Head injuries are taken seriously in the emergency department (ED) because of the potential for poor outcomes, including death, if not diagnosed properly. Attempting to prevent negative outcomes (and to reduce medical malpractice risk) drives many ED providers to treat all head injury patients aggressively with computed tomography (CT) imaging, despite that it is unnecessary in most cases. This defensive medicine strategy leads to unnecessary imaging studies that comfort the provider but that do not provide better patient care.
Surveying PAs, NPs and Physicians
We designed a study to explore the prevalence of defensive medicine in emergency care and to identify measures that might help eliminate it. Specifically, we sought to determine whether providers followed standard-of-care guidelines, or whether they ordered CT scans for many if not all head injury patients simply to reduce the perceived risk of legal exposure.
We recruited physicians, PAs and NPs from several central New York EDs to complete an anonymous and confidential 18-question survey. Respondents' characteristics are in the accompanying table.
Results showed that 83% of respondents have altered the way they practice in order to reduce the risk of litigation, and that 17% are currently named in a malpractice case. Among respondents, 13% said they would order a CT for a patient meeting the criteria for a minor head injury; this percentage increased to 21% if the patient had been involved in a motor vehicle accident. For a head injury patient with only a 3% chance of intracranial lesion, 29% of respondents still would order CT in an attempt to further reduce the risk.
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If a patient claimed to have had a fall, had no symptoms but still requested CT, 21% of respondents would order it despite no medical indication to do so. A patient with a minor head injury who requests a third CT scan "just to make sure" would receive the scan from 14% of respondents.
A total of 71% of respondents said they would practice differently if litigation were not a concern when making medical decisions. All 24 respondents said they believe that attorney advertising encourages patients to file litigation against healthcare providers, and that litigation should not be possible when a negative outcome occurs with no healthcare provider negligence. Ninety-three percent of participants said tort reform is a possible means of reducing defensive medicine, and 84% identified a financial cap on malpractice awards as another solution.
Impact Beyond the ED
Many providers feel that defensive practices such as CT scans for minor head injuries not only represent good care but also lead to patient satisfaction. If patients request CT because of a fear of a negative outcome, providers often give in and order the scan, setting the stage for overuse of diagnostic tests throughout healthcare, not just for head injuries in the ED.
Sick or injured patients often have a negative outcome despite clinicians' best intentions, and attorneys often encourage litigation in an attempt to reach an out-of-court settlement. Being named in a lawsuit is enough to damage a career, and the results of the litigation may not matter, because providers now must report that they have been named in a lawsuit. The two survey questions that yielded a unanimous answer - that lawyers' ads persuade patients to sue, and that non-negligent providers should not be sued when a negative outcome occurs - suggest that providers believe reducing the risk of being named in a lawsuit is worth the increased costs of defensive medicine.
Malpractice caps could reduce annual U.S. healthcare expenditures by billions of dollars. Large "pain and suffering" awards can be the incentive to seek litigation, whether or not a legitimate claim of provider negligence exists; many believe caps could restructure malpractice insurance costs and reduce malpractice litigation.
That 71% of participants said they would immediately change their practice habits if the threat of litigation were removed suggests that defensive medicine not only exists but also is necessary in the current system. The rising cost of healthcare and malpractice insurance likely will drive the changes needed to reduce litigation and perceived litigation risk, and with it, defensive medicine.
Jeremy M. Welsh is director of clinical education and assistant clinical professor at the Clarkson University PA program in Potsdam, N.Y. Jeffrey L. Alexander and Helen Ewing are on faculty at the A.T. Still University doctor of health sciences program in Mesa, Ariz. William H. Holmes on faculty at the LeMoyne College PA program in Syracuse, N.Y.