perception, then education may be the way forward. From the point of view of the clinician, the implications are pretty obvious, whatever the mechanism.
— Richard Lilford, CLAHRC WM Director
- Jena AB, Schoemaker L, Bhattacharya J, Seabury SA. Physician spending and subsequent risk of malpractice claims: observational study. BMJ. 2015; 351: h5516.