Defensive medicine: A symptom of uncertainty?

Defensive medicine is a well-documented phenomenon and refers to the practice of over-cautious management of patients, leading to excessive clinical activity such as over-investigation, unnecessary appointments and additional interventions. Adopting this approach is not in the best interest of patients and can lead to clinical reasoning being replaced by lists, guidelines and algorithms which do not consider the complexity of a patients presentation or the reasoning inherent in good clinical judgement. The drivers of defensive medicine are varied and include a high level of uncertainty alongside other factors including clinical experience with past cases, system pressures and patient expectations. This paper explores these drivers and considers strategies on how best to avoid a defensive medicine approach. It reinforces the need to adopt a patient centred focus and use sound clinical reasoning to support the management of patients.

Safety netting; best practice in the face of uncertainty.

Safety netting is a recognised General Practitioner (GP) diagnostic strategy often used in the face of uncertainty to help ensure that a patient with unresolved or worsening symptoms knows when and how to access further advice. It is an important way of reducing clinical risk. In the context of the COVID-19 pandemic and the rapid move to mainly remote consultations within the musculoskeletal field, safety netting is an important strategy to embed within all consultations. Only those presenting with potentially serious conditions are offered face to face consultations. Screening for Red Flags and any indication of a serious cause of symptoms is always first line in any consultation, however, clinical presentations are not always black and white with patients falling into a clear diagnostic category. With patients minds more focussed on COVID-19 symptoms this can be problematic. With the additional ramifications of public health social restrictions, onward management can be a conundrum. Many people with risk factors of serious pathology are also as a consequence, vulnerable to contracting COVID-19. In situations of uncertain clinical presentations, to avoid unnecessary social contact, safety netting can help to monitor symptoms over time until the clinical context becomes more certain. Embedding safety netting within physiotherapy best practice could be a silver lining in this pandemic black cloud.

International Framework for Red Flags for Potential Serious Spinal Pathologies.

SYNOPSIS: The International Federation of Orthopaedic Manipulative Physical Therapists (IFOMPT) led the development of a framework to help clinicians assess and manage people who may have serious spinal pathology. While rare, serious spinal pathology can have devastating and life-changing or life-limiting consequences, and must be identified early and managed appropriately. Red flags (signs and symptoms that might raise suspicion of serious spinal pathology) have historically been used by clinicians to identify serious spinal pathology. Currently, there is an absence of high-quality evidence for the diagnostic accuracy of most red flags. This framework is intended to provide a clinical-reasoning pathway to clarify the role of red flags. J Orthop Sports Phys Ther 2020;50(7):350-372. Epub 21 May 2020. doi:10.2519/jospt.2020.9971.