Challenges of New Healthcare Reform Act 2017 and Possible Rise of Defensive Medicine in Nepal.

Hippocratic oath, written 4th or 5th century BC, is still the binding mantra for physicians, which swears to fulfill to the best of one's ability and judgement, and treat sick human beings not just illness. But with changing health trends in southeast Asia region, there is a dramatic shift in patients and patients' party expectations regarding treatment, recovery, complications, and death. Such expectations havelead to violence against physicians and shift towards alternative medical practice. This article explores the possible rise of defensive medicine and its broader implications in health care system in Nepal with regard to the new 'Muluki Aparadh Samhita Ain 2074/Criminal (Code) Act 2017'. Keywords: Changing health; criminal act; defensive medicine; muluki ain, Nepal.

Damage caps and defensive medicine, revisited.

Does tort reform reduce defensive medicine and thus healthcare spending? Several (though not all) prior studies, using a difference-in-differences (DiD) approach, find lower Medicare spending for hospital care after states adopt caps on non-economic or total damages ("damage caps"), during the "second" reform wave of the mid-1980s. We re-examine this issue in several ways. We study the nine states that adopted caps during the "third reform wave," from 2002 to 2005. We find that damage caps have no significant impact on Medicare Part A spending, but predict roughly 4% higher Medicare Part B spending. We then revisit the 1980s caps, and find no evidence of a post-adoption drop (or rise) in spending for these caps.

[Overdiagnosis and defensive medicine in occupational medicine]. / Overdiagnosis e medicina difensiva in Medicina del Lavoro.

In clinical medicine since some years overdiagnosis is giving rise to growing attention and concern. Overdiagnosis is the diagnosis of a "disease" that will never cause symptoms or death during a patient's lifetime. It is a side effect of testing for early forms of disease which may turn people into patients unnecessarily and may lead to treatments that do no good and perhaps do harm. Overdiagnosis occurs when a disease is diagnosed correctly, but the diagnosis is irrelevant. A correct diagnosis may be irrelevant because treatment for the disease is not available, not needed, or not wanted. Four drivers engender overdiagnosis: 1) screening in non symptomatic subjects; 2) raised sensitivity of diagnostic tests; 3) incidental overdiagnosis; 4) broadening of diagnostic criteria for diseases. "Defensive medicine" can play a role. It begs the question of whether even in the context of Occupational Medicine overdiagnosis is possible. In relation to the double diagnostic evaluation peculiar to Occupational Medicine, the clinical and the causal, a dual phenomenon is possible: that of overdiagnosis properly said and what we could define the overattribution, in relation to the assessment of a causal relationship with work. Examples of occupational "diseases" that can represent cases of overdiagnosis, with the possible consequences of overtreatment, consisting of unnecessary and socially harmful limitations to fitness for work, are taken into consideration: pleural plaques, alterations of the intervertebral discs, "small airways disease", sub-clinical hearing impairment. In Italy the National Insurance for occupational diseases (INAIL) regularly recognizes less than 50% of the notified diseases; this might suggest overdiagnosis and possibly overattribution in reporting. Physicians dealing with the diagnosis of occupational diseases are obviously requested to perform a careful, up-to-date and active investigation. When applying to the diagnosis of occupational diseases, proper logical criteria should be even antecedent to a good diagnostic technique, due to social outcome for the worker.

Maternity care and liability: pressing problems, substantive solutions.

BACKGROUND: This paper summarizes a new report presenting the best available research about the impact of the liability environment on maternity care, and policy options for improving this environment. Improved understanding of these matters can help to transcend polarized discourse and guide policy intervention. METHODS: We used a best available evidence approach and drew on more recent empirical legal studies and health services research about maternity care and liability when available, and considered other studies when unavailable. FINDINGS: The best available research does not support a series of widely held beliefs about maternity care and liability, including the economic impact of liability insurance premiums on maternity care clinicians, the existence of extensive defensive maternity care practice, and the impact of limiting the size of awards for non-economic damages in a malpractice lawsuit. In the practice of an average maternity caregiver, negligent injury of mothers and newborns seems to occur more frequently than any claim and far more frequently than a payout or trial. Many important gaps in knowledge relating to maternity care and liability remain. Some improvement strategies are likely to be more effective than others. CONCLUSIONS: Empirical research does not support many widely held beliefs about maternity care and liability. The liability system does not currently serve well childbearing women and newborns, maternity care clinicians, or those who pay for maternity care. A number of promising strategies might lead to a higher functioning liability system, whereas others are unlikely to contribute to needed improvements.

'Everybody expects the perfect baby...and perfect labour...and so you have to protect yourself ': discourses of defence in midwifery practice in Aotearoa/New Zealand.

Increasing fears of litigation among those involved in childbirth impact differently on the 40 midwives I interviewed and observed in the field during the course of my doctoral research. 'Defensive practice' within a culture of 'risk' was a theme that emerged strongly from the interview transcript data from this study, the primary aim of which was to analyse the actions between women and midwives that constitute midwifery partnerships. The context for the analysis was a large ethnographic study undertaken with a variety of midwives working in a main city in Aotearoa/New Zealand in 2003. Complex and contesting forms of knowledge production were analysed drawing on insights from Foucauldian-influenced discourse analysis. My work highlights the ways in which the practices of contemporary midwives in Aotearoa/New Zealand are caught within the intersection of an array of competing discourses. In the data from my study, the midwives talked of their complex negotiations of time and space, and their abilities to balance elements of risk within realms of restraint and responsibility in partnership with women. For the midwives I interviewed, 'keeping ourselves safe' takes place in different locations. Risk is located by some midwives as within the birthing body, and by some, within the spaces of labour ward itself. Both labouring bodies in the midwifery partnership, however, that of the pregnant body of the woman, and that of the working body of the midwife, together occupy spaces of risk/safety where they are amenable to various, and increasingly subtle, forms of governance.

The malpractice liability crisis.

Most medical malpractice cases are tried under the civil tort of negligence and are often triggered by adverse outcomes. These proceedings are aimed primarily at determining whether the conduct of a health care provider was reasonable. Such legal actions have mostly been subject to state jurisdiction. Increasingly, a number of factors are converging that are threatening the continued practice of medicine in some states and hence patients' access to care. These include higher amounts of monetary damages awarded to successful plaintiffs, consequent rising malpractice premiums, and the threatened economic insolvency of medical liability insurance carriers as a result of the broader economic downturn. The result is a serious public health dilemma. The national scope of the problem has been considered a crisis, which has prompted unprecedented federal legislative proposals directed toward providing new and preemptive parameters for capitated noneconomic damages, restrictions on certain civil procedures affecting lawsuit outcomes, and methods for attorney compensation, which some states have either not previously addressed or found unconstitutional. A survey of different states' problems and common issues should assist the reader in understanding the nature of the crisis and proposed solutions.

The effect on medical practice of disciplinary complaints: potentially negative for patient care.

AIM: To explore the personal and professional effect on general practitioners (GPs) of receiving a complaint against them to the (former) Medical Practitioners Disciplinary Committee, when the complaint did not proceed to a formal hearing. METHODS: Ten GPs were interviewed by telephone, following an enrollment procedure that protected identities from the interviewer. Qualitative (thematic) analysis of indepth interviews was used to categorise doctors' perceived effects of complaints on practice and to develop a theory on why such effects should occur. RESULTS: Receipt of a complaint had both short- and long-term effects on the doctor, and on their views of patients, society and the disciplinary process. There were immediate negative emotional responses that were sustained in the long-term in a way that adversely effected doctor-patient relationships beyond the relationship with the original complainant. Doctors reported short-term changes in their practice of medicine, with reduced ability to work confidently and decisively. Doctors also reported altered practice in the long-term in the direction of defensive medicine, by withdrawing from providing some services and avoiding perceived at-risk activities. CONCLUSION: The impact of a complaint on the self of the doctor suggests a shame response. There may be a need for the relevant professional college to establish a rapid response 'crash team' to minimize the negative personal and professional effects of a complaint, even when the complaint does not proceed to a formal hearing.