Physician perceptions of medical malpractice and defensive medicine

Collateral Victims of Defensive Medical Practice

This paper analyzes the phenomenon of defensive medical practice, starting from the doctor–patient relationship, and the behavioral and professional factors that can influence the proper functioning of this relationship and the healthcare system. We analyze medical malpractice, given the increase in the number of accusations, as an essential factor in triggering the defensive behavior of doctors, together with other complementary factors that emphasize the need for protection and safety of doctors. The possible consequences for the doctor–patient relationship that defensive practice can generate are presented and identified by analyzing the determining role of the type of health system (fault and no-fault). At the same time, we investigate the context in which overspecialization of medical personnel can generate a form of defensive practice as a result of the limiting effect on the performance of a certain category of operations and procedures. The increase in the number of malpractice accusations impacts the medical community—“the stress syndrome induced by medical malpractice”—turning doctors into collateral victims who, under the pressure of diminishing their reputational safety, practice defensively to protect themselves from future accusations. This type of defensive behavior puts pressure on the entire healthcare system by continuously increasing costs and unresolved cases, which impact patients by limiting access to medical services in the public and private sectors.

How defensive medicine is defined in European medical literature: a systematic review

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.

Internal Medicine Residents and the Practice of Defensive Medicine: A Pilot Study Across Three Internal Medicine Residency Programs

Background

Defensive medicine is becoming increasingly prevalent in the United States and is estimated to cost billions of dollars in excess healthcare spending. There is evidence that the practice of defensive medicine starts early in the medical career. Defensive medicine has been investigated among residents in high medico-legal risk specialties, but there is a paucity of information on its prevalence among internal medicine residents.

Objective 

To examine the prevalence and patterns of defensive medical practices among internal medicine residents.

Methods

We conducted an online survey among the residents of three internal medicine residency programs in the 2018-2019 academic cycle. We invited all internal medicine residents within the selected programs to participate through email and asked them to complete an electronic survey assessing defensive medical practices.

Results

A total of 49 out of 143 residents participated in the study (response rate: 34.3%); 55% (n = 27) of the residents who participated considered the risk of being sued during residency to be low, compared to 40.8% (n = 20) who considered it to be moderate and 4.1% (n = 2) who considered it to be high. Defensive medical practices were found to be widely prevalent (40.0-91.3%) among internal medicine residents across all three clinical training stages. Assurance defensive practices were more common than avoidance practices.

Conclusion

Defensive medical practices, especially of the assurance type, were widely prevalent among our sample of internal medicine residents.

Determining the frequency of defensive medicine among general practitioners in Southeast Iran

BACKGROUND

Defensive medicine prompts physicians not to admit high-risk patients who need intensive care. This phenomenon not only decreases the quality of healthcare services, but also wastes scarce health resources. Defensive medicine occurs in negative and positive forms. Hence, the present study aimed to determine frequency of positive and negative defensive medicine behaviors and their underlying factors among general practitioners in Southeast Iran.

METHODS

The present cross-sectional study was performed among general practitioners in Southeast Iran. 423 subjects participated in the study on a census basis and a questionnaire was used for data collection. Data analysis was carried out using descriptive and analytical statistics through SPSS 20.

RESULTS

The majority of participants were male (58.2%). The mean age of physicians was 40 ± 8.5. The frequency of positive and negative defensive medicine among general practitioners in Southeast Iran was 99.8% and 79.2% respectively. A significant relationship was observed between working experience, being informed of law suits against their colleagues, and committing defensive medicine behavior (P< 0.001).

CONCLUSION

The present study indicated high frequency of defensive medicine behavior in the Southeast Iran. So, it calls policy-makers special attention to improve the status quo.

Defensive practice among psychiatrists: a questionnaire survey

OBJECTIVE

There has been little research on the prevalence of defensive practice within hospital settings. The aim of this report was to examine the extent of defensiveness among psychiatrists and to examine the relationship between defensiveness and seniority, as well as the effect of previous experiences on the level of defensiveness.

DESIGN

A postal questionnaire survey on defensive practice.

SETTING

Northern Region of England.

SUBJECTS

154 psychiatrists in the region.

RESULTS

96 responses were received from 48 equivalent consultants, 18 specialist registrars, and 23 equivalent senior house officers. Overall, 75% of those who replied had taken defensive actions within the past month. In particular, 21% had admitted patients overcautiously and 29% had placed patients on higher levels of observations. Junior psychiatrists were particularly prone to practise defensively. Important contributing factors included previous experience of complaints (against colleague or self), critical incidents, and legal claims.

CONCLUSION

Almost three quarters of the psychiatrists who responded had practised defensively within the past month. The higher propensity of junior trainees to practise defensively may be attributable to their lack of confidence and experience. Experience of complaints (colleague or self) and critical incidents were important factors for defensive practice. Better and more structured training might reduce the high level of defensive practice and the way complaints and investigations are handled should be improved to maintain a truly "no blame" environment conducive to learning from past experience.

Patient, physician and presentational influences on clinical decision making for breast cancer: results from a factorial experiment

This study examines the influence of six patient characteristics (age, race, socioeconomic status, comorbidities, mobility and presentational style) and two physician characteristics (medical specialty and years of clinical experience) on physicians' clinical decision making behaviour in the evaluation treatment of an unknown and known breast cancer. Physicians' variability and certainty associated with diagnostic and treatment behaviour were also examined. Separate analyses explored the influence of these non-medical factors on physicians' cognitive processes. Using a fractional factorial design, 128 practising physicians were shown two videotaped scenarios and asked about possible diagnoses and medical recommendations. Results showed that physicians displayed considerable variability in response to several patient-based factors. Physician characteristics also emerged as important predictors of clinical behaviour, thus confirming the complexity of the medical decision-making process.