Neurosurgeons avoid brain surgery, conduct unnecessary tests 'out of lawsuit fear'

According to a new study published in the journal Neurosurgery, "the vast majority" of neurosurgeons operating in the USA conduct additional procedures and tests out of fear of malpractice lawsuits rather than necessarily for the benefit of the patient.

Neurosurgeons in high-risk states pay almost twice as much in malpractice insurance premiums as those in low-risk states. These malpractice premiums were found to cost 15-20% of neurosurgeons' annual income.

Along with orthopedic surgery and obstetrics and gynecology, neurosurgery is a specialty with a high risk of expensive malpractice claims.

To examine how this risk might affect the way neurosurgeons treat their patients, researchers at Northwestern University in Chicago, IL, sent questionnaires to 3,344 board-certified neurosurgeons on the subject of "defensive medicine."

Defensive medicine is when doctors make medical decisions out of fear of potential legal action rather than for the benefit of the patient.

The researchers were particularly interested in assessing the relationship between the practice of defensive medicine and the "liability risk environment" of the state in which the neurosurgeon practices.

A total of 1,026 of the neurosurgeons completed the survey, with those practicing in high-risk liability states being more likely to respond. 

The researchers found that the majority of the surveyed neurosurgeons were able to accurately perceive the liability risk of their state.

The study reports that more than 80% of the respondents admitted to ordering imaging tests solely for defensive reasons, and more than three quarters said they had ordered laboratory tests and made extra referrals for these reasons. 

About half of the neurosurgeons reported ordering extra medications and procedures because they were worried they might get sued if they did not.

These defensive actions were more common among the neurosurgeons in the high-risk states, where there was a 30% increase in likelihood of ordering additional imaging studies and 40% increased likelihood of ordering additional lab tests, both for defensive purposes.

Neurosurgeons in high-risk states 'less likely to perform brain surgery'

The high-risk state surgeons were also less inclined to perform high-risk procedures out of concerns for potential lawsuits. The study reports that a quarter of these surgeons had stopped performing brain surgery for this reason, and 40% were even considering retirement as a consequence of their local liability environment.

Liability risk was graded on a five-point scale. The researchers found that defensive medicine actions increased by 50% at each grade of the scale. 

As an example of how this increase works, the authors explain that a neurosurgeon practicing in a state at the highest risk of liability is six times more likely than a neurosurgeon in a lowest-risk state to practice defensive medicine.

To illustrate the basis for this fear of litigation, the authors describe how neurosurgeons in high-risk states pay almost twice as much in malpractice insurance premiums as those in low-risk states. These malpractice premiums were found to cost 15-20% of neurosurgeons' annual income.

The majority of respondents in the study also said they believed their malpractice coverage was inadequate.

"Defensive medicine practices do not align with patient-centered care, and may contribute to increased inefficiency in an already taxed health care system," the authors conclude.

References:

1.     Defensive medicine in neurosurgery: does state-level liability risk matter?, Timothy Smith, et al., Neurosurgery, doi: 10.1227/NEU.0000000000000576, published online 30 January 2015.

2.     Walters Kluwer Health news release, accessed 2 February 2015 via EurekAlert.