An internet television program that explores the intersection of medicine and the law.

BMJ Study: Physician spending and subsequent risk of malpractice claims: observational study

By Richard E. Anderson MD, CEO and Chairman of The Doctors Company, the nation’s largest physician-owned medical malpractice insurer to Defensive Medicine


The State of Defensive Medicine Our guest on Healthcare Matters is Richard E. Anderson MD, CEO and Chairman of The Doctors Company, the nation’s largest physician-owned medical malpractice insurer. In part 3 of our State of Defensive Medicine series, we ask Dr. Anderson about the 2015 BMJ study: Physician spending and subsequent risk of malpractice claims: observational study. What did he find interesting about the results and did he have any issues with the way the study was conducted? We asked Dr. Anderson questions on many different topics:
  1. Defining “Defensive Medicine” and why it’s a violation of the doctor/patient relationship.
  2. How should physicians handle patients requesting unnecessary tests?
  3. The BMJ study: Physician spending and subsequent risk of malpractice claims: observational study
  4. Alternative dispute resolution systems.
  5. MICRA’s most effective provisions.
  6. Is further tort reform necessary?
  7. The current state of the medical liability insurance landscape.
  8. Watch the full interview with Dr. Anderson.
Make sure you subscribe to our YouTube channel. You don't want to miss out on any of the upcoming guests we're going to have on the show.  


Mike: Recently, the BMJ, the International Peer-reviewed Medical Journal, published a study of Florida physicians, where it correlated that physicians who spend more money conducting test and procedures for patients were less likely to be sued for medical negligence. Do you agree with the premises of the article and why?

Dr. Anderson: Yeah, it’s a very interesting study, and a very valuable and an important one because defensive medicine has been, I think, sadly underappreciated from the point of view of medical research and the medical research community and also terribly underappreciated from the point of view of policy makers and those who have to create health care law as well as those who have to pay for the cost of health care in the United States. So I certainly commend the authors in a very serious way for making an important contribution.

I think there are several truths that emerge from this paper and then several areas of concern as well. One of the truths is that physicians believe in defensive medicine. In other words, physicians believe when they order additional studies that…and, again, think back to what my definition of defensive medicine is. The definition of defensive medicine is a test or procedure or therapy that is ordered primarily to reduce the liability of the physician rather than to benefit the patient. So again, by definition, what we are saying is the physician believes that it will reduce its liability. So it’s not surprising…and what this study validates…the data in the study validates that notion that physicians strongly believe that defensive medicine reduces liability.

Now, the second point of the paper is that using a very sophisticated, statistical analysis, the authors found data that they believe supports the notion that defensive medicine does reduce liability. And here, I’m not so sure that that’s true. Again, if you take my definition of defensive medicine, it can’t be true. In other words, if it is the right test or therapy to order in the first place, then it wasn’t defensive. Then ordering a test that isn’t the right treatment is not going to reduce your liability. So almost by definition, what they say can’t be true but it shows how difficult it is to separate all of these factors out, and it also shows that physicians believe that more test ordering and more therapies and so forth reduce their liability profile.

The authors quite appropriately themselves make the point that they are unable to evaluate the acuity, in other words the degree of illness, of the patients from one year to the next. They are only doing a one year…year over year but only two year comparison. And so the data, I think, is challenging. They use C-section as an example of the same notion. And C-sections are a very interesting to look at in terms of defensive medicine because I think it is a universally acknowledged by both public policy makers and physicians and obstetricians that we do too many C-section in the United States. And that too many can be defined almost anyway that you like. Too many because they are too expensive, too many because a C-section that isn’t necessary and is, without question, riskier on than the average, normal, vaginal delivery.

But also we have international data. United States does about twice as many C-sections as any other first world country. If C-sections were just generically produce better outcomes, then we would have better birth outcomes than other first world countries. And the truth is we don’t. So it’s really clear beyond a shadow of a doubt that once you get beyond necessary threshold…and interestingly enough, there is some data that would suggest that roughly 15% of deliveries ought to be C-section using modern medical standards of care. United States, that number is closer to 35%. So really, very, very high.

The authors themselves make a very interesting point which is that C-section births in the United states have increased by 60% since 1996. So basically, in the course of two decades, there’s a 60% increase in the number of C-sections. Now, if you sort of think about that, it is basically, physically impossible for the characteristics of the human pelvis and the human gestation process to have changed to circumstances where 60% increases in the number of C-sections could ever have been medically mandated. And what it points out and, again, this is very fundamental to my belief and to this point that I have been preaching for many years, is that medical standards of care in the United States have been polluted by the medical legal standards of care. In fact, most standards of care that purport to be medical and should be medical, of course, are in fact medical legal standards of care. And in the United States, I think it is really easy to argue that the medical legal standards of care induces a C-section rate that’s probably 25% or 30% as opposed to what is more likely whereas medical standard of care will probably produce a C-section rate a lot closer to 15%.