Fear of litigation

It has long been known that hospital emergency rooms are one of the most expensive places to receive care. There are many reasons why this is so, but the main factor is the inherent nature of emergency care: fast-paced and resource-intensive, with everything to lose if a potentially lethal illness or injury is somehow overlooked or misdiagnosed.

The pressure to overtest and overtreat is enormous, as an Associated Press story recently explained:

The fear of missing something weighs heavily on every doctor’s mind. But the stakes are highest in the ER, and that fear often leads to extra blood tests and imaging scans for what may be harmless chest pains, run-of-the-mill head bumps, and non-threatening stomachaches.

Many ER doctors say the No. 1 reason is fear of malpractice lawsuits. "It has everything to do with it," said Dr. Angela Gardner, president of the American College of Emergency Physicians.

The fast ER pace plays a role, too: It’s much quicker to order a test than to ask a patient lots of questions to make sure that test is really needed.

If you haven’t been following the Associated Press’s "Overtreated" series, I’d urge you to do so. Besides tackling the overall mindset that "more is better," the various installments in the series have addressed back pain, cancer screening, medical imaging and end-of-life care. You also can find a great multimedia interactive tool here.

The concept of overtreatment isn’t something many Americans are accustomed to talking about. Although it’s easy to blame physicians for ordering too many expensive tests or prescribing too many expensive drugs, the fact is that consumers share some of the responsibility. As the AP story points out, patients’ expectations are often high:

Many think every ache and pain deserves a high-tech test.

"Our society puts more weight on technology than on physical exams," Gardner said. "In other words, why would you believe a doctor who only examines you when you can get an X-ray that can tell something for sure?"

Refusing those demands creates unhappy patients. And concern that unhappy patients will sue remains the elephant in the emergency room.

In light of this, it was interesting to come across a newly released study in the Archives of Internal Medicine that found nine in 10 physicians who responded to a survey believed doctors overtest and overtreat to protect themselves from being sued. The survey involved more than 1,200 physicians nationwide and included emergency-room doctors, primary care doctors and surgeons. The vast majority of the physicians who were surveyed said they believed it would help decrease unnecessary testing if physicians didn’t have to fear unwarranted accusations of malpractice.

What we have here is a standoff: fear of litigation and a long-standing philosophy that more medicine is better medicine vs. valid concerns about the cost and potential harms of overtreatment. Until we figure out how to reconcile these opposing beliefs, bringing down the cost of health care in the U.S. will likely continue to be an uphill battle.

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