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

Defensive healthcare practice: systematic review of qualitative evidence

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.

A confirmatory factor analysis of the Iranian version of the interpersonal communication skills scale among healthcare professionals

BACKGROUND

Identifying healthcare professionals' (HCPs) communication skills is crucial to improving patient outcomes. Iranian HCPs' interpersonal communication skills (ICS) were validated using a culturally appropriate and indigenous scale.

MATERIALS AND METHODS

In November and December 2021, convenience sampling was used to collect data from 170 HCPs. Seven factors were covered by the questionnaire, which consisted of 30 items. In order to validate the scale, first- and second-order confirmatory factor analyses (CFA) were performed. Various indices were used during the CFA, including Goodness of Fit Index (GFI), Adjusted Goodness of Fit (AGFI), Comparative Fit Index (CFI), Normed Fit Index (NFI), Standardized Root Mean Square Residual (SRMR), and Root Mean Square Error of Approximation (RMSEA). The Fornell-Larcker Criterion was used to assess discriminant validity. We analyzed the data in Lisrel 8.8 and SmartPLS 3.2.8.

RESULTS

According to the Q2-index obtained from the blindfold test, the model had 44% predictive power. First-order CFA results showed acceptable indices (χ2 = 767.17; DF = 375; CFI = 0.98; GFI = 0.82; AGFI = 0.80; NFI = 0.97; SRMR = 0.22; RMSEA = 0.068). Furthermore, the second-order measurement model demonstrated adequate and desirable fit indices (χ2 = 797.24; DF = 381; CFI = 0.98; GFI = 0.82; AGFI = 0.78; NFI = 0.97; SRMR = 0.059; RMSEA = 0.068). General and listening skills were ranked highest in the importance-performance map analysis (IPMA).

CONCLUSION

HCPs could benefit from this scale as it can assist them in developing ICS. It is recommended that skills training programs be replicated among different populations to evaluate their effectiveness.

Curricular Interventions in Medical Schools: Maximizing Community Engagement Through Communities of Practice

This article explains the importance of a communities of practice (CoP) model for continually aligning medical education and clinical transformation with contemporary health issues. It describes the evolution and advantages of using CoP as a model for transforming medical education and clinical practice and applies the CoP methodology to addressing the changing needs of socially vulnerable populations (LGBTQ [lesbian, gay, bisexual, transgender, and queer/questioning], persons experiencing homelessness, and migrant farm workers). In conclusion, this article describes CoP-led activities, achievements, and value creation in medical education by the National Center for Medical Education Development and Research established at the Meharry Medical College.

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"

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.