Medical errors, malpractice, and defensive medicine: an ill-fated triad

Abstract

For the first 180 years following the founding of the US, physicians occasionally were sued for medical malpractice. Allegations of negligence were errors of commission -i.e. the physician made a mistake by doing something wrong, usually mistreatment of a fracture or dislocation, a complication or death following a surgical procedure, prescribing the wrong medication, and after the discovery of the X-ray by Roentgen in 1895, causing radiation burns. In the mid twentieth century malpractice allegations slowly changed from errors of commission to errors of omission -i.e. the physician failed to do something right: almost always, failed to make a diagnosis. The number of malpractice lawsuits increased at a geometric rate beginning in the 1960s, and in the 1970s physicians began practicing defensive medicine, which lead physicians to order unnecessary radiology exams and tests. In the past 20 years the number of malpractice lawsuits has been decreasing, but the practice of defensive medicine has continued. Unnecessary exams and tests increase the likelihood of overdiagnosis and overtreatment, i.e. a new kind of error of commission.

Defensive medicine in Europe: a ‘full circle’?

“…DM practice is generally divided into two categories [1,17]: (1) 'positive' DM occurs when physicians prescribe unnecessary or repetitive tests, referrals and/or procedures;…”

“…Since any medical practice may virtually offer patients some benefit [8,40,41], it is hard to draw a line between cautious and defensive practices [19,21,30], with participants giving black or white answers to necessarily gray questions [18]. As a consequence, cost estimates of DM sourced from surveys are hardly reliable too [1].…”

Real World Evidence: Can We Really Expect It to Have Much Influence?

“…If we couple this difficulty in understanding with the worldwide prevalence of defensive medicine (the perception that HCPs can be sued by patients or relatives if they have made a presumed medical error) that has been well documented (see for example Berlin 2017 or Vento et al 2018) [14,15], then there can be little hope that the findings from RWE are likely to be affecting clinical practice in anything but the most limited way, since why would anyone change their behaviour on the basis of something they don't understand if they feared the end result might expose them to litigation? If these new findings were to be incorporated into guidelines then clearly this problem could be minimised; however, this returns us to the problem that current guideline coverage is relatively low (in terms of the number of treatments/procedures covered) and, until we can utilise the undoubted potential of RWE to expand guideline coverage, is likely to remain so for the immediate future.…”

Analysis of medical malpractice claims to improve quality of care: Cautionary remarks

“…The link between malpractice litigation and defensive medicine is controversial, for it can be difficult to distinguish between defensive medicine and appropriate increases in care . But it is an important distinction to make, in light of the significant risks and inefficiencies defensive medicine can generate …”