Acute Care/Hospitalization

Fear of malpractice prompts emergency physicians to practice defensive medicine with potential heart attack patients

Of the 7 million people who arrive at U.S. emergency departments (EDs) with chest pain or other symptoms of possible heart attack or unstable angina, about half are hospitalized or admitted for observation. The majority of these patients will end up not having either problem; however, since a missed heart attack is one of the most frequent reasons for medical malpractice in adult medicine, doctors are reluctant to send low-risk patients home. Emergency physicians' fear of malpractice is associated with increased hospitalization of low-risk heart attack patients and greater use of diagnostic tests, according to a new study supported in part by the Agency for Healthcare Research and Quality (HS10466).

Researchers surveyed 33 emergency physicians from 2 university hospitals. The six-item malpractice survey addressed physician concerns about lawsuits; a five-item survey assessed physicians' tendencies toward risk aversion.

Overall, emergency physicians in the upper tertile of malpractice fear were 66 percent less likely than those in the lower tertile to discharge low-risk ED patients with heart attack symptoms, who can generally be treated as outpatients. They were also more likely to order a chest x-ray and blood tests for cardiac troponin, a protein released from dead or injured cells in the heart muscle due to even a mild heart attack.

Similarly, patients treated by emergency physicians in the upper tertile of malpractice fear were nearly twice as likely to be admitted to an intensive care unit or a cardiac monitoring (telemetry) bed than those of doctors in the lower tertile. The more cautious approach by the upper-tertile doctors did not change after controlling for individual doctors' degree of risk aversion. The findings were also adjusted for patient characteristics, patient risk group, study site, and clustering by emergency physician.

See "Emergency physicians' fear of malpractice in evaluating patients with possible acute cardiac ischemia," by David A. Katz, M.D., M.Sc., Geoffrey C. Williams, M.D., Ph.D., Roger L. Brown, Ph.D., and others, in the December 2005 Annals of Emergency Medicine 46(6), pp. 525-533.

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