Glassman P A, Rolph J E, Petersen L P, Bradley M A, Kravitz R L
Veterans Affairs Medical Center, West Los Angeles, USA.
J Health Polit Policy Law. 1996 Summer;21(2):219-41. doi: 10.1215/03616878-21-2-219.
Whether personal malpractice experience is part of a tort signal prompting physicians to practice defensively is unclear. To explore this issue further, we assessed how physicians' malpractice experiences affect clinical decision making. We surveyed 1,540 physicians from four specialty groups (cardiologists, surgeons, obstetrician-gynecologists, and internists) using specialty-specific clinical scenarios. Physicians were in active private practice, were covered by a single malpractice insurer for five or more years, and worked in an eastern state. The net response rate was 54 percent (835 of 1,540) but measurable bias, based on practice characteristics, was negligible. Physicians evaluated clinical scenarios that were designed to maximize potential for finding positive defensive practices (extra tests and procedures). Then they rated how various factors influenced their decisions and answered questions on practice attitudes. The study compared management and testing recommendations among physicians with varying levels of malpractice exposure, which we defined in three separate ways. Participants were unaware of the study hypotheses. Physicians with greater malpractice experience showed no systematic differences in initial management choice or subsequent test recommendations. For example, similar percentages of internists in the top and bottom claims rate quartiles admitted a patient with syncope (78 percent versus 73 percent; p = 42), discharged a patient with nonspecific chest pain (80 percent versus 80 percent; p = .88), and delayed surgery in a patient with nonspecific changes on a electrocardiograph (58 percent versus 68 percent; p = .18). Attitudes about malpractice also did not differ with varying malpractice experience. Personal malpractice experience is not a predominant factor in the tort signal that prompts physicians to engage in defensive practices, to the extent that such practices exist.
个人医疗事故经历是否是促使医生采取防御性医疗行为的侵权信号的一部分尚不清楚。为了进一步探讨这个问题，我们评估了医生的医疗事故经历如何影响临床决策。我们使用特定专业的临床案例，对来自四个专业组（心脏病专家、外科医生、妇产科医生和内科医生）的1540名医生进行了调查。这些医生均在积极从事私人执业，由单一医疗事故保险公司承保五年或更长时间，且在东部某州工作。净回复率为54%（1540人中的835人），但基于执业特征的可测量偏差可忽略不计。医生们评估了旨在最大限度地发现积极防御性医疗行为（额外检查和程序）可能性的临床案例。然后，他们对各种因素如何影响其决策进行评分，并回答有关执业态度的问题。该研究比较了不同医疗事故暴露水平的医生之间的管理和检查建议，我们用三种不同的方式对医疗事故暴露水平进行了定义。参与者并不知晓研究假设。有更多医疗事故经历的医生在初始管理选择或后续检查建议方面没有表现出系统性差异。例如，索赔率最高和最低四分位数的内科医生中，承认晕厥患者入院的比例相似（分别为78%和73%；p = 0.42），让非特异性胸痛患者出院的比例相似（均为80%；p = 0.88），以及对心电图有非特异性变化的患者延迟手术的比例相似（分别为58%和68%；p = 0.18）。关于医疗事故的态度也不因医疗事故经历的不同而有所差异。在存在防御性医疗行为的程度上，个人医疗事故经历并非促使医生采取防御性医疗行为的侵权信号中的主要因素。
