Some Canadian doctors envy American MDs, others pity them,
but very few are uninterested in the lives of their counterparts
down south. Their present might be a looking glass into
our own future, if the proponents of deregulated and privatized
medicine ever get their way here.
However, malpractice litigation
is one US phenomenon that could find its way across
the border without much deregulation or privatization.
In fact, US and Canadian malpractice law is almost identical
already. Here the Canadian Medical Protective Association
has been highly effective in dealing with cases quietly.
Given the climate in the US, it's not surprising that
many doctors alter their practice to avoid litigation.
Defensive medicine is the theme
of a recent issue of the Journal of the American
Medical Association. The journal carries a survey
that quizzed Pennsylvania doctors in high-risk specialties
on their use of defensive medicine and how they have
altered their practices to avoid lawsuits.
The results were unequivocal. Ninety-three
percent of 824 physicians admitted to deviating from
sound medical practice to reduce the risk of litigation.
The most common act was ordering unnecessary diagnostic
tests. This sort of "assurance behaviour" is known as
"positive defensive medicine", because it actually improves
the standard of care offered, albeit in a wasteful fashion.
COURTING
DISASTER
But there is "negative defensive medicine" too. Forty-two
percent of respondents reported taking steps to restrict
their practice, including eliminating procedures prone
to complications, such as trauma surgery, and avoiding
patients who had complex medical problems or were perceived
as litigious.
Emergency doctors were the specialty
most likely to engage in positive defensive medicine.
Neurosurgeons, orthopedic surgeons, and ob/gyn specialists
were the most likely to engage in negative defensive
medicine. When it came to avoiding 'high-risk' patients,
orthopedic surgeons led the pack by some distance, with
57% admitting to turning away difficult cases.
As Dr Peter Budetti argues in the
issue's editorial, the tort system does little to encourage
better or safer care of patients. It's just as likely
to lead physicians to turn folks away. Courts base their
standard of care not on medical evidence, but on current
mainstream practice. In fact, warns Budetti, by ordering
unnecessary diagnostic tests, litigation-conscious physicians
risk making those tests the new gold standard.
A good start to tort reform, Budetti
suggests, would be "tying liability law restructuring
to systemic, evidence-based changes in medical practice
that ensure adherence to, not deviation from, good medical
care."
JAMA June 1, 2005;293(21):2609-17
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