Monday, October 26, 2015

Better thanked than sued

Diagnostic tests such as CT scans are not perfect. A test can make two errors. It can call a diseased person healthy: a false negative. This is like acquitting a person guilty of a crime. Or a test can falsely call a healthy person disease: a false positive. This is like convicting an innocent person of a crime that she did not commit. There is a trade-off between false negatives and false positives. To achieve fewer false negatives we incur more false positives.

Physicians do not want to be wrong. Since error is possible, we must choose which side to err towards. That is we must choose between two wrongness. We have chosen to reduce false negatives at the expense of false positives. Why this is so is illustrated by screening mammography for breast cancer.

A woman who has cancer which the mammogram picks up is thankful to her physician for picking up the cancer and, plausibly, saving her life.

A woman who does not have cancer and whose mammogram is normal is also thankful to her physician. The doctor does not deserve to be thanked as she played no hand in the absence of the patient’s cancer. But instead of thanking genes or the cosmic lottery, the patient thanks the doctor.

How about the false negative — the cancer missed on the mammogram? A common reason doctors get sued is missing cancer on mammography. The false negative is not a statistic but a real person. We promised her early detection of cancer, but we failed. It is not surprising that she sues us for breaking our promise.

Now consider the false positive. She doesn’t have cancer. The mammogram flags a possible cancer because of a suspicious finding. Abnormalities in mammograms are seldom binary. There are shades of gray. Because the shade of gray is a suspicious shade, she has an ultrasound and then a biopsy. She is waiting for the results of the biopsy. Her heart is pounding with anxiety. The physician breaks the news to her “no cancer, your biopsy is negative.”

Imagine her relief. Far from being angry with the doctors for taking her into a rabbit hole she is grateful. That the possible abnormality in her mammogram was not ignored shows that her doctor cares. You can never care too much. You can never be too safe. Better safe than sorry.

This reminds me of the Stockholm syndrome — a curious phenomenon first described in a bank robbery. This is when hostages develop positive feelings for their captors, and have an exaggerated appreciation for acts of unexpected kindness. Is the gratitude of the false positive the medical variant of the Stockholm syndrome?

Doctors are thanked by the false positives but can be sued by the false negatives. When you don’t know what the outcome will be the choice is simple — better thanked than sued.

Doctors haven’t stopped being wrong. We just make more tolerable mistakes. But we are not alone. We live in a society that is obsessed with safety. Precaution is the new morality. False positive is precaution by another name.
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  1. NEW YORK (Reuters Health) - Providing more care than necessary may work to lower a doctor's risk of being accused of malpractice, suggests a new U.S. study.

    Although the results can't prove extra expenditures are due to defensive medicine, the researchers found that doctors in Florida who provided the most costly care between 2000 and 2009 were also least likely to be sued between 2001 and 2010.

    "By no means would I consider it to be conclusive, but it does signal to us that defensive medicine could work in lowering malpractice risk, but more research is needed to know if that's true or not," lead author Dr. Anupam Jena, of Massachusetts General Hospital and Harvard Medical School in Boston told Reuters Health.

    He and his colleagues write in an article online November 4 in BMJ that critics of the U.S. malpractice system suggest it encourages defensive medicine.

    "If you ask physicians what's the number one concern they have when you talk to them about their careers, I would say malpractice will come up as one of their top concerns," Dr. Jena said.

    While it's commonly accepted that doctors practice defensive medicine, the researchers write, no studies have been able to answer whether the practice actually reduces the risk of lawsuits.

    For the new study, Dr. Jena's team examined data from Florida hospitals, looking specifically at whether doctors within seven medical specialties were less likely to face lawsuits in the year following one when they racked up higher than average hospital charges.

    Overall, they had data on nearly 25,000 doctors who oversaw about 18.3 million hospital admissions and faced over 4,300 malpractice claims.

    "If you look at doctors who spend more in a given specialty, higher spending physicians get sued less often than low-spending physicians," Dr. Jena said of the findings.

    For example, an internist whose average hospitalization cost about $20,000 (the lowest spending group) faced a 1.2% probability of being sued the following year. That compared to a 0.3% probability of being sued if the internist's average hospitalization cost about $39,000 (the highest spending group).

  2. Jena AB, Schoemaker L, Bhattacharya J, Seabury SA. Physician spending and subsequent risk of malpractice claims: observational study. BMJ. 2015 Nov 4;351:h5516.



    Is a higher use of resources by physicians associated with a reduced risk of malpractice claims?


    Using data on nearly all admissions to acute care hospitals in Florida during 2000-09 linked to malpractice history of the attending physician, this study investigated whether physicians in seven specialties with higher average hospital charges in a year were less likely to face an allegation of malpractice in the following year, adjusting for patient characteristics, comorbidities, and diagnosis. To provide clinical context, the study focused on obstetrics, where the choice of caesarean deliveries are suggested to be influenced by defensive medicine, and whether obstetricians with higher adjusted caesarean rates in a year had fewer alleged malpractice incidents the following year.


    The data included 24 637 physicians, 154 725 physician years, and 18 352 391 hospital admissions; 4342 malpractice claims were made against physicians (2.8% per physician year). Across specialties, greater average spending by physicians was associated with reduced risk of incurring a malpractice claim. For example, among internists, the probability of experiencing an alleged malpractice incident in the following year ranged from 1.5% (95% confidence interval 1.2% to 1.7%) in the bottom spending fifth ($19 725 (£12 800; €17 400) per hospital admission) to 0.3% (0.2% to 0.5%) in the top fifth ($39 379 per hospital admission). In six of the specialties, a greater use of resources was associated with statistically significantly lower subsequent rates of alleged malpractice incidents. A principal limitation of this study is that information on illness severity was lacking. It is also uncertain whether higher spending is defensively motivated.


    Within specialty and after adjustment for patient characteristics, higher resource use by physicians is associated with fewer malpractice claims.


    This study was supported by the Office of the Director, National Institutes of Health (grant 1DP5OD017897-01 to ABJ) and National Institute of Aging (R37 AG036791 to JB). The authors have no competing interests or additional data to share.

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