Malpractice Concerns, Defensive Medicine, and the Histopathology Diagnosis of Melanocytic Skin Lesions

Linda J. Titus, PhD; Lisa M. Reisch, PhD; Anna N. A. Tosteson, ScD; Heidi D. Nelson, MD, MPH; Paul D. Frederick, MPH, MBA; Patricia A. Carney, PhD; Raymond L. Barnhill, MD, MSc; David E. Elder, MBChB, FRCPA; Martin A. Weinstock, MD, PhD; Michael W. Piepkorn, MD, PhD; Joann G. Elmore, MD, MPH


Am J Clin Pathol. 2018;150(4):338-345. 

In This Article


Although national rates of medical malpractice lawsuits and paid claims have decreased since the early 1990s, indemnity payments have increased,[16,17] and physicians' malpractice concerns remain widespread.[18] In pathology, the temporal increase of average indemnity payments from 1992 to 2014 is greater than in any other specialty.[16] Despite the fact that melanoma misdiagnosis is a leading cause of pathology malpractice litigation,[19–21] previous studies have not addressed the influence of malpractice concerns on pathologists' interpretation of MSLs.

In our study of pathologists from 10 US states, roughly one (28%) of four pathologists reported being influenced toward a more severe MSL diagnosis due to concern about medical malpractice litigation. In addition, nearly all pathologists (95%) self-reported practicing at least one assurance behavior due to malpractice concerns. A juxtaposition of these two findings suggests the practice of assurance behaviors is a more common strategy for alleviating malpractice concerns than rendering a more severe MSL diagnosis.

Our data indicated an association between using assurance behaviors and rendering a more severe MSL diagnosis due to malpractice concerns. This association was expected, as upgrading a diagnosis can be viewed as a form of assurance behavior. We also found that pathologists with at least 20 years of experience interpreting MSLs were less likely to report having their diagnoses influenced by malpractice concerns, possibly reflecting greater confidence due to longer term experience. Although our data showed no association between actual malpractice experience and upgrading MSL diagnoses due to malpractice concerns, this result should be interpreted cautiously due to the small number of pathologists with malpractice experience and limited statistical power for that analysis.

The questions used in our analysis specifically asked pathologists about the influence of malpractice concerns on their use of assurance behaviors and the direction of diagnostic interpretation. It is highly likely that these behaviors are also motivated by concerns about patient safety, but we did not assess whether patient safety concerns directly influenced the use of assurance behaviors or the direction of MSL diagnosis, topics that merit future study. Other limitations of this study include the use of self-reported data on diagnostic practices, as opposed to actual practice data. In addition, it is outside the scope of this study to determine the extent to which these practices might inflate health care costs, bring benefit to patients by reducing underdiagnosis, or cause harm to patients due to unnecessary treatment. Similarly, it is outside the scope of this study to assess the possible impact of malpractice concerns on possible melanoma overdiagnosis. Strengths of our study include the large number of pathologists in the study and the spectrum of pathologists surveyed, both in terms of the nature of their clinical training and practices and in geographic location. Nevertheless, our data may not be generalizable to all US pathologists or to those outside of the United States.