The New Health Dialogue

Let’s talk about risk for a moment. Statistically, you are far more likely to experience a fatal accident in the car on the road than you are in an airplane. But somehow, hurtling through the sky thousands of feet in the air just feels more risky than being planted firmly on the ground. We perceive that we’re taking on more risk in an airplane than we are in a car, statistics be damned. According to a recent article in Health Affairs, a similar phenomenon happens to doctors when they think about malpractice. And it doesn't diminish all that much even when their states impose caps on malpractice damages.

We attended an event this morning, Medical Liability and Emergency Care, to mark the release of the September issue of Health Affairs. (Not that September Issue.) We got to listen to the minds behind the articles talk about some major issues in the health policy world -- medical malpractice reform, avoiding and managing medical errors, and problems surrounding emergency room use. Emily Carrier, Senior Health Researcher at the Center for Studying Health System Change, and one of the co-authors of the article about physician perception of malpractice risk, explained the article’s main conclusions.

Carrier and her fellow researchers found that physicians perceive relatively high malpractice risk, even in areas where objective measures of malpractice risk indicate risk is low. (These indicators included factors such as the cost of premiums, how often physicians actually incurred a claim, how much was paid out for the claim, and the structure of state malpractice laws). Across the board, physicians tend to overestimate the fear of “dread risks,” which are like plane crashes in medicine -- “rare but devastating outcomes.” The fear of dread risk is overinflated among physicians in both general practice and specialties. Physicians in high risk states level of concern about malpractice was only 4.3 percent higher than physicians in low risk states.

Even in states that have enacted medical malpractice reforms, physicians still have a high level of concern about malpractice and argue that they practice defensive medicine to allay their fear. Defensive medicine is a term used to describe actions that doctors take (ordering extra tests, scans, or treatments) simply to avoid being sued, rather than to help their patient. As the chart above indicates, almost two-thirds of surveyed physicians said they order tests or consultations to avoid the appearance of malpractice. Part of fixing our health system will mean lowering costs by eliminating wasteful tests and treatments that don’t add value to patient care.

The panelists at the event largely agreed that medical malpractice reform was needed, reforms like hard caps on damages weren’t an effective solution to the problem. (According to Carrier and her co-authors, extending caps on total damages only decreased the level of physician over malpractice by six percent.) Though injured patients deserve to have their claims addressed, a lengthy legal process isn’t necessarily the best solution, said Professor Michelle Mello of the Harvard School of Public Health. Alternative solutions, such as disclose and apologize models or safe harbor policies (that protect doctors who adhere to clinical treatment guidelines). Mello argued that the system needs transparency, but merely disclosing errors  could lead to more lawsuits unless disclosure is complemented by policies such as early dispute resolution and settlement.

If you can't get in a plane without paralyzing fear, you're going to have a hard time travelling. And if you can't treat a patient without paralyzing fear, you're going to have a pretty hard time practicing medicine. (And a hard time changing the delivery system  in ways that move us away from a "more is always better" approach to ordering tests and procedures.) As this article shows, whether or not they actually have something to be afraid of, doctors are still worrying about medical malpractice -- a lot. There are methods to fix the system in a way that will raise the comfort level of both doctors and patients -- we just need the will to implement them.

Read the whole September Issue here (subscription required).

Also our colleague Joanne Kenen has written quite a bit about malpractice reform alternatives, including disclose and apologize. Here are some posts and magazine articles here, here, here and here.