Context How often physicians alter their clinical behavior because of the threat of malpractice liability, termed defensive medicine, and the consequences of those changes, are central questions in the ongoing medical malpractice reform debate. Objective To study the prevalence and characteristics of defensive medicine among physicians practicing in high-liability specialties during a period of substantial instability in the malpractice environment. Design, Setting, and Participants Mail survey of physicians in 6 specialties at high risk of litigation (emergency medicine, general surgery, orthopedic surgery, neurosurgery, obstetrics/gynecology, and radiology) in Pennsylvania in May 2003. Main Outcome Measures Number of physicians in each specialty reporting defensive medicine or changes in scope of practice and characteristics of defensive medicine (assurance and avoidance behavior). Results A total of 824 physicians (65%) completed the survey. Nearly all (93%) reported practicing defensive medicine. "Assurance behavior" such as ordering tests, performing diagnostic procedures, and referring patients for consultation, was very common (92%). Among practitioners of defensive medicine who detailed their most recent defensive act, 43% reported using imaging technology in clinically unnecessary circumstances. Avoidance of procedures and patients that were perceived to elevate the probability of litigation was also widespread. Forty-two percent of respondents reported that they had taken steps to restrict their practice in the previous 3 years, including eliminating procedures prone to complications, such as trauma surgery, and avoiding patients who had complex medical problems or were perceived as litigious. Defensive practice correlated strongly with respondents' lack of confidence in their liability insurance and perceived burden of insurance premiums. Conclusion Defensive medicine is highly prevalent among physicians in Pennsylvania who pay the most for liability insurance, with potentially serious implications for cost, access, and both technical and interpersonal quality of care.

Though substantial proportions of the public and practicing physicians report that they have had personal experience with medical errors, neither group has the sense of urgency expressed by many national organizations. To advance their agenda, national groups need to convince physicians, in particular, that the current proposals for reducing errors will be very effective.

For health information on the Internet to achieve its potential as a force for equity and patient well-being, actions are required to overcome the digital divide; assist the public in developing searching and appraisal skills; and ensure physicians have adequate communication skills.

BackgroundPublic use of the Internet for health information is increasing but its effect on health care is unclear. We studied physicians' experience of patients looking for health information on the Internet and their perceptions of the impact of this information on the physician-patient relationship, health care, and workload.MethodsCross-sectional survey of a nationally-representative sample of United States physicians (1050 respondents; response rate 53%).ResultsEighty-five percent of respondents had experienced a patient bringing Internet information to a visit. The quality of information was important: accurate, relevant information benefited, while inaccurate or irrelevant information harmed health care, health outcomes, and the physician-patient relationship. However, the physician's feeling that the patient was challenging his or her authority was the most consistent predictor of a perceived deterioration in the physician-patient relationship (OR = 14.9; 95% CI, 5.5-40.5), in the quality of health care (OR = 3.4; 95% CI, 1.1-10.9), or health outcomes (OR = 5.6; 95% CI, 1.7-18.7). Thirty-eight percent of physicians believed that the patient bringing in information made the visit less time efficient, particularly if the patient wanted something inappropriate (OR = 2.5; 95% CI, 1.5-4.4), or the physician felt challenged (OR = 3.6; 95% CI, 1.8-7.2).ConclusionsThe quality of information on the Internet is paramount: accurate relevant information is beneficial, while inaccurate information is harmful. Physicians appear to acquiesce to clinically-inappropriate requests generated by information from the Internet, either for fear of damaging the physician-patient relationship or because of the negative effect on time efficiency of not doing so. A minority of physicians feels challenged by patients bringing health information to the visit; reasons for this require further research.

This paper reports on a 2005 survey of sicker adults in Australia, Canada, Germany, New Zealand, the United Kingdom, and the United States. Sizable shares of patients in all six countries report safety risks, poor care coordination, and deficiencies in care for chronic conditions. Majorities in all countries report that mistakes occurred outside the hospital. The United States often stands out for inefficient care and errors and is an outlier on access/cost barriers. Yet no country consistently leads or lags across survey domains. Deficiencies in transition care during hospital discharge and coordination failures among patients seeing multiple physicians underscore shared challenges of improving performance across sites of care.