How do we tolerate uncertainty in medicine? Start with malpractice reform.

Defensive medicine is one of the biggest reasons clinicians provide unnecessary tests and procedures. In a recent survey of physicians, 84.7% said that fear of malpractice drives overtreatment. Even when doctors may recognize that doing more would not be helpful for the patient, many are pushed to offer more anyway, because they believe that it protects them in case of a lawsuit or bad outcome.

However, the impact of malpractice reforms such as damage caps (limiting compensation for pain and suffering in malpractice suits) on overuse has been unclear. Several studies over the past decade found that malpractice reform had a minimal effect on health care spending and waste in the states that adopted these policies. Does this mean that malpractice reform has no effect on clinicians’ treatment decisions? Or that the effect just hasn’t been picked up in studies that look at broad changes in health care spending? 

new study in JAMA Cardiology gives us a clue by providing a new look at the issue. Researchers examined the effect of malpractice reform on specific testing and treatment decisions for coronary artery disease, a condition that involves significant medical uncertainty and risk of malpractice (since not catching a heart attack is life-threatening).   

Researchers compared cardiologists’ treatment decisions in nine states that adopted damage caps between 2002 and 2005 to states that did not adopt a cap. They looked at changes in physician treatment decisions after the caps were instated and then compared these changes in states with no caps, what’s known as a “difference in differences” method. They found that in states that adopted the caps, physicians changed the way they treated patients for coronary artery disease. During the 3 years following cap adoption, physicians in “cap states” conducted 24% fewer angiographies as a first test, compared to physicians in no-cap states. Instead, they conducted more stress tests, a less-invasive test, as a first test.  

Physicians in cap states also referred 20% fewer patients for angiography after stress testing compared to physicians in no-cap states, and performed fewer stent procedures. This is an encouraging pattern, especially for stents, which may not be any more effective than placebo for patients with stable coronary disease.

“These findings suggest that physicians tolerate greater clinical uncertainty in coronary artery disease testing and treatment if they face lower malpractice risk,” the study authors wrote.

Fear of malpractice is very real among clinicians, but this fear is part of a larger issue driving overuse in our health system – intolerance of uncertainty. As much as physicians want to avoid lawsuits, they are also driven by the fear of harming a patient by missing something rare, or not doing everything they can to help. Our health system facilitates this drive, by putting few limits on the amount and type of care provided and paid for.

As the “less is more” movement has grown, many physicians feel frustrated because they are being given an impossible task – they are asked to cut unnecessary services but still face all the consequences of a health care culture that doesn’t tolerate uncertainty.

We tell doctors they have to reduce unnecessary scans and tests, but we also tell them it’s not okay to miss things,” said Dr. Saurabh Jha, Associate Professor of Radiology at the University of Pennsylvania in a Lown interview. “We have to tell people that you will occasionally miss things and that’s okay. It needs more than incentives, it needs a cultural shift,” he said.

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