Survey Shows ED Doctors Worry More About Patient Harm Than Getting Sued

Fear of patient harm may be a greater motivator than fear of being sued among emergency department (ED) clinicians making medical decisions, an online survey suggested.

Using a Likert scale of 1 (strongly disagree) to 6 (strongly agree), mean score was 4.40 for fear of harm versus 3.40 for fear of lawsuit (P<0.001) among all ED attending physicians and advanced practice clinicians (APCs) working in Massachusetts acute care hospitals, reported Linda M. Isbell, PhD, of the University of Massachusetts Amherst, and colleagues.

Mean fear-of-harm score was similar whether the survey was completed before or after the COVID-19 pandemic started (4.42 vs 4.39; P=0.70), as was mean fear-of-lawsuit score (3.41 vs 3.38; P=0.70), they wrote in a research letter published in JAMA Network Open.

Fear-of-harm scores were higher than fear-of-lawsuit scores, regardless of clinician type, experience, or sex, and positively correlated (Pearson r = 0.53; P<0.001), the authors said.

These findings challenge interpretations of previous research suggesting that physicians practice “defensive medicine,” opting for more tests or providing more referrals to shield themselves from malpractice suits, Isbell and team noted.

“When we look at defensive medicine, a lot of times people are really just focusing on a limited number of variables, and right at the top of the list, everyone thinks that doctors are ordering lots of tests because they’re afraid of malpractice,” Isbell told MedPage Today. “And we’re saying, actually, you can imagine a doctor who is just really afraid of harming people — a lot of doctors are — and they don’t care that much about malpractice.”

While few studies have evaluated excess testing and referrals alone, one 2019 review on waste in the U.S. healthcare system, which included testing, along with low-value screening, procedures, and medication use, yielded an estimate of overtreatment totaling $75.7 billion to $101.2 billion.

According to one overview, reasons for excess testing are varied and can range from uncertainty in diagnoses and gaps in training, to patient expectations and financial incentives.

In the current cross-sectional study, multivariable linear regressions showed that, compared with those with 0 to 4 years of experience, the adjusted fear-of-harm scores were different for respondents with 5 to 14 years of experience (regression coefficient [β] = -0.25; P=0.009) and those with 15 to 44 years of experience (β = -0.38; P<0.001). Differences were also noted between physicians and APCs (β = -0.30; P<0.001) and between men and women (β = -0.17, P=0.03).

Furthermore, fear-of-lawsuit scores were also different between respondents with 5 to 14 years of experience (β = -0.35; P<0.001) and 15 to 44 years of experience (β = -0.72; P<0.001) compared with those with 0 to 4 years of experience and for physician versus APCs (β = -0.18; P=0.053).

Isbell noted that fear of harm and fear of a lawsuit may not be entirely separate from one another — that is, a clinician could be worried about a lawsuit as the fallout of harming a patient — but interventions for one set of concerns would differ from the other. “Intervening on a physician who’s like, ‘yeah, malpractice is a concern, but I’m really freaking out about hurting someone,’ is going to be really different than intervening when you just assume that the person is concerned about malpractice,” she said.

For example, interventions to address fear of harming a patient could entail giving ED clinicians more feedback, both on the amount of tests they’re conducting, and how effective the tests were at preventing harm, she explained.

This study included 1,222 ED clinicians (physicians, nurse practitioners, or physician assistants) in acute care hospitals across Massachusetts (mean age 43.3, 54.2% men). Participants completed an online survey that asked them to rate how much they agreed with the statements, “In my day-to-day practice, I am fearful of making a mistake which results in harm to the patient” and “In my day-to-day practice, I am fearful of making a mistake which results in being sued.”

Response rates were similar between physicians (77.2%) and APCs (75.8%). Modal responses were moderately agree to fear-of-harm (31.1%) and slightly agree to fear-of-lawsuit (29.1%) questions.

The study’s sample of ED clinicians in Massachusetts limits its generalizability to other populations and settings, Isbell and team noted. It’s also unclear if those who took the online survey differed from those who did not.