Defensive medicine and cesarean sections in Brazil.

ABSTRACT: Brazil has a high rate of cesarean sections (CS) that cannot be solely justified by women's clinical conditions; thus, other causes, for example, CS on maternal request and physicians' fear of litigation as possible influencing factors, cannot be overlooked.This study aimed to identify through a survey whether Brazilian gynecologists and obstetricians (GOs) perform defensive CS.In this cross-sectional, descriptive study, a questionnaire was administered. The target population comprised of GOs who were members of premier Brazilian professional associations of gynecology and obstetrics. A total of 403 GOs participated in the survey using an obstetrics questionnaire about litigation and defensive medicine (DM). Statistical analyses were performed on pairs of variables to determine the risk factors of performing CS due to concerns of complications during vaginal delivery and to avoid lawsuits.The mean age of the GOs was 47.7 years who were mostly female (58.3%) and having worked professionally in both public and private sectors (71.7%). Of all participants, 80.6% had been sued or knew an obstetrician who had been sued. The obstetricians who had been sued or who knew a colleague that had been sued exhibited a significantly higher likelihood of performing defensive CS than physicians who had not been sued or did not know physicians who had been sued. The perception of a higher risk of lawsuits against obstetricians influenced the practice of DM and led to a more than six-fold increase in CSs in specialists with this perception compared to specialists who did not believe the presence of an increased risk of litigation in obstetrics existed.The majority of Brazilian GOs perform defensive CS. It is important to consider DM as one of the causes of high CS rates in Brazil and include it in the development of public policies to reduce these CS rates.

Polypharmacy: the whys, the so whats and the what nexts.

There is an increasing awareness that polypharmacy - the use of multiple medicines by one individual - may bring harm as well as benefit. This has been termed 'problematic polypharmacy' and is associated with increased risk of admission to hospital, decreased quality of life and psychological harm. This article addresses the factors that may be contributing to the global rise of polypharmacy (the whys), the problems it can cause (the so whats), and some opportunities and strategies for improving and avoiding problematic polypharmacy in the future (the what nexts).

Supportive networks, healthier doctors and 'just culture': Managing the effects of medico-legal complaints on doctors.

BACKGROUND: When an error leads to possible patient harm and a complaint, the impact on doctors and patients can be profound. Doctors may respond in ways that risk harm to themselves, colleagues and patients, including withdrawing from peers, risk-avoidance practice and even suicidal ideation. OBJECTIVE: This article discusses current research and public discourse on the impact of complaints on doctors' personal and professional lives, as well as the way complaints and the fear of complaints affects doctors' clinical practice. It suggests strategies to ameliorate these effects before a complaint is made. DISCUSSION: When colleagues support one another and collectively reflect on their practice within a culture focused on patient safety, doctors facing complaints or presented with an error are less likely to isolate themselves and fear the worst. Using a common adverse event, the author discusses how analysing minor errors and near-misses can benefit patients, practitioners and practices.

Triggers of defensive medical behaviours: a cross-sectional study among physicians in the Netherlands.

OBJECTIVES: This study investigated whether the attitudes of physicians towards justified and unjustified litigation, and their perception of patient pressure in demanding care, influence their use of defensive medical behaviours. DESIGN: Cross-sectional survey using exploratory factor analysis was conducted to determine litigation attitude and perceived patient pressure factors. Regression analyses were used to regress these factors on to the ordering of extra tests or procedures (defensive assurance behaviour) or the avoidance of high-risk patients or procedures (defensive avoidance behaviour). SETTING: Data were collected from eight Dutch hospitals. PARTICIPANTS: Respondents were 160 physicians and 54 residents (response rate 25%) of the hospital departments of (1) anaesthesiology, (2) colon, stomach and liver diseases, (3) gynaecology, (4) internal medicine, (5) neurology and (6) surgery. PRIMARY OUTCOME MEASURES: Respondents' application of defensive assurance and avoidance behaviours. RESULTS: 'Disapproval of justified litigation' and 'Concerns about unjustified litigation' were positively related to both assurance (ß=0.21, p<0.01, and ß=0.28, p<0.001, respectively) and avoidance (ß=0.16, p<0.05, and ß=0.18, p<0.05, respectively) behaviours. 'Self-blame for justified litigation' was not significantly related to both defensive behaviours. Perceived patient pressures to refer (ß=0.18, p<0.05) and to prescribe medicine (ß=0.23, p<0.01) had direct positive relationships with assurance behaviour, whereas perceived patient pressure to prescribe medicine was also positively related to avoidance behaviour (ß=0.14, p<0.05). No difference was found between physicians and residents in their defensive medical behaviour. CONCLUSIONS: Physicians adopted more defensive medical behaviours if they had stronger thoughts and emotions towards (un)justified litigation. Further, physicians should be aware that perceived patient pressure for care can lead to them adopting defensive behaviours that negatively affects the quality and safety of patient care.

Are multidisciplinary teams a legal shield or just a clinical comfort blanket?

Discussion about and management of patients through multidisciplinary team meetings has become the standard of care in medical and surgical specialties, but does the team nature of these provide a legal shield for clinicians? This article discusses the legal implications of decision making within a multidisciplinary team.

The opinion of Turkish cardiologists on current malpractice system and an alternative patient compensation system proposal: PCS study group.

OBJECTIVE: Cardiologists participate in the diagnosis and interventional treatment of numerous high-risk patients. The goal of this study was to investigate how the current malpractice system in Turkey influences cardiologists' diagnostic and interventional behavior and to obtain their opinions about an alternative patient compensation system. METHODS: The present cross-sectional study assessed the practice of defensive medicine among cardiologists who are actively working in various types of workplace within the Turkish healthcare system. A 24-item questionnaire was distributed to cardiology residents, specialists, and academics in Turkey in print format, by electronic mail, or via cell phone message. RESULTS: A total of 253 cardiologists responded to the survey. Among them, 29 (11.6%) had been sued for malpractice claims in the past. Of the cardiologists who had been sued, 2 (6.9%) had been ordered to pay financial compensation, and 1 (3.4%) was given a sentence of imprisonment due to negligence. In all, 132 (52.8%) of the surveyed cardiologists reported that they had changed their practices due to fear of litigation, and 232 (92.8%) reported that they would prefer the new proposed patient compensation system to the current malpractice system. Among the cardiologists surveyed, 78.8% indicated that malpractice fear had affected their decision-making with regard to requesting computed tomography angiography or thallium scintigraphy, 71.6% for coronary angiography, 20% for stent implantation, and 83.2% for avoiding treating high-risk patients. CONCLUSION: The results of this survey demonstrated that cardiologists may request unnecessary tests and perform unneeded interventions due to the fear of malpractice litigation fear. Many also avoid high-risk patients and interventions. The majority indicated that they would prefer the proposed alternative patient compensation system to the current malpractice system.

Si ocurrió un evento adverso piense en decir 'lo siento' / In case of an adverse event don’t forget to say sorry

Fundamento. La información al paciente víctima de un evento adverso (EA) presenta ciertas particularidades en función del marco legal del país en el que se produzca, especialmente en lo referido al ofrecimiento de una disculpa. En el presente trabajo se pretende establecer los límites y las condiciones que debemos considerar a la hora de trasladar una disculpa al paciente que ha sufrido un EA. Método. Conferencia de consenso entre 26 profesionales de distintas comunidades autónomas, instituciones y perfiles profesionales con experiencia acreditada en la gestión de sistemas de Seguridad del Paciente y Derecho Penal de diferentes ámbitos laborales (sanidad, aseguradoras, inspección, académico) (AU)

Background. Disclosing information to a patient who is a victim of an adverse event (AE) presents some particularities depending on the legal framework in the country where the AE occurred. The aim of this study is to identify the limits and conditions when apologizing to a patient who has suffered an AE. Methods. A consensus conference involving 26 professionals from different autonomous communities, institutions, and profiles (health, insurance, inspection, academic) with accredited experience in patient safety management systems and criminal law (AU)

Cross-sectional survey on defensive practices and defensive behaviours among Israeli psychiatrists.

OBJECTIVE: Psychiatry is a low-risk specialisation; however, there is a steady increase in malpractice claims against psychiatrists. Defensive psychiatry (DP) refers to any action undertaken by a psychiatrist to avoid malpractice liability that is not for the sole benefit of the patient's mental health and well-being. The objectives of this study were to assess the scope of DP practised by psychiatrists and to understand whether awareness of DP correlated with defensive behaviours. METHODS: A questionnaire was administered to 213 Israeli psychiatry residents and certified psychiatrists during May and June 2015 regarding demographic data and experience with malpractice claims, medicolegal literature and litigation. Four clinical scenarios represented defensive behaviours and reactions (feelings and actions) to malpractice claims. RESULTS: Forty-four (20.6%) certified psychiatrists and four (1.9%) residents were directly involved in malpractice claims, while 132 (62.1%) participants admitted to practising DP. Residents acknowledged the practice of DP more than did senior psychiatrists (p=0.038).Awareness of DP correlated with unnecessary hospitalisation of suicidal patients, increased unnecessary follow-up visits and prescribing smaller drug dosages than required for pregnant women and elderly patients. CONCLUSIONS: This study provides evidence that DP is well established in the routine clinical daily practice of psychiatrists. Further studies are needed to reveal whether DP effectively protects psychiatrists from malpractice suits or, rather, if it impedes providing quality psychiatric care and represents an economic burden that leads to more harm for the patient.

The determinants of defensive medicine in Italian hospitals: The impact of being a second victim / Los determinantes de la medicina defensiva en hospitales italianos: el efecto de ser una segunda víctima

Background. Defensive medicine affects healthcare systems worldwide. The concerns and perception about medical liability could lead practitioners to practise defensive medicine. Second victim is a healthcare worker involved in an unanticipated adverse patient event. The role of being second victim and the other possible determinants for defensive medicine is mostly unclear. Objective. To study the condition of being second victim as a possible determinants of defensive medicine among Italian hospital physicians. Design, setting and participants. A secondary analysis of the database of the national survey study on the prevalence and the costs of defensive medicine in Italy that was carried out between April 2014 and June 2014 in 55 Italian hospitals was performed for this study. The demographic section of the questionnaire was selected including the physician's age, gender, specialty, activity volume, grade and the variable being a second victim after an adverse event. Results. A total sample of 1313 physicians (87.5% response rate) was used in the data analyses. Characteristics of the participants included a mean age 49.2 of years and 19.4 average years of experience. The most prominent predictor for practising defensive medicine was the physicians’ experience of being a second victim after an adverse event (OR=1.88; 95%CI, 1.38-2.57). Other determinants included age, years of experience, activity volume and risk of specialty. Conclusions. Malpractice reform, effective support to second victims in hospitals together with a systematic use of evidence-based clinical guidelines, emerged as possible recommendations for reducing defensive medicine (AU)

Antecedentes. La medicina defensiva afecta a los sistemas de salud de todo el mundo. Las preocupaciones y la percepción acerca de la responsabilidad médica podrían llevar a los médicos a ejercer la medicina defensiva. La segunda víctima es un trabajador sanitario que participa en un episodio adverso imprevisto del paciente. Sin embargo, el papel de segunda víctima y otros posibles determinantes de la medicina defensiva son poco claros. Objetivo. Estudiar la situación de segunda víctima como posible determinante de la medicina defensiva entre los médicos hospitalarios italianos. Diseño, entorno y participantes. En este estudio se realizó un análisis secundario de la base de datos de la encuesta nacional sobre prevalencia y costes de la medicina defensiva en Italia, que se había llevado a cabo entre abril y junio de 2014 en 55 hospitales italianos. Se seleccionaron los datos personales del cuestionario, como edad del médico, sexo, especialidad, volumen de la actividad, grado y la variable de ser segunda víctima después de un episodio adverso. Resultados. Se utilizó una muestra total de 1.313 médicos (87,5% de tasa de respuesta) en el análisis de datos. Las características de los participantes incluyeron una media de edad de 49,2 años y 19,4 años de experiencia por término medio. El factor predisponente más importante para la práctica de la medicina defensiva fue la experiencia de los médicos de haber sido segunda víctima después de un episodio adverso (OR=1,88; IC 95%: 1,38-2,57). Otros factores determinantes fueron: edad, años de experiencia, volumen de la actividad y riesgo de la especialidad. Conclusiones. La reforma de la responsabilidad médica, un apoyo efectivo a segundas víctimas en hospitales y un uso sistemático de las guías clínicas basadas en la evidencia se presentaron como posibles recomendaciones para la reducción de la medicina defensiva (AU)

¿En qué momento perdimos la cabeza? / When did we lose our heads?

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On defensive decision making: how doctors make decisions for their patients.

BACKGROUND: In the past decade, the number of lawsuits for medical malpractice has risen significantly. This could affect the way doctors make decisions for their patients. OBJECTIVE: To investigate whether and why doctors practice defensive medicine with their patients. DESIGN: A questionnaire study was conducted in general practice departments of eight metropolitan hospitals in Spain, between January and February 2010. SETTING AND PARTICIPANTS: Eighty general practitioners (48% men; mean age 52 years) with an average of 15.3 years of experience and their 80 adult patients (42% men; mean age 56 years) participated in the study. MAIN OUTCOME MEASUREMENTS: Participants completed a self-administered questionnaire involving choices between a risky and a conservative treatment. One group of doctors made decisions for their patients. Another group of doctors predicted what their patients would decide for themselves. Finally, all doctors and patients made decisions for themselves and described the factors they thought influenced their decisions. RESULTS: Doctors selected much more conservative medical treatments for their patients than for themselves. Most notably, they did so even when they accurately predicted that the patients would select riskier treatments. When asked about the reasons for their decisions, most doctors (93%) reported fear of legal consequences. DISCUSSION AND CONCLUSIONS: Doctors' decisions for their patients are strongly influenced by concerns of possible legal consequences. Patients therefore cannot blindly follow their doctor's advice. Our study, however, suggests a plausible method that patients could use to get around this problem: They could simply ask their doctor what he or she would do in the patient's situation.

'Creating a protective picture:' a grounded theory of RN decision making when using a charting-by-exception documentation system.

Creating a protective picture, a grounded theory, describes the three-step process medical-surgical nurses use in deciding whether to follow a charting-by-exception policy.