Defensive medicine in Europe: a 'full circle'?

The effects of loving-kindness meditation on doctors' communication anxiety, trust, calling and defensive medicine practice

OBJECTIVE

The study investigated the effects of loving-kindness meditation (LKM) on doctors' communication anxiety, trust, calling, and defensive medicine practice.

METHODS

This study recruited 94 doctors from a hospital in China, randomized them to an LKM group (n = 47), and waited for the control group (n = 47). The experimental group accepted an 8-week LKM interference while the waiting for the control group underwent no interference. Researchers measured four major variable factors (communication anxiety, trust, calling, and defensive medicine practice) before and after the LKM intervention.

RESULTS

In the experimental group, trust, and calling were significantly higher, and communication anxiety, and defensive medicine practice were significantly lower than in the control group. In the control group, there were no noticeable differences in any of the four variables between the pre-test and post-test.

CONCLUSIONS

The results of this study demonstrate that LKM may help to improve trust, and calling, and reduce communication anxiety and defensive medicine practice. The finding of LKM's effect extends the understanding of the integrative effects of positive psychology on the decrease of defensive medicine practice.

TRIAL REGISTRATION

ChiCTR2300074568. Registered in Chinese Clinical Trial Registry (ChiCTR), 9 August, 2023.

Volatility, Uncertainty, Complexity, and Ambiguity (VUCA) in Healthcare

Our professional activity is constantly under pressure from a multitude of elements and factors that can be classified into the four components of the VUCA phenomenon-volatility, uncertainty, complexity, and ambiguity-components that define the turbulence and challenges of the external environment. Considering the general elements of this phenomenon, we designed a new VUCA dimension specific to the healthcare field within which we have identified and analyzed all the factors that can influence the main actors of the doctor-patient relationship and the effects that can occur within the healthcare system in which this relationship is born. In this context, we generated the VUCA treatment in healthcare capable of mitigating the impact of this phenomenon; this treatment involves essential elements in overcoming possible crises and vulnerabilities of the medical profession. The VUCA treatment in healthcare requires combating volatility, uncertainty, complexity, and ambiguity through vision, understanding, clarity, and agility, which are grounded in the doctor's need to acquire cross-functional competencies (soft skills). These competencies are applicable by using functional mechanisms and techniques that support the doctor in developing adaptability and anticipation skills, understanding the patient's needs and addressing them, and ensuring the functionality and efficiency of the healthcare system by transferring these elements from micro-management to macro-management levels.

Comparative study on informed consent regulation in health care among Italy, France, United Kingdom, Nordic Countries, Germany, and Spain

The information and subsequent expression of will, so-called informed consent, have become the essential element of health right, understood as the right to autonomous choice in health, based on the fiduciary relationship between physician and patient. This gradually leads European Countries to adopt special legislations and to issue frequent judgments on the subject. However, new challenges in daily clinical practice call for further study of legal solutions. The authors analyse and compare the regulations on informed consent in health care of Italy, France, the United Kingdom, the Nordic Countries, Germany, and Spain. The health and legal contexts, existence of special regulations on informed consent and their characteristics are discussed. Informed consent resulted a mandatory requirement. Clear communication about treatment, therapeutic alternatives, and major risks, discussed in conversation, but preferably documented in writing, are agreed upon. The possibility of dissent and withdrawal of consent are also included. There is a growing interest in involving and regulating the entire health team in information and consent. Lowering the age of consent for minors or analysing the maturity of minors are attempts to increase their participation in health decisions. On another side, the protection of adult incapables persons requires greater involvement of family and fiduciaries to better adapt to changing health needs. Health policy must take responsibility for training health professionals and citizens about the value of health information and communication as a shared choice in care planning, to strengthen the bond of trust with the healthcare system and users.

Eyecare practitioner perspectives and attitudes towards myopia and myopia management in the UK

OBJECTIVE

Many children with progressive myopia are still prescribed single-vision correction. An investigation into UK eyecare practitioners' (ECPs) perceptions of myopia management was carried out to ascertain factors which may be limiting its implementation and uptake within clinical practice.

METHODS AND ANALYSIS

Online focus groups were held with UK ECPs. Participants were encouraged to discuss their knowledge of the available myopia management options, their perception of how myopia management is being delivered in the UK and any barriers limiting ECPs' prescribing of these management options in practice. The discussions were transcribed and analysed thematically.

RESULTS

Focus groups were held with 41 ECPs from primary and secondary eyecare. ECPs felt that provision of myopia management in the UK is variable. Most ECPs believe they have sufficient knowledge, but felt a lack of confidence in decision-making and practical experience. Less experienced ECPs sought more definitive guidance to support their decision-making. ECPs desired clarity on their duty of care obligations and were concerned over possible future litigation if they had not offered, or referred for, myopia management when indicated. The greatest barrier appears to be financial-treatment is expensive and ECPs are uncomfortable communicating this to parents. Many barriers were indicative of systemic problems within UK eyecare, such as commercial pressures, inadequate National Health Service funding and poor public awareness of paediatric eyecare.

CONCLUSION

Myopia management is not implemented consistently across the UK. To improve accessibility, changes are required at multiple levels, from individual ECPs through to wider stakeholders in UK eyecare provision.

Virtual reality evidence on the impact of physicians' open versus defensive communication on patients

Using virtual reality (VR) in an experimental setting, we analyse how communicating more openly about a medical incident influences patients' feelings and behavioural intentions. Using VR headsets, participants were immersed in an actual hospital room where they were told by a physician that a medical incident had occurred. In a given scenario, half of the participants were confronted by a physician who communicated openly about the medical incident, while the other half were confronted with the exact same scenario except that the physician employed a very defensive communication strategy. The employed technology allowed us to keep everything else in the environment constant. Participants exposed to open disclosure were significantly more likely to take further steps (such as contacting a lawyer to discuss options and filing a complaint against the hospital) and express more feelings of blame against the physician. At the same time, these participants rated the physician's communication skills and general impression more highly than those who were confronted with a defensive physician. Nevertheless, communicating openly about the medical incident does not affect trust in the physician and his competence, perceived incident severity and likelihood of changing physician and filing suit.

The practice of defensive medicine among physicians in the United Arab Emirates: A clinician survey

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.

Vox clamantis in deserto: a survey among Italian psychiatrists on defensive medicine and professional liability

Due to recent events, professional liability for psychiatrists in Italy is currently a matter of lively debate. Specifically, overwhelming pressure on psychiatrists' duties has been brought by regulatory developments, such as the closure of forensic psychiatric hospitals, with the consequent return of offenders to community-based care, and the mental health consequences of the pandemic. According to Italian courts, psychiatrists are not only responsible for diagnostic and therapeutic appropriateness but also for the effects of their interventions on patients, and their behaviors. The aim of this study was to explore the attitude and behaviors of Italian psychiatrists regarding defensive medicine and professional liability. A total sample of 254 psychiatrists was surveyed by means of a quantitative online questionnaire. Most psychiatrists reported practicing defensive medicine (no. 153/254, 60.2%) and felt that their position of guarantee compromised their work in healthcare for patients (no. 138/253, 54.3%). Age correlated inversely with acknowledgment of defensive practices (r = -0.245, p < 0.001), with younger physicians more prone to defensive medicine (p = 0.013), particularly for patients at risk of suicide or violence. Psychiatrists in 'closed' settings (hospital wards, residential and rehabilitation centers, mental health service units in prison) reported more malpractice claims (p = 0.037) and complaints (p = 0.031), as well as a greater propensity to act defensively. In the treatment of patients with violent behavior, suicidal ideation, dual diagnoses, and criminal convictions, defensive practices were associated more with perceived legal risks (r = 0.306, p < 0.001) than actual legal involvement (p > 0.05). Anxiety, anger, and restlessness were common reactions to legal complaints, involving no. 50/254 (19.7%) respondents, with 40% reporting impaired functioning. Most psychiatrists (no. 175/253, 68.9%) were concerned about both civil and criminal laws regarding their professional responsibility, but many were not fully informed about recent legislative regulations and younger physicians resulted scarcely trained in risk management (p < 0.001). In conclusion, our findings suggest that defensive medicine is a common phenomenon among psychiatrists and their position of guarantee drives this attitude. Education on legal implications and risk management should be provided starting from the university and continuing over time, to improve the knowledge of young and senior doctors on professional liability and inform their decision-making processes. This would also reduce defensive practices and improve the quality of healthcare. Considering the concerns of younger physicians, as well as of professionals working in acute and high-intensity medical care facilities, there is also an urgent need for a revision of the medical liability to ensure the sustainability of the National Health Service.

Thyroid cytology: The reality before and after the introduction of ultrasound classification systems for thyroid nodules

BACKGROUND

Several ultrasound-based systems for classification of thyroid nodules are available. They allow for a better triage of the nodules that require cytological assessment, and lead to standardized recommendations. Our aim was to compare patients and nodules referred to fine-needle aspiration (FNA) before and after the introduction of these systems.

METHODS

A retrospective study comparing two cohorts of patients referred for FNA was performed (386 patients and 463 nodules in 2015; 220 patients and 263 nodules in 2021).

RESULTS

The sex distribution (89.1% vs 85.9% females, p=0.243), number of nodules referred to FNA per patient (median of 1), and the distribution of the Bethesda categories (p=0.082) was similar in both years. In 2021, patients were older (53.4±14.5 years vs 57.8±13.2 years, p<0.001) and nodules over one centimetre were larger (median 17.0mm vs 19.0mm, p=0.002), especially the ones categorized as Bethesda III (median size 11mm vs 23mm, p=0.043). In 2021, at least 23.1% of the nodules referred to FNA did not have any criteria, and 38.8% of the nodules were not categorized by any system.

CONCLUSION

This analysis draws attention to the importance of systematically applying ultrasound-based classification systems. It seems that, by not being focused mainly on size thresholds, they allow for longer surveillance periods, without aggravating the cytology results when FNA becomes indicated. Nevertheless, greater efforts are needed to ensure more standardized reports, and to increase adherence to the resulting recommendations to reduce clinical uncertainty, unnecessary FNA, and overtreatment.

'We're gonna end up scared to do anything': A qualitative exploration of how client complaints are experienced by UK veterinary practitioners

BACKGROUND

UK veterinary practitioners are reported to be fearful of client complaints, but their experiences have not been formally captured. Understanding how complaints impact veterinary practitioners is key to mitigating detrimental consequences.

METHODS

A qualitative exploration of how UK veterinary practitioners experience and respond to adverse events was conducted. Data were collected via focus groups and interviews, which were transcribed and simultaneously analysed. Coding and theme development were inductive rather than restricted by preconceived theories.

RESULTS

Twelve focus groups and 15 individual interviews took place. One theme identified focused on the impact of client complaints. Practitioners experienced unintentional distraction and disengagement from clinical work, as well as employing defensive strategies as a direct result of complaints. The vexatious nature of some complainants was highlighted, along with concerns about practice and regulatory complaint management, lack of appropriate support, discriminatory behaviours and the influence of 'trial by media'.

CONCLUSIONS

Client complaints present a threat to practitioner mental health and workforce sustainability, as well as having implications for patient safety. Mitigating these effects is a complex and multifaceted undertaking, but fairness, transparency and timeliness of practice and regulatory complaint investigation must be prioritised, along with provision of tailored support for those facing complaints.

Integrated care in Western Europe: a wise solution for the future?

INTRODUCTION

IC is a term commonly adopted across the world underpinning a positive attitude against fragmentation of healthcare service provision. While the principles supporting IC are simple, their implementation is more controversial.

AREAS COVERED

The growing number of IC definitions is related to the increasing domains of applications, which reflect the increasing demand induced by aging multi-morbid patients. A comprehensive definition of IC should now include the coordination of health and social services useful to deliver continuous care across organizational boundaries. The recent debate on IC is largely influenced by the mismatch between the increasing burden of health and social needs for chronic conditions from the demand side, and the design of health-care systems still focused on acute care from the supply side.

EXPERT OPINION

The major reasons of persisting IC weakness in European countries stem from arguable choices of health policy taken in the recent past. The political creed in 'market competition' is probably the most emblematic. All initiatives encouraging health-care providers to compete with each other are likely to discourage IC. Since most European GPs are still self-employed professionals working in their own cabinets, the anachronistic professional status of GPs is another historically rooted reason of IC weakness.

Frequency and estimated costs of ten low-value practices in the Spanish Primary Care: a retrospective study

BACKGROUND

The frequency of low-value practices (LVPs) in the healthcare system is a worldwide challenge. Far less is known about the related extra cost. This study aimed to evaluate the LVPs trend in Spanish primary care (PC), its frequency in both sexes, and estimate its related extra cost.

METHODS

A multicentric, retrospective, and national research project was conducted. Ten LVPs highly frequent and potentially harmful for patients were analyzed. Algorithms were applied to collect the data from 28,872,851 episodes registered into national databases (2015-2017). Cost estimation was made.

RESULTS

LVPs registered a total of 7,160,952 (26.5%) episodes plus a total of 259,326 avoidable PSA screening tests. In adults, a high frequency was found for prescription of 1g paracetamol >3 days, antibiotics for acute bronchitis (unconfirmed comorbidity), and benzodiazepines in patients >65 years with insomnia. Women received more jeopardizing practices (p≤0.001). Pediatrics presented a downward of antibiotic and paracetamol-ibuprofen prescription combination. The estimated extra cost was close to €292 million (2.8% of the total cost in PC).

CONCLUSION

LVPs reduction during the analyzed period was moderate compared to studies following 'Choosing Wisely list' of LVPs and must improve to reduce patient risk and the extra related costs.

Views of healthcare consumer representatives on defensive practice: 'We are your biggest advocate and supporter… not the enemy'

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.

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

OBJECTIVE

To examine the occurrence of and types of defensive medicine (DM), and the reasons for practicing DM in general practice.

DESIGN

Prospective survey registration of consecutive consultations regarding defensive medicine defined as: Actions that are not professionally well founded but are carried out due to demands and pressure. The GPs registered the degree of defensiveness, the type(s) of defensive action(s) and the reason(s) for acting defensively.

SETTING

Danish general practice.

SUBJECTS

A total of 26 GPs registered a total of 1,758 consultations.

MAIN OUTCOME MEASURES

Defensive medical actions.

RESULTS

Defensive actions were performed in 12% (210/1749) of all consultations. A fifth (46/210) of the defensive actions were characterised by the GPs as 'moderately' or 'highly' defensive. Frequent types of defensive actions were: blood tests, point-of-care-tests (POCTs) and referrals. Common reasons for defensive actions were: Influence from patients, 37% (78/210), concerns of overlooking severe disease, 32% (67/210) and influence from patient relatives, 12% (25/210).

CONCLUSION

Danish GPs registered self-perceived defensive actions in a prospective survey. DM was carried out in one out of eight consultations, most often due to patient influence. The most frequent defensive actions were blood tests, POCTs and referrals.

Analysis of General Practitioners' Attitudes and Beliefs about Psychological Intervention and the Medicine-Psychology Relationship in Primary Care: Toward a New Comprehensive Approach to Primary Health Care

The biopsychosocial paradigm is a model of care that has been proposed in order to improve the effectiveness of health care by promoting collaboration between different professions and disciplines. However, its application still faces several issues. A quantitative-qualitative survey was conducted on a sample of general practitioners (GPs) from Milan, Italy, to investigate their attitudes and beliefs regarding the role of the psychologist, the approach adopted to manage psychological diseases, and their experiences of collaboration with psychologists. The results show a partial view of the psychologist's profession that limits the potential of integration between medicine and psychology in primary care. GPs recognized that many patients (66%) would often benefit from psychological intervention, but only in a few cases (9%) were these patients regularly referred to a psychologist. Furthermore, the referral represents an almost exclusive form of collaboration present in the opinions of GPs. Only 8% of GPs would consider the joint and integrated work of the psychologist and doctor useful within the primary health care setting. This vision of the role of psychologists among GPs represents a constraint in implementing a comprehensive primary health care approach, as advocated by the World Health Organization.

The fine line of defensive medicine

Defensive medicine is a practice that has been utilized by clinicians in efforts of preventing patient dissatisfaction and malpractice claims and may be done through either omission or commission. As much as 57% of physicians have disclosed that they practice defensive medicine. However, this practice does not necessarily prevent malpractice claims and more importantly, neither does it equate to good medical practice, with some leading to poor outcomes. Unfortunately, there is a high percentage of malpractice claims lodged against clinicians in both primary care and hospital settings. Specialists such as surgeons, obstetricians, and gynecologists face the highest claims. In particular, during the SARS CoV-2 pandemic, with new challenges and limited treatment algorithms, there is an even greater concern for possible bourgeoning claims. Counteracting defensive medicine can be accomplished through decriminalizing malpractice claims, leaving physician oversight up to state medical boards and hospital claims management committees. Additional tort reform measures must also be taken such as caps on noneconomic damages to ensure emphasis on beneficence and nonmaleficence. Once these are in place, it may well serve to increase clinician-patient trust and improve patient independence in the shared decision-making process of their treatment, allowing clinicians to practice their full scope of practice without feeling wary of potential malpractice claims.