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Lorenc T, Khouja C, Harden M, Fulbright H, Thomas J. Defensive healthcare practice: systematic review of qualitative evidence. BMJ Open 2024; 14:e085673. [PMID: 39025824 PMCID: PMC11261683 DOI: 10.1136/bmjopen-2024-085673] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2024] [Accepted: 07/05/2024] [Indexed: 07/20/2024] Open
Abstract
OBJECTIVE To synthesise qualitative evidence on clinicians' views and experiences of defensive practice. DESIGN Systematic review of qualitative data. DATA SOURCES MEDLINE, Embase, PsycINFO, AMED, Maternity and Infant Care, CINAHL, ASSIA, Sociological Abstracts, Proquest Dissertations & Theses and PROSPERO were searched from 2000 to October 2023. ELIGIBILITY CRITERIA We included English-language studies of clinicians which reported qualitative data on the impact of litigation or complaints on clinical practice. DATA EXTRACTION AND SYNTHESIS We coded findings data line by line using a grounded theory approach. We assessed quality using Hawker et al's tool and synthesised data thematically. RESULTS 17 studies were included. Participants identify a range of clinical decisions which may be defensively motivated, relating to diagnosis and documentation as well as to treatment. Defensive practice often relates to a diffuse sense of risk rather than the direct threat of litigation and may overlap with other motivations, such as perceived pressure from patients or the desire to avoid harm. Defensive practice is seen to be harmful in many ways, but again, these perceptions may gain force from broader narratives of mistrust and disempowerment, as much as from the risk of litigation. CONCLUSIONS The idea of defensive practice, as enacted, is more complex than some theoretical accounts suggest and may often function to express broader concerns about the work of clinical care. The qualitative evidence calls into question the view of defensive practice as a key mediator linking litigation risk to inappropriate treatment and excess costs.
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Affiliation(s)
- Theo Lorenc
- Centre for Reviews and Dissemination, University of York, York, UK
| | - Claire Khouja
- Centre for Reviews and Dissemination, University of York, York, UK
| | - Melissa Harden
- Centre for Reviews and Dissemination, University of York, York, UK
| | - Helen Fulbright
- Centre for Reviews and Dissemination, University of York, York, UK
| | - James Thomas
- University College London Social Science Research Unit, London, UK
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Wen M, Li L, Zhang Y, Shao J, Chen Z, Wang J, Zhang L, Sun J. Advancements in defensive medicine research: Based on current literature. Health Policy 2024; 147:105125. [PMID: 39018785 DOI: 10.1016/j.healthpol.2024.105125] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2024] [Revised: 07/05/2024] [Accepted: 07/10/2024] [Indexed: 07/19/2024]
Abstract
To investigate and comprehend the evolving research hotspots, cutting-edge trends, and frontiers associated with defensive medicine. The original data was collected from the Web of Science core collection and then subjected to a preliminary retrieval process. Following screening, a total of 654 relevant documents met the criteria and underwent subsequent statistical analysis. Software CiteSpace was employed for conducting a customized visual analysis on the number of articles, keywords, research institutions, and authors associated with defensive medicine. The defensive medicine research network was primarily established in Western countries, particularly the United States, and its findings and conceptual framework have significantly influenced defensive medicine research in other regions. Currently, quantitative methods dominated most studies while qualitative surveys remained limited. Defensive medicine research mainly focused on high-risk medical specialties such as surgery and obstetrics. Research on defensive medicine pertained to the core characteristics of its conceptual framework. An in-depth investigation into the factors that give rise to defensive medicine is required, along with the generation of more generalizable research findings to provide valuable insights for improving and intervening in defensive medicine.
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Affiliation(s)
- Minhui Wen
- School of Health Care Management, Anhui Medical University, Hefei, China
| | - Limin Li
- School of Health Care Management, Anhui Medical University, Hefei, China
| | - Yuqing Zhang
- School of Health Care Management, Anhui Medical University, Hefei, China
| | - Jiayi Shao
- School of Health Care Management, Anhui Medical University, Hefei, China
| | - Zhen Chen
- The First Affiliated Hospital of Anhui Medical University, Hefei, Anhui, China
| | - Jinian Wang
- The First Affiliated Hospital of Anhui Medical University, Hefei, Anhui, China
| | - Liping Zhang
- School of Marxism, Anhui Medical University, Hefei, China
| | - Jiangjie Sun
- School of Health Care Management, Anhui Medical University, Hefei, China; School of Management, Hefei University of Technology, Hefei, Anhui, China.
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Lilly AG, Newman IP, Bjork-James S. Our hands are tied: abortion bans and hesitant medicine. Soc Sci Med 2024; 350:116912. [PMID: 38723584 DOI: 10.1016/j.socscimed.2024.116912] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2023] [Revised: 04/10/2024] [Accepted: 04/22/2024] [Indexed: 05/21/2024]
Abstract
Trained for decades to analyze risks, benefits, unique body compositions, and complex medical scenarios, healthcare providers are now faced with one of medicine's most trying obstacles: how to practice medicine when new abortion bans contradict best practice standards. Drawn from qualitative interviews with medical providers in Tennessee, USA conducted between October 2022 and December 2022, this study shows how medical providers often must make medical decisions based on legal risks as opposed to standards of care. This is particularly significant as malpractice insurance does not cover criminal charges. In states with abortion bans, often hastily implemented and subject to changes by lawmakers, medical providers are now practicing a new kind of defensive medicine in an effort to protect themselves from legal threats. We call this hesitant medicine, where providers often experience a tension between their own legal protection and the well-being of their patients, making them hesitant to provide necessary abortion care. This has serious, far-reaching consequences. We focus on three distinct arenas impacted by this new form of defensive medicine, specifically: providers' decision-making around patient care, impacts on patient relationships, and finally, what we call the ultimate defense, leaving states with abortion bans to move to states with fewer legal risks. We conclude with commentary on potential ways to reduce the negative impacts of these trends.
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Affiliation(s)
- Anna-Grace Lilly
- Anthropology Department, Vanderbilt University, Garland Hall, Nashville, TN, 37240, USA.
| | - Isabelle P Newman
- Anthropology Department, Vanderbilt University, Garland Hall, Nashville, TN, 37240, USA.
| | - Sophie Bjork-James
- Anthropology Department, Vanderbilt University, Garland Hall, Nashville, TN, 37240, USA.
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Miljeteig I, Førde R, Rø KI, Bååthe F, Bringedal BH. Moral distress among physicians in Norway: a longitudinal study. BMJ Open 2024; 14:e080380. [PMID: 38803245 PMCID: PMC11129035 DOI: 10.1136/bmjopen-2023-080380] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2023] [Accepted: 05/10/2024] [Indexed: 05/29/2024] Open
Abstract
OBJECTIVES To explore and compare physicians' reported moral distress in 2004 and 2021 and identify factors that could be related to these responses. DESIGN Longitudinal survey. SETTING Data were gathered from the Norwegian Physician Panel Study, a representative sample of Norwegian physicians, conducted in 2004 and 2021. PARTICIPANTS 1499 physicians in 2004 and 2316 physicians in 2021. MAIN OUTCOME MEASURES The same survey instrument was used to measure change in moral distress from 2004 to 2021. Logistic regression analyses examined the role of gender, age and place of work. RESULTS Response rates were 67% (1004/1499) in 2004 and 71% (1639/2316) in 2021. That patient care is deprived due to time constraints is the most severe dimension of moral distress among physicians, and it has increased as 68.3% reported this 'somewhat' or 'very morally distressing' in 2004 compared with 75.1% in 2021. Moral distress also increased concerning that patients who 'cry the loudest' get better and faster treatment than others. Moral distress was reduced on statements about long waiting times, treatment not provided due to economic limitations, deprioritisation of older patients and acting against one's conscience. Women reported higher moral distress than men at both time points, and there were significant gender differences for six statements in 2021 and one in 2004. Age and workplace influenced reported moral distress, though not consistently for all statements. CONCLUSION In 2004 and 2021 physicians' moral distress related to scarcity of time or unfair distribution of resources was high. Moral distress associated with resource scarcity and acting against one's conscience decreased, which might indicate improvements in the healthcare system. On the other hand, it might suggest that physicians have reduced their ideals or expectations or are morally fatigued.
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Affiliation(s)
- Ingrid Miljeteig
- Bergen Centre for Ethics and Priority Setting, Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway
- Department for Research and Development, Bergen Hospital Trust, Bergen, Norway
| | - Reidun Førde
- Center for Medical Ethics, University of Oslo Faculty of Medicine, Oslo, Norway
- Institute for Studies of the Medical Profession, Oslo, Norway
| | | | - Fredrik Bååthe
- Institute for Studies of the Medical Profession, Oslo, Norway
- Institute of Stress Medicine, Gothenburg, Sweden
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Bolcato V, Franzetti C, Fassina G, Basile G, Martinez RM, Tronconi LP. Comparative study on informed consent regulation in health care among Italy, France, United Kingdom, Nordic Countries, Germany, and Spain. J Forensic Leg Med 2024; 103:102674. [PMID: 38502996 DOI: 10.1016/j.jflm.2024.102674] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2023] [Revised: 03/02/2024] [Accepted: 03/05/2024] [Indexed: 03/21/2024]
Abstract
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.
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Affiliation(s)
- Vittorio Bolcato
- Unit of Legal Medicine, IRCCS Fondazione Istituto Neurologico Nazionale C. Mondino, Pavia, Italy
| | - Chiara Franzetti
- Forensic Medicine Unit, Department of Public Health, Experimental and Forensic Medicine, University of Pavia, Pavia, Italy
| | - Giovanni Fassina
- Forensic Medicine Unit, Department of Public Health, Experimental and Forensic Medicine, University of Pavia, Pavia, Italy; Unit of Legal Medicine, IRCCS Fondazione Istituto Neurologico Nazionale C. Mondino, Pavia, Italy.
| | - Giuseppe Basile
- Trauma Unit and Emergency Department, IRCCS Galeazzi Orthopaedics Institute, Milano, Italy; Head Section of Legal and Forensic Medicine Clinical Institute San Siro, Milan, Italy
| | - Rosa Maria Martinez
- Office of Forensic Sciences, Bellinzona, Republic and Canton of Ticino, Switzerland
| | - Livio Pietro Tronconi
- Forensic Medicine Unit, Department of Public Health, Experimental and Forensic Medicine, University of Pavia, Pavia, Italy; Maria Cecilia Hospital, GVM Care & Research, Cotignola RA, Italy
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Riganti P, Kopitowski KS, McCaffery K, van Bodegom-Vos L. The paradox of using SDM for de-implementation of low-value care in the clinical encounter. BMJ Evid Based Med 2024; 29:14-16. [PMID: 37080738 DOI: 10.1136/bmjebm-2022-112201] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/26/2023] [Indexed: 04/22/2023]
Affiliation(s)
- Paula Riganti
- Family and Community Medicine Department, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Karin Silvana Kopitowski
- Family and Community Medicine Department, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Kirsten McCaffery
- Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Leti van Bodegom-Vos
- Biomedical Data Sciences, Leiden University Medical Center, Leiden, Zuid-Holland, The Netherlands
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Goetz K, Oldenburg D, Strobel CJ, Steinhäuser J. The influence of fears of perceived legal consequences on general practitioners' practice in relation to defensive medicine - a cross-sectional survey in Germany. BMC PRIMARY CARE 2024; 25:23. [PMID: 38216861 PMCID: PMC10785451 DOI: 10.1186/s12875-024-02267-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/03/2023] [Accepted: 01/04/2024] [Indexed: 01/14/2024]
Abstract
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.
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Affiliation(s)
- Katja Goetz
- Institute of Family Medicine, University Medical Center Schleswig-Holstein, Campus Lübeck, Ratzeburger Allee 160, 23538, Lübeck, Germany.
| | - Dorothee Oldenburg
- Institute of Family Medicine, University Medical Center Schleswig-Holstein, Campus Lübeck, Ratzeburger Allee 160, 23538, Lübeck, Germany
| | - Christina Jana Strobel
- Institute of Family Medicine, University Medical Center Schleswig-Holstein, Campus Lübeck, Ratzeburger Allee 160, 23538, Lübeck, Germany
| | - Jost Steinhäuser
- Institute of Family Medicine, University Medical Center Schleswig-Holstein, Campus Lübeck, Ratzeburger Allee 160, 23538, Lübeck, Germany
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Arafa A, Negida A, Elsheikh M, Emadeldin M, Hegazi H, Senosy S. Defensive medicine practices as a result of malpractice claims and workplace physical violence: a cross-sectional study from Egypt. Sci Rep 2023; 13:22371. [PMID: 38102200 PMCID: PMC10724153 DOI: 10.1038/s41598-023-47720-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2023] [Accepted: 11/17/2023] [Indexed: 12/17/2023] Open
Abstract
Defensive medicine refers to practices motivated mainly by legal rather than medical purposes. Increased healthcare costs, overutilization of medical services, and potential harm to patients from unnecessary procedures are among its drawbacks. We performed this study to assess the prevalence of defensive medicine practices in Egypt and their associations with experiencing malpractice claims and workplace physical violence. We investigated 1797 physicians (68.1% male), with an average age of 36.8 ± 9.1 years, practicing in Egypt between January 14th and February 23rd, 2023. SPSS was used for statistical analysis. The majority reported engaging in defensive medicine practices. Specifically, 89.6% acknowledged avoiding high-risk procedures, 87.8% refrained from treating high-risk patients, 86.8% admitted to making unnecessary referrals, 84.9% acknowledged ordering unnecessary tests, 61.4% reported performing unnecessary procedures, and 56.4% disclosed prescribing unnecessary medications. Obstetricians and surgeons exhibited the highest rates of defensive medicine. Using linear regression analysis adjusted for age and sex, malpractice claims and workplace physical violence were associated with defensive medicine score (zero-100): βs (95% CIs) = 5.05 (3.10, 6.99) and 5.60 (3.50, 7.71), respectively, (p values < 0.001). In conclusion, defensive medicine is deeply ingrained in the clinical routines of Egyptian physicians. Establishing a comprehensive national medical liability framework is required.
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Affiliation(s)
- Ahmed Arafa
- Department of Public Health and Community Medicine, Faculty of Medicine, Beni-Suef University, Beni-Suef, Egypt.
| | - Ahmed Negida
- Department of Neurology, Virginia Commonwealth University, Richmond, VA, USA
- Faculty of Medicine, Zagazig University, Zagazig, Egypt
| | - Mohamed Elsheikh
- Department of Health Informatics, Graduate School of Medicine and Public Health, Kyoto University, Kyoto, Japan
- Department of Emergency Medicine and Traumatology, Faculty of Medicine, Tanta University, Tanta, Egypt
| | - Mohamed Emadeldin
- Department of Urology, Faculty of Medicine, Beni-Suef University, Beni-Suef, Egypt
| | - Hesham Hegazi
- Wirral University Teaching Hospital NHS Foundation Trust, Wirral, UK
| | - Shaimaa Senosy
- Department of Public Health and Community Medicine, Faculty of Medicine, Beni-Suef University, Beni-Suef, Egypt
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Zheng J, Lu Y, Li W, Zhu B, Yang F, Shen J. Prevalence and determinants of defensive medicine among physicians: a systematic review and meta-analysis. Int J Qual Health Care 2023; 35:mzad096. [PMID: 38060672 DOI: 10.1093/intqhc/mzad096] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2023] [Revised: 11/12/2023] [Accepted: 11/28/2023] [Indexed: 12/18/2023] Open
Abstract
Defensive medicine, characterized by physicians' inclination toward excessive diagnostic tests and procedures, has emerged as a significant concern in modern healthcare due to its high prevalence and detrimental effects. Despite the growing concerns among healthcare providers, policymakers, and physicians, comprehensive synthesis of the literature on the prevalence and determinants of defensive medicine among physicians has yet been reported. A comprehensive literature search was conducted to identify eligible studies published between 1 January 2000 and 31 December 2022, utilizing six databases (i.e. Web of Science, PubMed, Embase, Scopus, PsycINFO, and Cochrane Library). A meta-analysis was conducted to determine the prevalence and determinants of defensive medicine. Of the 8892 identified articles, 64 eligible studies involving 35.9 thousand physicians across 23 countries were included. The overall pooled prevalence of defense medications was 75.8%. Physicians engaged in both assurance and avoidance behaviors, with the most prevalent subitems being increasing follow-up and avoidance of high-complication treatment protocols. The prevalence of defensive medicine was higher in the African region [88.1%; 95% confidence interval (CI): 80.4%-95.8%] and lower-middle-income countries (89.0%; 95% CI: 78.2%-99.8%). Among the medical specialties, anesthesiologists (92.2%; 95% CI: 89.2%-95.3%) exhibited the highest prevalence. Further, the pooled odds ratios (ORs) of the nine factors at the individual, relational, and organizational levels were calculated, and the influence of previous experience in medical-legal litigation (OR: 1.65; 95% CI: 1.13-2.18) should be considered. The results of this study indicate a high global prevalence of defensive medicine among physicians, underscoring the necessity of implementing targeted interventions to reduce its use, especially in certain regions and specialties. Policymakers should implement measures to improve physicians' medical skills, enhance physician-patient communication, address physicians' medical-legal litigation fears, and reform the medical liability system. Future research should focus on devising and assessing interventions to reduce the use of defensive medicine and to improve the quality of patient care.
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Affiliation(s)
- Junyao Zheng
- School of International and Public Affairs, Shanghai Jiao Tong University, 1954 Huashan Road, Shanghai, 200030 China
- China Institute for Urban Governance, Shanghai Jiao Tong University, 1954 Huashan Road, Shanghai 200030, China
| | - Yongbo Lu
- School of Public Policy and Administration, Xi'an Jiaotong University, 28 West Xianning Road, Xi'an 710049, China
| | - Wenjie Li
- School of International and Public Affairs, Shanghai Jiao Tong University, 1954 Huashan Road, Shanghai, 200030 China
| | - Bin Zhu
- School of Public Health and Emergency Management, Southern University of Science and Technology, 1008 Xueyuan Road, Shenzhen, Guangdong 518005, China
| | - Fan Yang
- School of International and Public Affairs, Shanghai Jiao Tong University, 1954 Huashan Road, Shanghai, 200030 China
- China Institute for Urban Governance, Shanghai Jiao Tong University, 1954 Huashan Road, Shanghai 200030, China
| | - Jie Shen
- Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, 600 Yishan Road, Shanghai 200030, China
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Ropers FG, Rietveld S, Rings EHHM, Bossuyt PMM, van Bodegom-Vos L, Hillen MA. Diagnostic testing in children: A qualitative study of pediatricians' considerations. J Eval Clin Pract 2023; 29:1326-1337. [PMID: 37221991 DOI: 10.1111/jep.13867] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Revised: 05/02/2023] [Accepted: 05/04/2023] [Indexed: 05/25/2023]
Abstract
AIMS AND OBJECTIVES Studies in adult medicine have shown that physicians base testing decisions on the patient's clinical condition but also consider other factors, including local practice or patient expectations. In pediatrics, physicians and parents jointly decide on behalf of a (young) child. This might demand more explicit and more complex deliberations, with sometimes conflicting interests. We explored pediatricians' considerations in diagnostic test ordering and the factors that influence their deliberation. METHOD We performed in-depth, semistructured interviews with a purposively selected heterogeneous sample of 20 Dutch pediatricians. We analyzed transcribed interviews inductively using a constant comparative approach, and clustered data across interviews to derive common themes. RESULTS Pediatricians perceived test-related burden in children higher compared with adults, and reported that avoiding an unjustified burden causes them to be more restrictive and deliberate in test ordering. They felt conflicted when parents desired testing or when guidelines recommended diagnostic tests pediatricians perceived as unnecessary. When parents demanded testing, they would explore parental concern, educate parents about harms and alternative explanations of symptoms, and advocate watchful waiting. Yet they reported sometimes performing tests to appease parents or to comply with guidelines, because of feared personal consequences in the case of adverse outcomes. CONCLUSION We obtained an overview of the considerations that are weighed in pediatric test decisions. The comparatively strong focus on prevention of harm motivates pediatricians to critically appraise the added value of testing and drivers of low-value testing. Pediatricians' relatively restrictive approach to testing could provide an example for other disciplines. Improved guidelines and physician and patient education could help to withstand the perceived pressure to test.
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Affiliation(s)
- Fabienne G Ropers
- Department of Pediatrics, Willem-Alexander Children's Hospital, Leiden University Medical Center, Leiden, The Netherlands
| | - Sophie Rietveld
- Department of Pediatrics, Willem-Alexander Children's Hospital, Leiden University Medical Center, Leiden, The Netherlands
| | - Edmond H H M Rings
- Department of Pediatrics, Willem-Alexander Children's Hospital, Leiden University Medical Center, Leiden, The Netherlands
- Department of Pediatrics, Sophia Children's Hospital, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Patrick M M Bossuyt
- Amsterdam University Medical Centers, University of Amsterdam, Epidemiology & Data Science, Amsterdam, The Netherlands
- Amsterdam Public Health, Methodology, Amsterdam, The Netherlands
| | - Leti van Bodegom-Vos
- Biomedical Data Sciences, Medical Decision Making, Leiden University Medical Center, Leiden, The Netherlands
| | - Marij A Hillen
- Amsterdam University Medical Centers, location AMC, Amsterdam Public Health, Medical Psychology, Amsterdam, The Netherlands
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11
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Izatt A, Greenberg RA, Thorne J, Erdman J, Chauhan N. Ethical and Legal Considerations for Sterilization Refusal in Nulliparous Women. Obstet Gynecol 2023; 142:1316-1321. [PMID: 37884012 DOI: 10.1097/aog.0000000000005414] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2023] [Accepted: 08/31/2023] [Indexed: 10/28/2023]
Abstract
We address the ethical and legal considerations for elective tubal sterilization in young, nulliparous women in Canada, with comparison with the United States and the United Kingdom. Professional guidelines recommend that age and parity should not be obstacles for receiving elective permanent contraception; however, many physicians hesitate to provide this procedure to young women because of the permanence of the procedure and the speculative possibility of regret. At the practice level, this means that there are barriers for young women to access elective sterilization; they are questioned or not taken seriously, or their desire for sterilization is more generally belittled by health care professionals. This article argues for further consideration of these requests and considers the ethical and legal issues that arise when preventing regret is prioritized over autonomy in medical practice. In Canada, there is a paucity of professional guidelines and articles offering practical considerations for handling such requests. Compared with the U.S. and U.K. policy contexts, we propose a patient-centered approach for practice to address requests for tubal sterilization that prioritizes informed consent and respect for patient autonomy. We ultimately aim to assure physicians that when the conditions of informed consent are met and documented, they practice within the limits of the law and in line with best ethical practice by respecting their patients' choice of contraceptive interventions and by ensuring their access to care.
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Affiliation(s)
- Alyssa Izatt
- Department of Philosophy and the W. Maurice Young Centre for Applied Ethics, University of British Columbia, Vancouver, British Columbia, the Department of Paediatrics, University of Toronto and Trillium Health Partners, the Department of Obstetrics & Gynaecology, Women's College Hospital and University of Toronto, and Sinai Health, University of Toronto, Toronto, Ontario, and the Schulich School of Law, Dalhousie University, Halifax, Nova Scotia, Canada
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Snyder C, Smith M, Snyder K. The feasibility of a mystery case curriculum to enhance diagnostic reasoning skills among medical students: a process evaluation. Diagnosis (Berl) 2023; 10:406-411. [PMID: 37497880 DOI: 10.1515/dx-2023-0053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2023] [Accepted: 07/14/2023] [Indexed: 07/28/2023]
Abstract
OBJECTIVES Within a Hospital Medicine division at a large academic institution, an innovative program has been developed to offer third year medical learners enrolled in their Internal Medicine Clerkship the opportunity to deepen their diagnostic reasoning skills with a weekly case-based learning activity entitled "Hospital Medicine's Mystery Case of the Week". The mystery case curriculum has four primary learning objectives (1): To understand the value of employing a multisystem approach to a common presenting problem (2); To apply a diagnostic schema to a clinical problem (3); To apply knowledge of cost appropriate workups to a clinical case and (4) To identify cognitive biases that can influence decision making in the context of treating a clinical problem. METHODS A process evaluation of the mystery case curriculum was conducted over a 6-month implementation period. The process evaluation was guided by eight domains of focus: program acceptability, demand, implementation, practicality, adaptation, integration, expansion and limited-efficacy testing. Measures included a pre/post mixed-methods survey, attendance log and timesheet. Pre/post survey data was analyzed via paired samples t-tests and open-ended responses were analyzed via a deductive content analysis. RESULTS Process evaluation findings demonstrated the program had high levels of acceptability and demand. Survey findings suggest the curriculum may increase feelings of preparedness for Internal Medicine exams as well as student interest, comfort and confidence related to diagnostic processes. CONCLUSIONS Future evaluations should work to understand the influence this curriculum has on diagnostic accuracy within a clinical setting.
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Affiliation(s)
- Christopher Snyder
- Division of Hospital Medicine, Department of Internal Medicine, University of Nebraska Medical Center, Omaha NE, USA
| | - Michael Smith
- Division of Hospital Medicine, Department of Internal Medicine, University of Nebraska Medical Center, Omaha NE, USA
| | - Kailey Snyder
- Education and Child Development, Munroe Meyer Institute, University of Nebraska Medical Center, Omaha NE, USA
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Pischedda G, Marinò L, Corsi K. Defensive medicine through the lens of the managerial perspective: a literature review. BMC Health Serv Res 2023; 23:1104. [PMID: 37848915 PMCID: PMC10580549 DOI: 10.1186/s12913-023-10089-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Accepted: 09/29/2023] [Indexed: 10/19/2023] Open
Abstract
PURPOSE Several studies have been carried out on defensive medicine, but research from the managerial viewpoint is still scarce. Therefore, the aim of the present study is to conduct a literature review to better understand defensive medicine from a managerial perspective. DESIGN/METHODOLOGY/APPROACH A literature review was conducted of studies focusing on the organisational (meso) level of healthcare providers and managerial practices. A final sample of 28 studies was processed. FINDINGS Defensive medicine has mainly been studied in the USA, and scholars have principally used quantitative surveys. High-risk specialities have been a critical field of investigation, and a large portion of the papers are published in journals that cover medicine, health policy, education and law fields. The analysis showed that operations and the organisation of staffing were the most discussed managerial practices. No study considered planning and budgeting aspects. ORIGINALITY/VALUE The review confirmed that the managerial aspect of defensive medicine has not been fully addressed. Stimulated by this gap, this study analyses the managerial background of the defensive medicine phenomenon and shows which managerial practices have been most analysed. This paper also contributes to developing the literature on defensive medicine from the managerial side. Areas for future research include qualitative studies to investigate the behaviour of managers of healthcare companies to give a different perspective on defensive medicine and organisations' decision-making. RESEARCH LIMITATIONS/IMPLICATIONS Some important publications might have been missed in this work because of the choice of only two databases. A further limit could be imposed by the use of the English language as an inclusion criterion.
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Affiliation(s)
- Gianfranco Pischedda
- Department of Economics and Business, University of Sassari, Via Muroni, 25, 07100, Sassari, Italy.
| | - Ludovico Marinò
- Department of Economics and Business, University of Sassari, Via Muroni, 25, 07100, Sassari, Italy
| | - Katia Corsi
- Department of Economics and Business, University of Sassari, Via Muroni, 25, 07100, Sassari, Italy
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Eftekhari MH, Parsapoor A, Ahmadi A, Yavari N, Larijani B, Gooshki ES. Exploring defensive medicine: examples, underlying and contextual factors, and potential strategies - a qualitative study. BMC Med Ethics 2023; 24:82. [PMID: 37817191 PMCID: PMC10563204 DOI: 10.1186/s12910-023-00949-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2023] [Accepted: 08/31/2023] [Indexed: 10/12/2023] Open
Abstract
BACKGROUND Medical errors, unsatisfactory outcomes, or treatment complications often prompt patient complaints about healthcare providers. In response, physicians may adopt defensive practices to mitigate objections, avoid complaints, and navigate lengthy trial processes or other potential threats. However, such defensive medicine (DM) practices can carry risks, including potential harm to patients and the imposition of unnecessary costs on both patients and the healthcare system. Moreover, these practices may run counter to accepted ethical standards in medicine. METHODS This qualitative study involved conducting semi-structured interviews with 43 physicians, among whom 38 were faculty members at medical universities, 42 had administrative experience at various levels of the health system, and 23 had previously served as health system policymakers. On average, the participants had approximately 23.5 years of clinical experience. The selection of participants was based on purposive sampling. Data collection through interviews continued until data saturation was achieved. RESULTS Based on the findings, DM manifests in both positive and negative forms, illustrated by instances like ordering unnecessary lab tests, imaging, or consultations, reluctance to admit high-risk patients, and avoiding high-risk procedures. The study participants identified a range of underlying and contextual factors contributing to DM, encompassing organizational-managerial, social, personal, and factors inherent to the nature of defensive medical practices. The results also highlight proposed strategies to address and prevent DM, which can be grouped into organizational-managerial, social, and those focused on modifying the medical complaints management system. CONCLUSION DM is a multifaceted and significant phenomenon that necessitates a comprehensive understanding of its various aspects, including interconnected and complex structures and underlying and contextual factors. While the results of this study offer a solid foundation for informing policy decisions within the healthcare system and include some explanatory policy suggestions, we encourage policymakers to complement the findings of this study with other available evidence to address any potential limitations and to gain a more comprehensive understanding of the policymaking process related to DM.
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Affiliation(s)
- Mohammad Hossein Eftekhari
- Medical Ethics and History of Medicine Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Alireza Parsapoor
- Medical Ethics and History of Medicine Research Center, Tehran University of Medical Sciences, Tehran, Iran.
| | - Ayat Ahmadi
- Knowledge Utilization Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Neda Yavari
- Department of Medical Ethics, School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Bagher Larijani
- Endocrinology and Metabolism Research Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Ehsan Shamsi Gooshki
- Medical Ethics and History of Medicine Research Center, Tehran University of Medical Sciences, Tehran, Iran.
- Monash Bioethics Center, Monash University, Melbourne, Australia.
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Joniak-Grant E, Blackburn NA, Dasgupta N, Nocera M, Dorris SW, Chelminski PR, Carey TS, Ranapurwala SI. "Cookbook medicine": Exploring the impact of opioid prescribing limits legislation on clinical practice and patient experiences. SSM. QUALITATIVE RESEARCH IN HEALTH 2023; 3:10.1016/j.ssmqr.2023.100273. [PMID: 38798786 PMCID: PMC11120475 DOI: 10.1016/j.ssmqr.2023.100273] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/29/2024]
Abstract
Opioid dependence and overdose are serious public health concerns. States have responded by enacting legislation regulating opioid-prescribing practices. Through in-depth interviews with clinicians, state officials, and organizational stakeholders, this paper examines opioid prescribing limits legislation (PLL) in North Carolina and how it impacts clinical practice. Since the advent of PLL, clinicians report being more mindful when prescribing opioids and as expected, writing for shorter durations for both acute and postoperative pain. But clinicians also report prescribing opioids less frequently for acute pain, refusing to write second opioid prescriptions, foisting responsibility for patient pain care onto other clinicians, and no longer writing opioid prescriptions for chronic pain patients. They directly credit PLL for these changes, including institutional policies enacted in response to PLL, and, to a lesser degree, notions of "do no harm." However, we argue that misapplication of and ambiguities in PLL along with defensive medicine practices whereby clinicians and their institutions center their legal interests over patient care, amplify these restrictive changes in clinical practice. Clinicians' narratives reveal downstream consequences for patients including undertreated pain, being viewed as drug-seeking when questioning opioid-prescribing decisions, and having to overuse the medical system to achieve pain relief.
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Affiliation(s)
- Elizabeth Joniak-Grant
- University of North Carolina Injury Prevention Research Center, 725 Martin Luther King Blvd., Chapel Hill, NC, 27599-7505, USA
| | - Natalie A. Blackburn
- University of North Carolina Injury Prevention Research Center, 725 Martin Luther King Blvd., Chapel Hill, NC, 27599-7505, USA
- Department of Health Behavior, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, 135 Dauer Drive, Chapel Hill, NC, 27599-7440, USA
| | - Nabarun Dasgupta
- University of North Carolina Injury Prevention Research Center, 725 Martin Luther King Blvd., Chapel Hill, NC, 27599-7505, USA
- Office of Research, Innovations, and Global Solutions, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, 135 Dauer Drive, Chapel Hill, NC, 27599-7415, USA
| | - Maryalice Nocera
- University of North Carolina Injury Prevention Research Center, 725 Martin Luther King Blvd., Chapel Hill, NC, 27599-7505, USA
| | - Samantha Wooten Dorris
- University of North Carolina Injury Prevention Research Center, 725 Martin Luther King Blvd., Chapel Hill, NC, 27599-7505, USA
| | - Paul R. Chelminski
- Departments of Allied Health Sciences and Medicine, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, 27599, USA
| | - Timothy S. Carey
- Department of Medicine, School of Medicine, Cecil G. Sheps Health Center for Services Research, University of North Carolina at Chapel Hill, Chapel Hill, NC, 27599, USA
| | - Shabbar I. Ranapurwala
- University of North Carolina Injury Prevention Research Center, 725 Martin Luther King Blvd., Chapel Hill, NC, 27599-7505, USA
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, 135 Dauer Drive, Chapel Hill, NC, 27599-7435, USA
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Strobel CJ, Oldenburg D, Steinhäuser J. Factors influencing defensive medicine-based decision-making in primary care: A scoping review. J Eval Clin Pract 2023; 29:529-538. [PMID: 36433885 DOI: 10.1111/jep.13799] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2022] [Revised: 10/26/2022] [Accepted: 11/01/2022] [Indexed: 11/28/2022]
Abstract
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.
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Affiliation(s)
- Christina J Strobel
- Institute of Family Medicine, University Medical Center Schleswig Holstein, Lübeck, Germany
| | - Dorothee Oldenburg
- Institute of Family Medicine, University Medical Center Schleswig Holstein, Lübeck, Germany
| | - Jost Steinhäuser
- Institute of Family Medicine, University Medical Center Schleswig Holstein, Lübeck, Germany
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Fan Z, Cong X, Tao M, Wu S, Gao P. Development of the Chinese Version of the Physician Internalized Occupational Stigma Scale (PIOSS). Psychol Res Behav Manag 2022; 15:3445-3459. [PMID: 36471790 PMCID: PMC9719362 DOI: 10.2147/prbm.s386724] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2022] [Accepted: 11/15/2022] [Indexed: 08/10/2023] Open
Abstract
BACKGROUND/OBJECTIVE Internalized occupational stigma may develop in physicians as a result of their identification with the public negative labels and stereotypes about them, and then internalization of them as a part of their self-concept. This study aims to develop the Physician Internalized Occupational Stigma Scale (PIOSS) and to examine its reliability and validity. METHODS In study 1, the initial scale was used to investigate 356 physicians. While in study 2, a total of 346 physicians were investigated with the survey tools named the PIOSS, the Career Commitment Scale (CCS), the Workplace Well-Being Scale (WWBS), the Scale for the Doctor with Patient-doctor Relationship (DDPRQ-10), the Intent to Leave Scale (ILS) and the Occupational Disidentification Scale (ODS). RESULTS The PIOSS includes 19 items divided into 3 dimensions: label identification, status loss, and career denial. The results of confirmatory factor analysis (CFA) reveal that the three-factor model fitted well (χ 2/df=2.574, RMSEA= 0.068, CFI= 0.931, IFI= 0.931, TLI= 0.919, PNFI= 0.762, PCFI= 0.795). The PIOSS total and each dimension scores were significantly negatively correlated with the CCS and the WWBS scores and remarkably positively associated with the DDPRQ-10, the ILS, and the ODS scores. Cronbach's α coefficients for the PIOSS total scale and dimensions ranged from 0.775 to 0.914, and split-half reliability coefficients ranged from 0.801 to 0.931. In addition, the PIOSS exhibited cross-gender invariance. CONCLUSION Having good reliability and validity, the PIOSS can serve as a valid tool for the assessment of physician internalized occupational stigma.
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Affiliation(s)
- Zhiguang Fan
- Department of Education, Jilin International Studies University, Changchun City, Jilin Province, People’s Republic of China
- Department of Marxism, Changchun University of Chinese Medicine, Changchun City, Jilin Province, People’s Republic of China
| | - Xiangxin Cong
- Department of Education, Jilin International Studies University, Changchun City, Jilin Province, People’s Republic of China
| | - Min Tao
- Department of Education, Jilin International Studies University, Changchun City, Jilin Province, People’s Republic of China
| | - Shijia Wu
- Department of Traditional Chinese Medicine, Changchun University of Chinese Medicine, Changchun City, Jilin Province, People’s Republic of China
| | - Peng Gao
- Department of Traditional Chinese Medicine, Changchun University of Chinese Medicine, Changchun City, Jilin Province, People’s Republic of China
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Rosół I, Ciesielka J, Matlakiewicz M, Grześków M, Cebula M, Gruszczyńska K, Winder M. The Assessment of the Rationale for Urgent Head CT-Comparative Analysis of Referrals and Results of Examinations without and with Contrast Enhancement. MEDICINA (KAUNAS, LITHUANIA) 2022; 58:medicina58101468. [PMID: 36295628 PMCID: PMC9610557 DOI: 10.3390/medicina58101468] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/29/2022] [Revised: 10/03/2022] [Accepted: 10/14/2022] [Indexed: 11/06/2022]
Abstract
The study analyzes the correlation between the indications and results of head CT examinations in search of evidence of the excessive use of this diagnostic method. In total, 1160 referrals for urgent head CT were analyzed retrospectively, including the following parameters: patients’ sex and age, type of scan (C−, C+, angio-CT), description of symptoms and presence of diagnostic target. Pathologies identified by the radiologist were assigned to four classes, regarding the severity of diagnosed conditions. The analysis of the CT results has shown that over half (55.22%) of the examinations revealed no deviations or showed chronic, asymptomatic lesions. As many as 73.71% referrals constituted group 0 in terms of the lack of a diagnostic target of a specific pathology. The presence of specific clinical targeting in a referral correlated significantly with a higher frequency of acute diagnosis. Contrast-enhanced follow-up examinations allowed the unequivocal classification of patients into extreme classes (I or IV) and accurate identification of patients requiring urgent or chronic treatment. Excessive use of diagnostic imaging is harmful, not only to patients, who often are unnecessarily exposed to radiation, but also to the quality of healthcare, since it increases the costs and radiologists’ workload.
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Affiliation(s)
- Izabela Rosół
- Students’ Scientific Society, Department of Radiology and Nuclear Medicine, Medical University of Silesia, ul. Medyków 14, 40-752 Katowice, Poland
| | - Jakub Ciesielka
- Students’ Scientific Society, Department of Radiology and Nuclear Medicine, Medical University of Silesia, ul. Medyków 14, 40-752 Katowice, Poland
| | - Magdalena Matlakiewicz
- Students’ Scientific Society, Department of Radiology and Nuclear Medicine, Medical University of Silesia, ul. Medyków 14, 40-752 Katowice, Poland
| | - Michał Grześków
- Students’ Scientific Society, Department of Radiology and Nuclear Medicine, Medical University of Silesia, ul. Medyków 14, 40-752 Katowice, Poland
| | - Maciej Cebula
- Department of Radiology and Nuclear Medicine, Medical University of Silesia, ul. Medyków 14, 40-752 Katowice, Poland
| | - Katarzyna Gruszczyńska
- Department of Radiology and Nuclear Medicine, Medical University of Silesia, ul. Medyków 14, 40-752 Katowice, Poland
| | - Mateusz Winder
- Department of Radiology and Nuclear Medicine, Medical University of Silesia, ul. Medyków 14, 40-752 Katowice, Poland
- Correspondence: ; Tel.: +48-32-789-47-51
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Kakemam E, Arab-Zozani M, Raeissi P, Albelbeisi AH. The occurrence, types, reasons, and mitigation strategies of defensive medicine among physicians: a scoping review. BMC Health Serv Res 2022; 22:800. [PMID: 35725449 PMCID: PMC9210603 DOI: 10.1186/s12913-022-08194-w] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2022] [Accepted: 06/14/2022] [Indexed: 11/10/2022] Open
Abstract
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. Keywords Defensive medicine, Defensive practice, Medical malpractice, Physicians, Scoping review Supplementary Information The online version contains supplementary material available at 10.1186/s12913-022-08194-w.
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Affiliation(s)
- Edris Kakemam
- Clinical Research Development Unit of Tabriz Valiasr Hospital, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Morteza Arab-Zozani
- Social Determinants of Health Research Center, Birjand University of Medical Sciences, Birjand, Iran
| | - Pouran Raeissi
- Department of Health Services Management, School of Health Management and Information Sciences, Iran University of Medical Sciences, Tehran, Iran
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Anatomy of diagnosis in a clinical encounter: how clinicians discuss uncertainty with patients. BMC PRIMARY CARE 2022; 23:153. [PMID: 35715733 PMCID: PMC9205543 DOI: 10.1186/s12875-022-01767-y] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/03/2022] [Accepted: 06/12/2022] [Indexed: 12/27/2022]
Abstract
Background Studies consider the clinical encounter as linear, comprising six phases (opening, problem presentation, history-taking, physical examination, diagnosis, treatment and closing). This study utilizes formal conversation analysis to explore patient-physician interactions and understanding diagnostic utterances during these phases. Methods This study is a qualitative sub-analysis that explores how the diagnosis process, along with diagnostic uncertainty, are addressed during 28 urgent care visits. We analyzed physicians’ hypothesis-generation process by focusing on: location of diagnostic utterances during the encounter; whether certain/uncertain diagnostic utterances were revised throughout the encounter; and how physicians tested their hypothesis-generation and managed uncertainty. We recruited 7 primary care physicians (PCPs) and their 28 patients from Brigham and Women’s Hospital (BWH) in 3 urgent care settings. Encounters were audiotaped, transcribed, and coded using NVivo12 qualitative data analysis software. Data were analyzed inductively and deductively, using formal content and conversation analysis. Results We identified 62 diagnostic communication utterances in 12 different clinical situations. In most (24/28, 86%) encounters, the diagnosis process was initiated before the diagnosis phase (57% during history taking and 64% during physical examination). In 17 encounters (61%), a distinct diagnosis phase was not observed. Findings show that the diagnosis process is nonlinear in two ways. First, nonlinearity was observed when diagnostic utterances occurred throughout the encounter, with the six encounter phases overlapping, integrating elements of one phase with another. Second, nonlinearity was noted with respect to the resolution of diagnostic uncertainty, with physicians acknowledging uncertainty when explaining their diagnostic reasoning, even during brief encounters. Conclusions Diagnosis is often more interactive and nonlinear, and expressions of diagnostic assessments can occur at any point during an encounter, allowing more flexible and potentially more patient-centered communication. These findings are relevant for physicians’ training programs and helping clinicians improve their communication skills in managing uncertain diagnoses.
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Ries NM, Johnston B, Jansen J. A qualitative interview study of Australian physicians on defensive practice and low value care: "it's easier to talk about our fear of lawyers than to talk about our fear of looking bad in front of each other". BMC Med Ethics 2022; 23:16. [PMID: 35246129 PMCID: PMC8895622 DOI: 10.1186/s12910-022-00755-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Accepted: 02/18/2022] [Indexed: 12/27/2022] Open
Abstract
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. Supplementary Information The online version contains supplementary material available at 10.1186/s12910-022-00755-2.
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Affiliation(s)
- Nola M Ries
- Faculty of Law, University of Technology Sydney, PO Box 123, Sydney, NSW, 2007, Australia.
| | - Briony Johnston
- Faculty of Law, University of Technology Sydney, PO Box 123, Sydney, NSW, 2007, Australia
| | - Jesse Jansen
- School for Public Health and Primary Care, Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands
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Hofmann B, Andersen ER, Kjelle E. Visualizing the Invisible: Invisible Waste in Diagnostic Imaging. Healthcare (Basel) 2021; 9:1693. [PMID: 34946419 PMCID: PMC8702028 DOI: 10.3390/healthcare9121693] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2021] [Revised: 12/02/2021] [Accepted: 12/03/2021] [Indexed: 11/16/2022] Open
Abstract
There is extensive waste in diagnostic imaging, at the same time as there are long waiting lists. While the problem of waste in diagnostics has been known for a long time, the problem persists. Accordingly, the objective of this study is to investigate various types of waste in imaging and why they are so pervasive and persistent in today's health services. After a short overview of different conceptions and types of waste in diagnostic imaging (in radiology), we identify two reasons why these types of waste are so difficult to address: (1) they are invisible in the healthcare system and (2) wasteful imaging is driven by strong external forces and internal drivers. Lastly, we present specific measures to address wasteful imaging. Visualizing and identifying the waste in diagnostic imaging and its ingrained drivers is one important way to improve the quality and efficiency of healthcare services.
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Affiliation(s)
- Bjørn Hofmann
- Department of Health Sciences, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology, P.O. Box 191, N-2802 Gjøvik, Norway; (E.R.A.); (E.K.)
- Centre for Medical Ethics, Institute for Health and Society, Faculty of Medicine, University of Oslo, P.O. Box 1130, N-0318 Oslo, Norway
| | - Eivind Richter Andersen
- Department of Health Sciences, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology, P.O. Box 191, N-2802 Gjøvik, Norway; (E.R.A.); (E.K.)
| | - Elin Kjelle
- Department of Health Sciences, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology, P.O. Box 191, N-2802 Gjøvik, Norway; (E.R.A.); (E.K.)
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Ries NM, Johnston B, Jansen J. Views of healthcare consumer representatives on defensive practice: 'We are your biggest advocate and supporter… not the enemy'. Health Expect 2021; 25:374-383. [PMID: 34859547 PMCID: PMC8849368 DOI: 10.1111/hex.13395] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2021] [Revised: 11/01/2021] [Accepted: 11/16/2021] [Indexed: 12/25/2022] Open
Abstract
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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Affiliation(s)
- Nola M Ries
- Faculty of Law, Law Health Justice Research Centre, University of Technology Sydney, Sydney, New South Wales, Australia
| | - Briony Johnston
- Faculty of Law, Law Health Justice Research Centre, University of Technology Sydney, Sydney, New South Wales, Australia
| | - Jesse Jansen
- Faculty of Health, Medicine and Life Sciences, School for Public Health and Primary Care, Maastricht University, Maastricht, The Netherlands
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Tarrant C, Krockow EM. Antibiotic overuse: managing uncertainty and mitigating against overtreatment. BMJ Qual Saf 2021; 31:163-167. [PMID: 34285113 DOI: 10.1136/bmjqs-2021-013615] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/03/2021] [Indexed: 11/04/2022]
Affiliation(s)
- Carolyn Tarrant
- Department of Health Sciences, University of Leicester, Leicester, UK
| | - Eva M Krockow
- Department of Neuroscience, Psychology and Behaviour, University of Leicester, Leicester, UK
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