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David M. Studdert, LLB, ScD, MPH; Michelle M. Mello, JD, PhD, MPhil; William M. Sage, MD, JD; Catherine M. DesRoches, DrPH; Jordon Peugh, MA; Kinga Zapert, PhD; Troyen A. Brennan, MD, JD, MPH

JAMA. 2005;293:2609-2617.

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.

Author Affiliations: Department of Health Policy and Management, Harvard School of Public Health (Drs Studdert, Mello, DesRoches, and Brennan), Department of Medicine, Harvard Medical School (Dr Brennan), and Department of Medicine, Brigham and Women’s Hospital (Dr Brennan), Boston, Mass; Columbia Law School, New York, NY (Dr Sage); and Harris Interactive Inc, Rochester, NY (Mr Peugh and Dr Zapert).

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