Studdert David M, Mello Michelle M, Sage William M, DesRoches Catherine M, Peugh Jordon, Zapert Kinga, Brennan Troyen A
Department of Health Policy and Management, Harvard School of Public Health, Boston, Mass 02115, USA.
JAMA. 2005 Jun 1;293(21):2609-17. doi: 10.1001/jama.293.21.2609.
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.
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.
Number of physicians in each specialty reporting defensive medicine or changes in scope of practice and characteristics of defensive medicine (assurance and avoidance behavior).
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.
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.
医生因医疗事故责任威胁（即防御性医疗）而改变临床行为的频率以及这些改变的后果，是当前医疗事故改革辩论中的核心问题。
研究在医疗事故环境大幅不稳定时期，从事高风险专业的医生中防御性医疗的患病率及特征。
设计、地点和参与者：2003年5月对宾夕法尼亚州6个高诉讼风险专业（急诊医学、普通外科、整形外科、神经外科、妇产科和放射科）的医生进行邮件调查。
各专业报告防御性医疗或执业范围变化的医生数量以及防御性医疗的特征（保障行为和回避行为）。
共有824名医生（65%）完成了调查。几乎所有医生（93%）报告有防御性医疗行为。“保障行为”，如开具检查、进行诊断程序以及转诊患者进行会诊，非常普遍（92%）。在详细描述其最近一次防御行为的防御性医疗从业者中，43%报告在临床不必要的情况下使用了影像技术。避免进行被认为会增加诉讼可能性的程序和患者也很普遍。42%的受访者报告称，他们在过去3年中采取了限制执业的措施，包括取消容易出现并发症的手术，如创伤手术，以及回避有复杂医疗问题或被认为爱打官司的患者。防御性医疗行为与受访者对其责任保险缺乏信心以及感知到的保险费负担密切相关。
在宾夕法尼亚州，防御性医疗在支付最高责任保险费的医生中非常普遍，这可能对成本、医疗可及性以及医疗技术和人际质量产生严重影响。
