Derm low-risk specialty for 'defensive medicine'


According to a new Harvard study, more than 90 percent of Pennsylvania physicians practicing in high-liability specialties admit to practicing defensive medicine.

According to a new Harvard study, more than 90 percent of Pennsylvania physicians practicing in high-liability specialties admit to practicing defensive medicine.

The assurance and avoidance behaviors involve ordering tests, performing diagnostic procedures and referring patients for consultation, even though physicians believe these practices are not necessary for quality care.

While dermatology is not considered a high-liability specialty, as are emergency medicine, general surgery, orthopedic surgery, neurosurgery, obstetrics/gynecology and radiology, dermatologists, in many cases, are altering their daily practices as well.

The Pennsylvania study

David Studdert, LL.B., Sc.D., M.P.H., associate professor of law and public health at Harvard School of Public Health, Boston, led the study titled "Defensive medicine among high-risk specialist physicians in a volatile malpractice environment" (JAMA. 2005 Jun 1;293(21):2609-2617).

Dr. Studdert and colleagues mailed a survey to physicians in Pennsylvania in the six high-liability medical specialties in May 2003, asking the physicians if they practice defensive medicine or make changes in their scope of practice which are characteristic of defensive medicine.

Of the 824 respondents, 93 percent reported practicing defensive medicine. Of those who said they practiced defensive medicine, 43 percent reported using imaging technology in clinically unnecessary circumstances.

"Forty-two percent of respondents reported that they had taken steps to restrict their practice in the previous three years, including eliminating procedures prone to complications, such as trauma surgery, and avoiding patients who had complex medical problems or were perceived as litigious," according to the study.

"We expected to see more defensive practice, but what we saw was a lot, lot more defensive practice. I think this was the sort of key headline finding," Dr. Studdert says.

"The unusual thing about our study was we did it not in a random sample of doctors at a random time, but rather among a group of doctors who we knew were getting sued a fair bit, in a state that was particularly volatile in terms of its malpractice environment. So, we went right to the leading edge of defensive practice, if you like."

Dermatology, according to Dr. Studdert, is not considered low-risk, but is not in the high-risk bracket.

"We basically figured these based on the cost of malpractice insurance ... and dermatology, I think, is sort of a mid-ranking specialty," he explains. "One of the fastest-growing areas of claims is missed and delayed diagnoses of cancer. So, obviously dermatologists are sometimes involved in those cases."

Dermatologists weigh in

The highest risks in dermatology for malpractice cases are misdiagnoses of skin cancer, followed by adverse reactions to treatments, according to Dr. Pariser.

"Both of those are within the realm of medical dermatology, but the surgical and, perhaps, cosmetic aspects are ones where there may be additional liability exposure," he says.

"I think we all practice defensive medicine," says Daniel M. Siegel, M.D., dermatologist, clinical professor of dermatology and director of the procedural dermatology fellowship at SUNY (State University of New York) Downstate, Brooklyn, N.Y.

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