Defensive medicine in neurosurgery: Does state-level liability risk matter?

Timothy R. Smith*, Ali Habib, Joshua M. Rosenow, Brian V. Nahed, Maya A. Babu, George Cybulski, Richard Fessler, H. Hunt Batjer, Robert F. Heary

*Corresponding author for this work

Research output: Contribution to journalArticlepeer-review

46 Scopus citations


BACKGROUND: Defensive medicine is prevalent among US neurosurgeons due to the high risk of malpractice claims. This study provides national estimates of US neurosurgeons' defensive behaviors and perceptions. OBJECTIVE: To examine the relationship of defensive medicine-both "assurance" behaviors and "avoidance" behaviors-to the liability environment. METHODS: A 51-question online survey was sent to 3344 US neurosurgeon members of the American Board of Neurological Surgeons (ABNS). The survey was anonymous and conducted over 6 weeks in the spring of 2011. The previously validated questionnaire contained questions on neurosurgeon, patient, and practice characteristics; perceptions of the liability environment; and defensive-medicine behaviors. Bivariate and multivariate analyses examined the state liability risk environment as a predictor of a neurosurgeon's likelihood of practicing defensive medicine. RESULTS: A total of 1026 neurosurgeons completed the survey (31% response rate). Neurosurgeons' perceptions of their state's liability environment generally corresponded well to more objective measures of state-level liability risk because 83% of respondents correctly identified that they were practicing in a high-risk environment. When controlling for surgeon experience, income, high-risk patient load, liability history, and type of patient insurance, neurosurgeons were 50% more likely to practice defensive medicine in high-risk states compared with low-risk-risk states (odds ratio: 1.5, P < .05). CONCLUSION: Both avoidance and assurance behaviors are prevalent among US neurosurgeons and are correlated with subjective and objective measures of state-level liability risk. Defensive medicine practices do not align with patient-centered care and may contribute to increased inefficiency in an already taxed health care system.

Original languageEnglish (US)
Pages (from-to)105-113
Number of pages9
Issue number2
StatePublished - 2015


  • Defensive medicine
  • Health reform
  • Liability
  • Malpractice
  • Neurosurgery
  • Tort

ASJC Scopus subject areas

  • Clinical Neurology
  • Surgery


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