Defensive medicine in Danish general practice. Types of defensive actions and reasons for practicing defensively

Exploring the impact of workplace violence on defensive medicine and patient outcomes: an empirical analysis using regression discontinuity

Objective

This study aims to thoroughly examine the impact of workplace violence incidents in healthcare settings on the structure of medical expenses, with a particular focus on specific changes in defensive medical, and to further investigate the resulting patient outcomes.

Method

This study examines a high-profile workplace violence incident in W City, H Province, China, which had widespread societal impact, treating it as an exogenous shock. Utilizing inpatient medical record data from W City, the study constructs a regression discontinuity model to systematically analyze shifts in medical behaviors related to costs and decision-making following the incident, as well as the implications of these changes on patient burden and health outcomes.

Results

The findings indicate that workplace violence incidents lead to significant changes in the structure of medical costs, with a notable increase in comprehensive medical service fees and a significant decrease in invasive treatment fees. Further analysis reveals that such incidents trigger pronounced defensive medicine, including extended hospital stays, increased probabilities of departmental transfers, reduced surgical levels, and higher costs and a greater proportion of traditional Chinese medicine in total expenditures. Additionally, in terms of patient outcomes, workplace violence incidents slightly alleviate patients’ out-of-pocket expenses and payment ratios. However, these incidents significantly worsen patients’ primary health indicators and overall health status at discharge.

Conclusion

Workplace violence against healthcare professionals significantly impact the structure of medical costs and trigger defensive medicine, characterized by a tendency toward conservative treatment approaches and reduced treatment intensity. While such incidents may partially alleviate patients’ financial burdens, they have detrimental effects on patients’ health outcomes. Therefore, to enhance healthcare quality and safeguard patient well-being, it is imperative to implement measures to mitigate workplace violence in healthcare and encourage medical institutions to prioritize scientific and rational decision-making in treatment practices.

Factors associated with defensive medicine practice in United Arab Emirates: A cross-sectional study with multivariate analysis

Health services institutes worldwide are trying to reduce defensive medical practice to limit its negative impact on patient care. We evaluated the factors associated with this defensive medical practice among medical professionals in the United Arab Emirates. This study deployed multivariate logistic regression analysis. Defensive medical practice was defined according to the responses given to questions about potentially unnecessary referral, testing, and additional care in a cross-sectional 23-item questionnaire administered to medical professionals after obtaining ethical committee approval. The factors evaluated were: age, gender, medical specialty, job grade, years of practice, country of medical graduation, country of specialty board, current practice in hospital or private sector, feeling supported by workplace staff, being involved in litigation, and indemnity cover. Multivariate models determined the adjusted odds ratios (aOR) and 95% confidence intervals (CI) after taking account of confounding; aOR > 1 indicated a positive association of factors with defensive practice while aOR < 1 indicated a negative association. There were 562 respondents. The most common defensive medical practice related to referring on a case after sensing the possibility of a complaint (365, 64.9%); the factors associated were senior grades (aOR 0.74, 95% CI 0.56-0.98, P = .04), private sector (aOR 1.27, 95% CI 1.008-1.61, P = .04), and indemnity cover (aOR 0.49, 95% CI 0.26-0.93, P = .03). The second most common defensive practice was calling inpatient admission, delaying discharge, additional testing, etc without medical indication and solely on patient or family request (265, 47.1%); the factors associated were age (aOR 0.46, 95% CI 0.33-0.64, P = .001), private sector (aOR 0.66, 95% CI 0.53-0.83, P = .001), and support by workplace staff (aOR 0.50, 95% CI 0.34-0.73, P = .001). Other defensive practices included refraining from difficult procedures or referring cases to another colleague due to the fear of complications (166, 29.5%) and unwillingness to accept patients in case of previous litigation history (157, 28.1%). This multivariable analysis in the United Arab Emirates found that higher age, higher job grades, indemnity cover and support by workplace staff reduced the odds of defensive medicine practice while working in the private sector had a mixed effect.

The influence of fears of perceived legal consequences on general practitioners' practice in relation to defensive medicine - a cross-sectional survey in Germany

BACKGROUND

Medical decisions are influenced by a variety of factors also by legal requirements and feelings of uncertainty, which results in the term defensive medicine. The aim of the study was to evaluate the influence of fears of perceived legal consequences on the practice of defensive medicine from the perspective of German general practitioners (GPs).

METHODS

A cross-sectional study was performed from April to May 2022. GPs were invited via an e-mail newsletter of the Institute for Continuing Education in Family Medicine in the German Association of General Practitioners and via an online platform of the German College of General Practitioners and Family Physicians. The evaluation of legal fears, the general assessment of defensive medicine and reasons for and the frequency of defensive medical measures were surveyed in this study. Beside descriptive analyses, a stepwise linear regression analysis was used to explore potential associations between for the primary outcome variable 'fears of legal consequences' on the practice of defensive medicine.

RESULTS

413 general practitioners with an average age of 50 years (51% female) responded. The majority rated their fears of legal consequences as low to average whereas for almost a third (27%, n = 113) the fears were strong to very strong. Regarding legal fears, the physician-patient-relationship played a fairly to very large role for 48% (n = 198) of the respondents. One third estimated the probability of being sued civilly in the next 10 years as rather high to very high. 47% (n = 193) of the participants assumed that the risk of being sued could mostly to very much be reduced by defensive medicine. Legal self-protection was for 38% of the responders (n = 157) quite frequently to very frequently a reason for acting defensively. Consequently, half of the respondents stated that they performed unnecessary laboratory tests at least once per week and 40% indicated that they referred patients for radiological diagnostics without medical indication once per month.

CONCLUSIONS

As legal fears have an influence on medical practice and legal self-protection being a frequent reason for defensive behaviour, understanding and knowledge of the law should be improved by legal education at university and further training of post-graduate trainees and practicing physicians should be implemented. Additionally, a more in-depth enlightenment of society about the phenomenon of Protective and Defensive Medicine and its consequences could be a possibility to decrease the perceived fears of legal consequences on the physicians' side.

Factors influencing defensive medicine-based decision-making in primary care: A scoping review

RATIONALE, AIMS AND OBJECTIVES

Medical decision-making processes in primary care are influenced by defensive medical practice. This involves a high possibility for negative consequences on many levels, for example, patient's health, health care system costs and a crisis of trust in the patient-doctor relationship. Aim of this review was to identify factors of defensive medicine-based decision-making in primary care.

METHODS

This scoping review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping reviews (PRISMA-ScR) guidelines and included systematic research on MEDLINE, Google Scholar and two German databases for additional grey literature. References provided further literature. Articles in English and German published from 1 January 1982 to 15 June 2022 were assessed.

RESULTS

From 911 publications screened, 13 publications [6 qualitative studies and 7 quantitative (3 cross-sectional) studies] were included. In these, four main categories of factors influencing defensive medical practice were identified: (social) media, patients adopting a consumer attitude, health care system based working conditions and physician's tolerance for uncertainty. Pressure deriving from these four different sources is exerted on the general practitioner and may result in a defensive medical decision behaviour.

CONCLUSIONS

Four categories on influencing factors of defensive medicine could be identified. Strategies to tolerate uncertainty should be trained in under- and postgraduate training.

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.

“I had already tried that before going to the doctor” – exploring adolescents’ with knee pain perspectives on ‘wait and see’ as a management strategy in primary care; a study with brief semi-structured qualitative interviews

Objectives

The aim of this study was to examine how the “wait-and-see” recommendation affects adolescents’ understanding of their illness and symptoms and their care-seeking behavior.

Methods

This study included brief qualitative, semi-structured online interviews. Adolescents (age 10–19 years) with long-term knee pain, who had been recommended “wait-and-see” by their general practitioner (GP), were recruited via previous studies and social media. Two researchers conducted brief semi-structured interviews through Microsoft Teams. An interview guide with open questions was created prior to the interviews and updated as new questions emerged. The extracted data was transcribed and analyzed via a reflexive thematic approach in NVivo.

Results

Eight adolescents (mean age 17.8) with longstanding or recurrent knee pain (mean duration 3.5 years) were included. The analysis identified four main themes: (1) The perception of wait and see over time, (2) The GP’s acknowledgement and consideration, (3) experienced limitation from knee pain and (4) the importance of getting a diagnosis. The perception of “wait-and-see” approach changed from positive to negative when adolescents received the recommendation multiple times. Adolescents experienced frustration with their situation and a lack of consideration from their GP made them cautious about seeking additional care. Knee pain significantly limited the adolescents’ physical-and social activities. Receiving a diagnosis was important and helped adolescents dealing with their pain.

Conclusions

The connotation of wait-and-see changed from positive to negative for adolescents when receiving the recommendation multiple times. The participants felt getting a clinical diagnosis was a relief. Furthermore, the lack of consideration and acknowledgement from the GP plays an essential role in the adolescent’s understanding of their knee pain.

Implications

Recommending adolescents to “wait-and-see” multiple times in relation to their knee problems can lead adolescents experience frustration and a lack of consideration from their GP. It would be advisable for GPs to provide adolescents with a diagnosis as it can facilitate them in dealing with their pain and to use simple language when explaining adolescents their condition to improve communication.