RESUMO
Defensive medicine, a term known since the 1960s, may lead to risks in healthcare provision. Reported to be prevalent in North America and Europe, it is thought to be spreading globally. This study aims to evaluate defensive medicine practice among physicians in the United Arab Emirates. A quantitative cross-sectional survey consisting of a twenty-three point questionnaire was conducted after obtaining ethics approval. The response data concerning the practice of defensive medicine were summarized as a percentage of the total. There were 562 respondents. Of these, 307 (54.6%) and 258 (45.9%) were aware of positive and negative defensive medicine practice respectively. Of the respondents, 285 (50.7%) agreed that they feared patients or their attendants and 177 (31.5%) were not willing to accept patients involved in previous legal prosecutions against doctors. Case referral to other colleagues as a form of defensive medicine was reported by 186 (31.1%) respondents. The majority, 339 (60.3%) of the respondents thought that their medical decisions were backed by the hospital's managerial staff. The practice of defensive medicine is common among physicians working in the United Arab Emirates. It is a widespread practicing behavior in respondents who have more than fifteen years of working experience as compared to those with less experience.
Assuntos
Medicina Defensiva , Médicos , Humanos , Emirados Árabes Unidos , Estudos Transversais , Pessoal Técnico de SaúdeRESUMO
OBJECTIVES: Defensive medicine (DM) is the deviation of a physician from normal behavior or what is a good practice and is aimed at reducing or avoiding the risk of legal litigation from patients or their families. Therefore, this study aimed to determine DM-related behaviors and associated risk factors among Iranian surgeons. METHODS: In this cross-sectional study, 235 surgeons were selected using convenience sampling. The data gathering tool was a researcher-made questionnaire confirmed as a reliable and valid tool. Factors associated with DM-related behaviors were identified using logistic regression analysis. RESULTS: DM-related behaviors ranged from 14.9% to 88.9%. The most common positive DM-related behaviors, including unnecessary biopsy (78.7%), imaging and laboratory tests (72.4% and 70.6%), and refusing high-risk patients (61.7%), was the most common negative DM-related behavior. The likelihood of DM-related behaviors was more in younger and less experienced surgeons. Other variables, such as gender, specialty, and lawsuit history, positively affected some DM-related behaviors (p < 0.05). CONCLUSION: This study showed that the proportion of surgeons who frequently performed DM-related behaviors was higher than those who rarely performed it. Therefore, strategies including reforming the rules and regulations for medical errors and litigations, developing and implementing medical guidelines and evidence-based medicine, and improving the medical liability insurance system can reduce DM-related behaviors.
Assuntos
Medicina Defensiva , Cirurgiões , Humanos , Irã (Geográfico) , Estudos Transversais , Seguro de Responsabilidade CivilRESUMO
Technology-intensive birth practices are a hallmark of the overmedicalization of birth. For example, obstetricians routinely use continuous electronic fetal monitoring (EFM), even though this technology is not evidence-based, has a high rate of false positives, and does not improve outcomes in low-risk deliveries. Providers often argue that they must use EFM to protect themselves from malpractice liability, making it a form of defensive medicine. But does variation in actual liability risk contribute significantly to the use of non-evidence-based medical technology like EFM? This study uses multi-level logistic models to examine the effects of malpractice laws and lawsuits on EFM in low-risk births from 1995 to 2003. The models test the hypothesis that state-level variation in liability risk should influence the probability of EFM use. The models reveal that the probability of reporting EFM is higher when states artificially reduce liability risk by capping damage awards, suggesting that objective liability risk does not promote routine EFM and may deter it. In fact, caps on damages limit providers' legal exposure without doing anything to encourage higher quality care. It is possible that states without tort reforms place greater emphasis on patient rights, safety, and quality of care. On the other hand, by reducing liability risk without encouraging improvements in quality, tort reform laws may inadvertently promote more technology use.
Assuntos
Cardiotocografia , Imperícia , Gravidez , Feminino , Humanos , Estados Unidos , Responsabilidade Legal , Parto , Modelos Logísticos , Medicina DefensivaRESUMO
We describe the case of an eighty-four-year-old man with disseminated lung cancer who had been receiving palliative care in the hospital and was found by nursing staff unresponsive, with clinically obvious signs of death, including rigor mortis. Because there was no documentation to the contrary, the nurses commenced cardiopulmonary resuscitation and called a code blue, resulting in resuscitative efforts that continued for around twenty minutes. In discussion with the hospital ethicist, senior nurses justified these actions, mainly citing disciplinary and medicolegal concerns. We argue that moral harms arise from CPR performed on a corpse and that legal concerns about failing to perform it are unfounded. We contend that such efforts are an unintended consequence of managerialist policies mandating do-not-resuscitate orders and advance care plans and of defensive practices that can value the interests of institutions and practitioners over those of patients. Health management teaching should include managerialism and its pitfalls, while clinician training should prioritize ethical reasoning and legal knowledge over defensive practice.
Assuntos
Diretivas Antecipadas , Reanimação Cardiopulmonar , Masculino , Humanos , Idoso de 80 Anos ou mais , Medicina Defensiva , Ordens quanto à Conduta (Ética Médica)RESUMO
Defensive medicine; although a recent concept, is slowly beginning to cement its place in the Indian health system. An interaction of multiple factors has paved way for this form of practice. Need for certainty of the diagnosis, lack of hierarchy in medical care, exponential growth of micro/super specializations and private/corporate health institutions, incentive-based practice, increasing incidences of violence against health personnel, rising trend of defamation suites against doctors, bad publicity by media, and interference by elected representatives have jeopardized the situation. This has led to decline in practice of clinical medicine, increased burden of investigations, especially in already compromised public facilities, and high out-of-pocket health expenditure. As much as ethical medical practice, standard patient management protocols, strict protection of interest of medical practitioners by law, responsible role of media and elected representatives are the need of the hour; we need to find ways to accept and incorporate defensive medicine into the modern medicine. Different stakeholders are required to come together and take substantial steps to understand the phenomenon and preserve the art and science of practicing medicine in its true form.
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Medicina Defensiva , Médicos , HumanosRESUMO
The term defensive medicine is used to describe the behavior of healthcare providers motivated by fear of litigation due to malpractice. It includes both avoidance behavior when the physician is unwilling to perform high risk procedures, as well as excessive ordering of extra tests and procedures. This leads to unnecessary diagnostic and therapeutic interventions which may be invasive and costly. Additionally, such a setting causes harms the patient-doctor relationship. A more specific legal framework, developed with respect to the innate nature of medicine, may improve the situation.
Assuntos
Imperícia , Médicos , Medicina Defensiva , HumanosRESUMO
BACKGROUND: Defensive Medicine (DM) concept refers to all medical care provided by physicians without increasing the benefits to the patient, the primary purpose of which is to prevent the risk of litigation. Although several studies have been published investigating the occurrence of DM around the world, no review conducted on DM among physicians. Therefore, this study aims to summarize and map the available evidence on occurrence, types of behaviors, and reasons for practicing of DM among physicians and possible solutions and strategies to reduce DM in the literature. METHODS: This is a scoping review in which we searched Web of Science, Scopus, and PubMed in December 2021. Our target was original studies of any type that included data on DM among physicians between 2000 and 2021. We followed the JBI guideline for conducting a scoping review and for increasing the rigor of the study. First, the percentage was used to summarize the occurrence of DM, and then, findings related to types of behaviors and reasons for practicing DM and mitigation strategies were analyzed inductively in NVivo 10 in three stages. RESULTS: Twenty-seven studies were included in the review. The overall occurrence of DM practice ranged from 6.7 to 99.8%. Two types of DM behaviors including assurance and avoidance behaviors have been identified. The common reasons for practicing DM were categorized into four themes, patient-related reasons, physician-related reasons, organization-related reasons, and society-related reasons. The main strategies to prevent or reduce DM are structured training and education, restoring physician-patient relationships, reform of the health system, and reform of the liability system. CONCLUSIONS: The vast majority of research studies were conducted in high-income countries, and studies are needed to measure this phenomenon and its consequences in depth in low- and middle-income countries. Various solutions and strategies are needed to reduce defensive behaviors such as structured training and education, restoring physician-patient relationships, reforming the health system, and reforming the liability system.
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Imperícia , Médicos , Coleta de Dados , Medicina Defensiva , Humanos , Relações Médico-PacienteRESUMO
Error in medicine and medical liability has a long history dating back to Antiquity. During the 19th Century, most lawsuits related to errors in treating surgical problems were settled. However, in the first half of the 20th Century, lawsuits claimed that mistakes were related to the doctor's action: the doctor made something wrong (errors of commission). In Brazil, medical error is defined as inappropriate conduct, including negligence and recklessness, that causes harm to the patient. The physician's fear of being suited is the reason for some practice named defensive Medicine (D.M.), defined as ordering unnecessary tests and procedures or avoiding treatments for patients considered at high-risk. Thus, this narrative review aims to analyze and describe the relationship between medical errors, medical negligence, and the practice of D.M. So, the authors propose procedures and attitudes to avoid medical errors and the approach of D.M.: a national focus to create leadership and research tools to enhance the knowledge base about patient safety; a reporting system that would help to identify and learn from errors; the use of a computer-based protocol reminder; some technological devices to help the medical practice (electronic prescribing and information technology systems); creating risk management programs in hospitals. Therefore, the authors conclude that the most critical attitude to avoid medical liability is a good and ethical medical practice with the proper use of technology, based on knowledge of scientific evidence and ethical principles of medicine - for the benefit of patients.
Assuntos
Medicina Defensiva , Imperícia , Humanos , Erros Médicos , Segurança do Paciente , Gestão de RiscosRESUMO
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.
Assuntos
Medicina Defensiva , Assistência Centrada no Paciente , Humanos , Motivação , Assistência Centrada no Paciente/tendências , IncertezaRESUMO
BACKGROUND: Defensive practice occurs when physicians provide services, such as tests, treatments and referrals, mainly to reduce their perceived legal or reputational risks, rather than to advance patient care. This behaviour is counter to physicians' ethical responsibilities, yet is widely reported in surveys of doctors in various countries. There is a lack of qualitative research on the drivers of defensive practice, which is needed to inform strategies to prevent this ethically problematic behaviour. METHODS: A qualitative interview study investigated the views and experiences of physicians in Australia on defensive practice and its contribution to low value care. Interviewees were recruited based on interest in medico-legal issues or experience in a health service involved in 'Choosing Wisely' initiatives. Semi-structured interviews averaged 60 min in length. Data were coded using the Theoretical Domains Framework, which encapsulates theories of behaviour and behaviour change. RESULTS: All participants (n = 17) perceived defensive practice as a problem and a contributor to low value care. Behavioural drivers of defensive practice spanned seven domains in the TDF: knowledge, focused on inadequate knowledge of the law and the risks of low value care; skills, emphasising patient communication and clinical decision-making skills; professional role and identity, particularly clinicians' perception of patient expectations and concern for their professional reputation; beliefs about consequences, especially perceptions of the beneficial and harmful consequences of defensive practice; environmental context and resources, including processes for handling patient complaints; social influences, focused on group norms that encourage or discourage defensive behaviour; and emotions, especially fear of missing a diagnosis. Overall, defensive practice is motivated by physicians' desire to avoid criticism or scrutiny from a range of sources, and censure from their professional peers can be a more potent driver than perceived legal consequences. CONCLUSIONS: The findings call for strengthening knowledge and skills, for example, to improve clinicians' understanding of the law and their awareness of the risks of low value care and using effective communication strategies with patients. Importantly, supportive cultures of practice and organisational environments are needed to create conditions in which clinicians feel confident in avoiding defensive practice and other forms of low value care.
Assuntos
Medicina Defensiva , Médicos , Austrália , Medo , Humanos , Advogados , Cuidados de Baixo Valor , Médicos/psicologia , Pesquisa QualitativaRESUMO
OBJECTIVES: Defensive medicine has originally been defined as motivated by fear of malpractice litigation. However, the term is frequently used in Europe where most countries have a no-fault malpractice system. The objectives of this systematic review were to explore the definition of the term 'defensive medicine' in European original medical literature and to identify the motives stated therein. DESIGN: Systematic review. DATA SOURCES: PubMed, Embase and Cochrane, 3 February 2020, with an updated search on 6 March 2021. METHODS: Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses, we reviewed all European original peer-reviewed studies fully or partially investigating 'defensive medicine'. RESULTS: We identified a total of 50 studies. First, we divided these into two categories: the first category consisting of studies defining defensive medicine by using a narrow definition and the second category comprising studies in which defensive medicine was defined using a broad definition. In 23 of the studies(46%), defensive medicine was defined narrowly as: health professionals' deviation from sound medical practice motivated by a wish to reduce exposure to malpractice litigation. In 27 studies (54%), a broad definition was applied adding or other self-protective motives. These self-protective motives, different from fear of malpractice litigation, were grouped into four categories: fear of patient dissatisfaction, fear of overlooking a severe diagnosis, fear of negative publicity and unconscious defensive medicine. Studies applying the narrow and broad definitions of defensive medicine did not differ regarding publication year, country, medical specialty, research quality or number of citations. CONCLUSIONS: In European research, the narrow definition of defensive medicine as exclusively motivated by fear of litigation is often broadened to include other self-protective motives. In order to compare results pertaining to defensive medicine across countries, future studies are recommended to specify whether they are using the narrow or broad definition of defensive medicine. PROSPERO REGISTRATION NUMBER: CRD42020167215.
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Imperícia , Medicina , Medicina Defensiva , Europa (Continente) , HumanosRESUMO
Analyzing whether physicians use cesarean sections (c-sections) as defensive medicine (DM) has proven difficult. Using natural experiments arising out of Oregon court decisions overturning a state legislative cap on non-economic damages in tort cases, we analyze the impact of patient conditions on estimates of DM. Consistent with theory, we find heterogeneous impacts of tort laws across patient conditions. When medical exigencies dictate a c-section, tort laws have no impact on physician decisions. When physicians have latitude in their decision making, we find evidence of DM. When we estimate a model combining all women and not accounting for patient conditions (such as models estimated in previous studies) we obtain a result which is the opposite of DM, which we call offensive medicine (OM). The OM result appears to arise out of a bias in the difference-in-differences estimator associated with changes in the marginal distributions of patient conditions in control and treatment groups. The changes in the marginal distributions appear to arise from the impact of tort law on the market for midwives (substitutes for physicians for low-risk women). Our analysis suggests that not accounting for theoretically expected heterogeneity in physician reactions to changes in tort laws may produce biased estimates of DM.
Assuntos
Imperícia , Médicos , Cesárea , Medicina Defensiva , Feminino , Humanos , Responsabilidade Legal , Gravidez , Estados UnidosRESUMO
Physicians believe that malpractice concerns result in unnecessary testing, and many emergency physicians state that avoiding malpractice is a contributing factor to ordering medically unnecessary tests. Unfortunately, defensive medicine does not come without possible harm to patients who may be subject to non-beneficial, downstream testing, procedures, and hospitalizations. We submit a novel statistic, "NUTS" or "Number of Unnecessary Tests to avoid one Suit. " We calculated a NUTS of 4737 for troponin testing in ED patients with suspected myocardial infarction, meaning a clinician will need to order 4737 medically unnecessary troponin tests to avoid one missed myocardial infarction lawsuit. The NUTS framework offers us an evidence-based lens to examine defensive medicine less superstitiously and more based on currently available data.
Assuntos
Imperícia , Médicos , Medicina Defensiva , HumanosRESUMO
Mental health nursing is a skilled profession, well positioned to support patients towards recovery with evidence-based therapeutic interventions. However, the profession continues to be challenged by tensions surrounding the delivery of restrictive interventions and concerns over tendencies towards defensive practices. This paper examines the ambiguity this creates within the mental health nursing role. Organizational cultures that overvalue metrics and administrative tasks create barriers for therapeutic engagement while contributing to role confusion and stress within nursing. We need to address such structural constraints on nurses as mental health nurses' well-being is crucial to service delivery and the realization of therapeutic goals. From the UK perspective, authors argue that there is a need to examine service structures that foster compassionate and transformational leadership to enable mental health nurses to exercise the agency to practice therapeutically. Education and quality nursing research have a pivotal role to play in enabling this shift.
Assuntos
Enfermagem Psiquiátrica , Medicina Defensiva , Humanos , Liderança , Cultura Organizacional , Profissionalismo , Enfermagem Psiquiátrica/educaçãoRESUMO
AIM: Defensive medicine refers to practices with low marginal benefit to patients that doctors may undertake to protect themselves from legal liability. We aimed to develop a scale to measure the practice of defensive medicine. METHOD: We identified aspects of defensive medicine previously reported in the literature and conducted and analyzed semi-structured interviews with 21 physicians in Sakarya to augment and clarify these aspects between May 15, 2018, and June 15, 2018. Informed by these results, we developed, pilot tested, refined, and fielded a 10-item survey to 1724 doctors in Turkey between April 1, 2019, and July 16, 2019. We examined the psychometric properties of the scale using exploratory (EFA) and confirmatory factor analyses (CFA). RESULTS: The 10-item scale provided measures of 2 factors: positive defensive medicine (assurance) and negative defensive medicine (avoidance), with Cronbach's alpha >0.8 for the scale and both subscales in both the EFA and CFA subsamples and excellent goodness-of-fit measures. CONCLUSIONS: We developed a highly reliable scale to measure positive and negative defensive medicine practice that may be suitable for future research on physician decision making.
Assuntos
Medicina Defensiva , Médicos , Análise Fatorial , Humanos , Psicometria , Reprodutibilidade dos Testes , Inquéritos e QuestionáriosRESUMO
BACKGROUND: The patient-clinician interaction is a site at which defensive practice could occur, when clinicians provide tests, procedures and treatments mainly to reduce perceived legal risks, rather than to advance patient care. Defensive practice is a driver of low-value care and exposes patients to the risks of unnecessary interventions. To date, patient perspectives on defensive practice and its impacts on them are largely missing from the literature. This exploratory study conducted in Australia aimed to examine the views and experiences of healthcare consumer representatives in this under-examined area. METHODS: Semi-structured interviews were conducted with healthcare consumer representatives involved in healthcare consumer advocacy organisations in Australia. Data were transcribed and analysed thematically. RESULTS: Nine healthcare consumer representatives participated. Most had over 20 years of involvement and advocacy in healthcare, including personal experiences as a patient or carer and/or formal service roles on committees or complaint bodies for healthcare organisations. Participants uniformly viewed defensive practice as having a negative impact on the clinician-patient relationship. Themes identified the importance of fostering patient-clinician partnership, effective communication and informed decision-making. The themes support a shift from the concept of defensive practice to preventive practice in partnership, which focuses on the shared interests of patients and clinicians in achieving safe and high-value care. CONCLUSION: This Australian study offers healthcare consumers' perspectives on the impacts of defensive practice on patients. The findings highlight the features of clinician-patient partnership that will help to improve communication and decision-making, and prevent the defensive provision of low-value care. PATIENT OR PUBLIC CONTRIBUTION: Healthcare consumer representatives were involved as participants in this study.
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Comunicação , Medicina Defensiva , Defesa do Paciente , Participação do Paciente , Austrália , Conhecimentos, Atitudes e Prática em Saúde , Humanos , Relações Médico-Paciente , Pesquisa QualitativaRESUMO
OBJECTIVES: Infection prevention and control (IPC) practice in health facility (HF) is abysmally low in developing countries, resulting in significant preventable morbidity and mortality. This study assessed and compared health workers' (HWs) practice of IPC strategies in public and private secondary HFs in Kaduna State. MATERIAL AND METHODS: A cross-sectional comparative study was employed. Using multistage sampling, 227 participants each were selected comprising of doctors, midwives, and nurses from public and private HF. Data were collected using interviewer-administered questionnaire and observation checklist and analyzed using bivariate and multivariate analysis. Statistical significance determined at P < 0.05. RESULTS: The practice of infection prevention was poor. Overall, 42.3% of the HWs did not change their gowns in-between patients, with the significantly higher rates in 73.1% of private compared to 42.3% of public HF workers (P < 0.001). In addition, 30.5% and 10.1% of HWs do not use face mask and eye goggle, respectively, when conducting procedures likely to generate splash of body fluids, however, there was no significant difference in these poor practices in public compared to private HFs. The mean IPC practice was 51.6 ± 12.5%, this was significantly lower among public (48.8 ± 12.5%) compared to private (54.5 ± 11.9%) HF workers (P < 0.0001). Private HF workers were 3 times more likely to implement IPC interventions compared to public HF workers. CONCLUSION: IPC practice especially among public HF workers was poor.
