Cross-sectional survey on defensive practices and defensive behaviours among Israeli psychiatrists

Defensive medicine practices as a result of malpractice claims and workplace physical violence: a cross-sectional study from Egypt

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.

Prevalence and determinants of defensive medicine among physicians: a systematic review and meta-analysis

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.

Predictors of Defensive Practices among Italian Psychiatrists: Additional Findings from a National Survey

Background: Defensive medicine is characterized by medical decisions made primarily as a precaution against potential malpractice claims. For psychiatrists, professional responsibility encompasses not only the appropriateness of diagnosis and treatment but also the effects of their interventions on patients and their behaviors. Objective: To investigate the socio-demographic, educational, and occupational characteristics and work-related attitudes that may serve as predictors of defensive medicine among Italian psychiatrists. This research extends the results of a previous analysis based on a national survey. Methods: A secondary analysis of the database of a national survey on attitudes and behaviors of Italian psychiatrists regarding defensive medicine and professional liability was performed for this study. Results: Among 254 surveyed psychiatrists, 153 admitted to practicing defensive medicine, while 101 had this attitude with less than half of their patients. The first group was predominantly comprised of women (p = 0.014), who were younger in age (43.34 y 9.89 vs. 48.81 y 11.66, p < 0.001) and had fewer years of professional experience (12.09 y ± 9.8 vs. 17.46 y ± 11.2, p < 0.001). There were no significant differences in prior involvement in complaints (p = 0.876) or the usual place of work (p = 0.818). The most prominent predictors for practicing defensive medicine were (1) considering guidelines and good clinical practices not only for their clinical efficacy but also or exclusively for reducing the risk of legal complaints for professional liability (OR = 3.62; 95%CI, 1.75-7.49), and (2) hospitalizing patients with violent intentions even if not warranted according to their mental state (OR = 2.28; 95%CI, 1.50-3.46, p < 0.001). Prioritizing protection from professional liability over patients' actual needs in prescribing or adjusting drug dosages and in involuntary hospitalization, as well as prescribing lower dosages than recommended for pregnant patients, were identified as additional predictors. Finally, years of professional experience exhibited a protective function against defensive practices. Conclusions: Psychiatrists advocate the need to implement a 'risk management culture' and the provision of more balanced duties in order to ensure ethical and evidence-based care to their patients. A particular source of concern stems from their professional responsibility towards not only the health of patients but also their behavior. However, these aspects conflict with a limited potential for assessment and intervention based on effective clinical tools. A reform of professional liability that considers the specificities of patients cared for by mental health services could contribute to reducing the risk of defensive medicine.

Predictors of Defensive Practices among Italian Psychiatrists: Additional Findings from a National Survey

Background: Defensive medicine is characterized by medical decisions made primarily as a precaution against potential malpractice claims. For psychiatrists, professional responsibility encompasses not only the appropriateness of diagnosis and treatment but also the effects of their interventions on patients and their behaviors. Objective: To investigate the socio-demographic, educational, and occupational characteristics and work-related attitudes that may serve as predictors of defensive medicine among Italian psychiatrists. This research extends the results of a previous analysis based on a national survey. Methods: A secondary analysis of the database of a national survey on attitudes and behaviors of Italian psychiatrists regarding defensive medicine and professional liability was performed for this study. Results: Among 254 surveyed psychiatrists, 153 admitted to practicing defensive medicine, while 101 had this attitude with less than half of their patients. The first group was predominantly comprised of women (p = 0.014), who were younger in age (43.34 y 9.89 vs. 48.81 y 11.66, p < 0.001) and had fewer years of professional experience (12.09 y ± 9.8 vs. 17.46 y ± 11.2, p < 0.001). There were no significant differences in prior involvement in complaints (p = 0.876) or the usual place of work (p = 0.818). The most prominent predictors for practicing defensive medicine were (1) considering guidelines and good clinical practices not only for their clinical efficacy but also or exclusively for reducing the risk of legal complaints for professional liability (OR = 3.62; 95%CI, 1.75–7.49), and (2) hospitalizing patients with violent intentions even if not warranted according to their mental state (OR = 2.28; 95%CI, 1.50–3.46, p < 0.001). Prioritizing protection from professional liability over patients’ actual needs in prescribing or adjusting drug dosages and in involuntary hospitalization, as well as prescribing lower dosages than recommended for pregnant patients, were identified as additional predictors. Finally, years of professional experience exhibited a protective function against defensive practices. Conclusions: Psychiatrists advocate the need to implement a ‘risk management culture’ and the provision of more balanced duties in order to ensure ethical and evidence-based care to their patients. A particular source of concern stems from their professional responsibility towards not only the health of patients but also their behavior. However, these aspects conflict with a limited potential for assessment and intervention based on effective clinical tools. A reform of professional liability that considers the specificities of patients cared for by mental health services could contribute to reducing the risk of defensive medicine.

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.

Psychiatrists’ occupational stigma conceptualization, measurement, and intervention: A literature review

Psychiatrists require frequent contact with and treatment of patients with mental illnesses. Due to the influence of associative stigma, psychiatrists may also be targets of stigma. Occupational stigma warrants special consideration because it significantly affects psychiatrists' career advancement, well-being, and their patients’ health. Given that there is no complete summary of this issue, this study reviewed the existing literature on psychiatrists' occupational stigma to clearly synthesize its concepts, measurement tools, and intervention strategies. Herein, we emphasize that psychiatrists’ occupational stigma is a multifaceted concept that simultaneously encompasses physically, socially, and morally tainted aspects. Currently, standardized methods to specifically measure psychiatrists’ occupational stigma are lacking. Interventions for psychiatrists’ occupational stigma may consider the use of protest, contact, education, comprehensive and systematic methods, as well as the use of psychotherapeutic approaches. This review provides a theoretical basis for the development of relevant measurement tools and intervention practices. Overall, this review seeks to raise public awareness of psychiatrists' occupational stigma, thereby promoting psychiatric professionalism and reducing its stigma.

Collateral Victims of Defensive Medical Practice

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

Exploring the inner roots of discharge against medical advice (DAMA) in an academic psychiatric hospital: a qualitative study

Background

To explore the roots of DAMA in the Roozbeh Hospital, an academic mental hospital located in Tehran, Iran, the authors conducted a simple qualitative study. Twenty-four in-depth semi-structured interviews with families and eight with patients who were discharged against medical advice were done about the inner motivation and roots of DAMA. The sampling was convenient in trying to reach the maximum variation. The transcribed verbatim of the interviews was coded and categorized inductively by discussion. Ethical consideration was approved by the TUMS ethical committee.

Results

Findings were classified into six categories: The patient’s insistence, miss the beloved one, sense of improvement, outside hospital concerns, dissatisfaction with the quality of medical care, and worries about the hospitalization consequences.

Conclusions

Addressing the inner roots of DAMA can be an opportunity to understand better patients and their families’/relatives’ experiences and feelings. This will give a deep perspective and insight into the subject.

The occurrence, types, reasons, and mitigation strategies of defensive medicine among physicians: a scoping review

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.

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

OBJECTIVES

Defensive medicine has originally been defined as motivated by fear of malpractice litigation. However, the term is frequently used in Europe where most countries have a no-fault malpractice system. The objectives of this systematic review were to explore the definition of the term 'defensive medicine' in European original medical literature and to identify the motives stated therein.

DESIGN

Systematic review.

DATA SOURCES

PubMed, Embase and Cochrane, 3 February 2020, with an updated search on 6 March 2021.

METHODS

Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses, we reviewed all European original peer-reviewed studies fully or partially investigating 'defensive medicine'.

RESULTS

We identified a total of 50 studies. First, we divided these into two categories: the first category consisting of studies defining defensive medicine by using a narrow definition and the second category comprising studies in which defensive medicine was defined using a broad definition. In 23 of the studies(46%), defensive medicine was defined narrowly as: health professionals' deviation from sound medical practice motivated by a wish to reduce exposure to malpractice litigation. In 27 studies (54%), a broad definition was applied adding … or other self-protective motives. These self-protective motives, different from fear of malpractice litigation, were grouped into four categories: fear of patient dissatisfaction, fear of overlooking a severe diagnosis, fear of negative publicity and unconscious defensive medicine. Studies applying the narrow and broad definitions of defensive medicine did not differ regarding publication year, country, medical specialty, research quality or number of citations.

CONCLUSIONS

In European research, the narrow definition of defensive medicine as exclusively motivated by fear of litigation is often broadened to include other self-protective motives. In order to compare results pertaining to defensive medicine across countries, future studies are recommended to specify whether they are using the narrow or broad definition of defensive medicine.

PROSPERO REGISTRATION NUMBER

CRD42020167215.

Defensive Medicine Practices: Scale Development and Validation

AIM

Defensive medicine refers to practices with low marginal benefit to patients that doctors may undertake to protect themselves from legal liability. We aimed to develop a scale to measure the practice of defensive medicine.

METHOD

We identified aspects of defensive medicine previously reported in the literature and conducted and analyzed semi-structured interviews with 21 physicians in Sakarya to augment and clarify these aspects between May 15, 2018, and June 15, 2018. Informed by these results, we developed, pilot tested, refined, and fielded a 10-item survey to 1724 doctors in Turkey between April 1, 2019, and July 16, 2019. We examined the psychometric properties of the scale using exploratory (EFA) and confirmatory factor analyses (CFA).

RESULTS

The 10-item scale provided measures of 2 factors: positive defensive medicine (assurance) and negative defensive medicine (avoidance), with Cronbach's alpha >0.8 for the scale and both subscales in both the EFA and CFA subsamples and excellent goodness-of-fit measures.

CONCLUSIONS

We developed a highly reliable scale to measure positive and negative defensive medicine practice that may be suitable for future research on physician decision making.

Iatrogenic Complications of Compulsory Treatment in a Patient Presenting with an Emotionally Unstable Personality Disorder and Self-Harm

Attempted suicide and deliberate self-harm are common and challenging presentations in the emergency department. A proportion of these patients refuse interventions and this presents the clinical, legal, and ethical dilemma as to whether treatment should be provided against their will. Multiple factors influence this decision. It is difficult to foresee the multitude and magnitude of complications that can arise once it has been decided to treat individuals who do not consent. This case illustrates a particularly complex chain of events that occurred after treating someone against their will who presented with self-harm and suicidal ideation. These consequences are contrasted with those of not intervening when similar situations arose with the same patient.

Factors influencing lithium versus valproate prescription preference in the maintenance treatment of bipolar patients: a report from the Italian Early Career Psychiatrists (SOPSI-GG)

BACKGROUND

Objective of the present manuscript is to investigate, among Italian early career psychiatrists (ECPs), prescriber and patient-related factors associated with lithium or valproate preference to treat patients affected by Bipolar Disorder (BD).

METHODS

An on-line survey was carried out among 252 ECPs, investigating their prescription patterns in relation to lithium and the differences with prescription of valproate. Collected data were compared according to lithium or valproate prescription preference in the long-term treatment of BD by χ² tests for qualitative variables.

RESULTS

Over two thirds of ECPs preferred lithium over valproate for the maintenance treatment of BD. Less than half of the sample used lithium as first-line agent for mania or major depression, and less than one third for mixed episodes. Factors associated with lithium preference as first-line maintenance treatment include perception of having a good knowledge of lithium (p < 0.001) and complete satisfaction with education on lithium (p < 0.001). One of the main factors to prefer valproate was the concern about long-term side effects of lithium (p < 0.001).

CONCLUSIONS

Type of education, source of information, clinical experience and safety concerns influence the choice of lithium versus valproate in the long-term treatment of BD. Present findings may guide educational training of ECPs.KEY POINTSLithium has been less prescribed in the last years for long-term treatment of Bipolar Disorder.Educational and clinical factors seem to influence the attitude to prescribe lithium.Only half of the Italian early career psychiatrists declare to have at least an adequate knowledge of lithium.Residency program in psychiatry should consider the implementation of education on lithium.

Physicians' views and experiences of defensive medicine: An international review of empirical research

This study systematically maps empirical research on physicians' views and experiences of hedging-type defensive medicine, which involves providing services (eg, tests, referrals) to reduce perceived legal risks. Such practices drive over-treatment and low value healthcare. Data sources were empirical, English-language publications in health, legal and multi-disciplinary databases. The extraction framework covered: where and when the research was conducted; what methods of data collection were used; who the study participants were; and what were the study aims, main findings in relation to hedging-type defensive practices, and proposed solutions. 79 papers met inclusion criteria. Defensive medicine has mainly been studied in the United States and European countries using quantitative surveys. Surgery and obstetrics have been key fields of investigation. Hedging-type practices were commonly reported, including: ordering unnecessary tests, treatments and referrals; suggesting invasive procedures against professional judgment; ordering hospitalisation or delaying discharge; and excessive documentation in medical records. Defensive practice was often framed around the threat of negligence lawsuits, but studies recognised other legal risks, including patient complaints and regulatory investigations. Potential solutions to defensive medicine were identified at macro (law, policy), meso (organisation, profession) and micro (physician) levels. Areas for future research include qualitative studies to investigate the behavioural drivers of defensive medicine and intervention research to determine policies and practices that work to support clinicians in de-implementing defensive, low-value care.

Communicating suicide risk to families of chronically suicidal borderline personality disorder patients to mitigate malpractice risk

OBJECTIVE

The distinction between acute and chronic suicidality is important, because interventions designed to address acute suicidality can worsen chronic suicidality, resulting in an escalating cycle of suicide threats, suicide attempts, and futile hospitalizations. Though most chronically suicidal borderline personality disorder patients improve and do not complete suicide, the potential for suicide contributes to these hospitalizations and a paucity of outpatient services due to treaters' concern over malpractice lawsuits in case of suicide. Communicating with patients' families about the suicide risk has been suggested as a means to mitigate this malpractice risk, but the approach to such communication has not been described.

METHOD

Once chronic suicidality is identified, a stepwise approach to communicating with the patient's family is described.

RESULTS

The potential benefits of this risk communication are described, for patients, families, treaters, healthcare systems, and health and malpractice insurers.

CONCLUSION

It helps to develop an alliance with families and patients around a shared understanding of outcomes in chronic suicidality - most eventually do better, but the risk of completed suicide is real. This enables patients and families to make a more fully informed choice about treatment, which in turn can reduce litigation risk in the minority of cases where the patient completes suicide.

Defensive practice is indefensible: how defensive medicine runs counter to the ethical and professional obligations of clinicians

Defensive medicine has become pervasive. Defensive medicine is often thought of as a systems issue, the inevitable result of an adversarial malpractice environment, with consequent focus on system-responses and tort reform. But defensive medicine also has ethical and professionalism implications that should be considered beyond the need for tort reform. This article examines defensive medicine from an ethics and professionalism perspective, showing how defensive medicine is deeply problematic. First, a definition of defensive medicine is offered that describes the essence of defensive practice: clinical actions with the goal of protecting the clinician against litigation or some adverse outcome. Ethical arguments against defensive medicine are considered: (1) defensive medicine is deceptive and undermines patient autonomy; (2) defensive medicine subjugates patient interests to physician interests and violate fiduciary obligations; (3) defensive medicine exposes patients to harm without benefit; (4) defensive medicine undermines trust in the profession; and (5) defensive medicine violates obligations of justice. Possible arguments in favor of defensive medicine are considered and refuted. Defensive practice is therefore unethical and unprofessional, and should be viewed as a challenge for medical ethics and professionalism.

Addressing Suicide Risk According to Different Healthcare Professionals in Spain: A Qualitative Study

This study analyzes the views of four groups of healthcare professionals who may play a role in the management of suicidal behavior. The goal was to identify key factors for suicide prevention in different areas of the healthcare system. Qualitative research was conducted using focus groups made up of different healthcare professionals who participated in the identification, management, and prevention of suicidal behavior. Professionals included were primary care physicians, psychologists, psychiatrists, and emergency physicians. 'Suicide' was amongst the most relevant terms that came up in discussions most of the times it appeared associated with words such as 'risk', danger', or 'harm'. In the analysis by categories, the four groups of professionals agreed that interventions in at-risk behaviors are first in importance. Prevention was the second main concern with greater significance among psychiatrists. Primary care professionals call for more time to address patients at risk for suicide and easier access to and communication with the mental health network. Emergency care professionals have a lack of awareness of their role in the detection of risk for suicide in patients who seek attention at emergency care facilities for reasons of general somatic issues. Mental health care professionals are in high demand in cases of self-harm, but they would like to receive specific training in dealing with suicidal behavior.

Balancing autonomy and beneficence at the time of psychiatric discharge

As in much of the world, mental health law in Israel has evolved over the past half-century toward greater protection of patients' liberty and an increased emphasis on due process. Part of that process in Israel involved taking decisions about prolonged involuntary hospitalization out of the hands of treating psychiatrists and turning them over to independent review panels. Argo and colleagues examined outcomes of discharge decisions made by these panels compared with treating psychiatrists. In this brief commentary, we describe related trends in mental health law in other countries, especially the U.S., consider countervailing perspectives on the role of review panels, and suggest how the Argo et al. study might be followed up with additional research.