Emergency physicians' fear of malpractice in evaluating patients with possible acute cardiac ischemia

Ann Emerg Med. 2005 Dec;46(6):525-33. doi: 10.1016/j.annemergmed.2005.04.016. Epub 2005 Jul 14.


Study objective: We evaluate the association between emergency physicians' fear of malpractice and the triage and evaluation patterns of patients with symptoms suggestive of acute coronary syndrome.

Methods: We surveyed 33 emergency physicians of 2 university hospitals during the preintervention phase of an implementation trial of the Agency for Health Care Policy and Research Unstable Angina guideline in 1,134 study patients. The survey included a 6-item instrument that addressed concerns about malpractice and a measure of general risk aversion. We used hierarchical logistic regression to model emergency department (ED) triage decisions and diagnostic testing as a function of fear of malpractice, with adjustment for patient characteristics, Agency for Health Care Policy and Research guideline risk group, study site, and clustering by emergency physician.

Results: Overall, emergency physicians in the upper tertile of malpractice fear were less likely to discharge low-risk patients compared with emergency physicians in the lower tertile (adjusted odds ratio [OR] 0.34; 95% confidence interval [CI] 0.12 to 0.99; P=.05). Patients treated by emergency physicians in this group were also more likely to be admitted to an ICU or telemetry bed (adjusted OR 1.7; 95% CI 1.2 to 2.4). In addition, emergency physicians in the upper tertile of malpractice fear were more likely to order chest radiography, as well as cardiac troponin. Malpractice fear accounted for a similar amount of variance after controlling for emergency physicians' risk aversion.

Conclusion: Malpractice fear accounts for significant variability in ED decisionmaking and is associated with increased hospitalization of low-risk patients and increased use of diagnostic tests.

Publication types

  • Research Support, Non-U.S. Gov't
  • Research Support, U.S. Gov't, P.H.S.

MeSH terms

  • Adult
  • Angina, Unstable / diagnosis
  • Angina, Unstable / etiology
  • Attitude of Health Personnel*
  • Chest Pain / diagnosis
  • Defensive Medicine / statistics & numerical data*
  • Diagnosis, Differential
  • Emergency Medicine / statistics & numerical data*
  • Fear
  • Female
  • Health Care Surveys
  • Humans
  • Logistic Models
  • Male
  • Models, Theoretical
  • Multivariate Analysis
  • Myocardial Ischemia / complications
  • Myocardial Ischemia / diagnosis*
  • Odds Ratio
  • Process Assessment, Health Care
  • Professional Practice / statistics & numerical data*
  • Risk Assessment / methods
  • Risk-Taking
  • Triage / methods
  • United States