Does Malpractice Fear Drive Overuse of Esophageal Cancer Screening?

Megan A. Adams, MD Gastroenterology Fellow University of Interview with
Megan A. Adams, MD
Gastroenterology Fellow
University of Michigan


Medical Research: What are the main findings of the study?

Dr. Adams: Surveys of doctors indicate that their fear of a malpractice lawsuit for missing a diagnosis of esophageal cancer might drive the overuse of tests called upper endoscopies in patients who are at low risk for the cancer. To examine whether this perception of medical liability risk accurately reflects the real likelihood of a malpractice claim, we looked at a national database of malpractice claims, and compared the rate of claims for delay in diagnosis of esophageal cancer in patients without alarm symptoms (weight loss, dysphagia, iron deficiency anemia), with the rate of claims alleging performance of an upper endoscopy without a good reason for performing the procedure.

The database contained 278,220 claims filed against physicians in 1985-2012. The incidence of reported medical liability claims for failure to screen for esophageal cancer in patients without alarm features was quite low (19 claims in 11 years, 4 paid). In contrast, there were 17 claims in 28 years for complications of upper endoscopies with questionable indication (8 paid).

Medical Research: What was most surprising about the results?

Dr. Adams: The most surprising finding was the discordance between physicians’ perceived risk of medical liability for delay in diagnosis of esophageal cancer and the actual risk of a medical professional liability claim.

Medical Research: What should clinicians and patients take away from your report?

Dr. Adams: All medical procedures carry risks. It is important to have an adequate indication for a procedure in order to justify these risks. Our study suggests that physicians should avoid screening patients at low risk for esophageal adenocarcinoma with upper endoscopy, which would be consistent with professional society guidelines. Fear of a medical professional liability claim for failure to screen does not justify subjecting a low-risk patient to the risks of procedural complications, even if those complications are rare.

Medical Research: What recommendations do you have for future research as a result of this study?

Dr. Adams: As we move toward greater transparency and accountability in health care, there has been increased focus in recent years on identifying the drivers of inappropriate use of testing. The practice of defensive medicine is frequently cited as a potential driver of overuse, though the magnitude of its effect on healthcare utilization and costs is controversial. Future research should continue to expand our understanding of the way in which physicians’ perceived risk of medical professional liability affects practice patterns, and whether and to what extent defensive medicine inflates overall health care costs through overutilization of invasive procedures.


Adams MA, Parikh P, Miller K, Rubenstein JH. Medical Professional Liability Claims Related to Esophageal Cancer Screening. JAMA. 2014;312(13):1348-1349. doi:10.1001/jama.2014.7960.


Last Updated on October 7, 2014 by Marie Benz MD FAAD