A Longitudinal Study of Emergency Medicine Residents' Malpractice Fear and Defensive Medicine


(Email: rrodriguez@sfghed.ucsf.edu).


Objectives:To determine the baseline level and evolution of defensive medicine and malpractice concern (MC) of emergency medicine (EM) residents.

Methods:Using a validated instrument consisting of case scenarios and Likert-type scale questions, the authors performed a prospective, longitudinal (June 2001 to June 2005) study of EM residents at five 4-year California residency programs.

Results:All 51 EM interns of these residencies were evaluated; four residents left their programs and one took medical leave, resulting in 46 graduating residents evaluated. MC did not affect the residency choice of interns. Although perceived likelihood of serious disease increased in case scenarios over time, defensive medicine decreased in 27% of cases and increased in 20%. On a scale with 1 representing extremely influential and 5 representing not at all influential, the mean (±SD) influence of MC on interns' and graduates' case evaluation and management was 2.5 (±1.1) and 2.7 (±1.0), respectively. Comparing interns and graduates, there was no significant difference in the percentages of respondents who declared MC (mean difference in proportions, 3.3%; 95% CI =−8.4% to 15%) or refused procedures because of MC (11.5%; 95% CI =−1.3% to 24.3%). More interns, however, declared substantial loss of enjoyment of medicine than graduates (48%; 95% CI = 30.3% to 65.5%).

Conclusions:Physicians enter four-year EM residencies in California with moderate MC and defensive medicine, which do not change significantly over time and do not markedly impact their decisions to perform emergency department procedures. Malpractice fear markedly decreases interns' enjoyment of medicine, but this effect decreases by residency completion.