How defensive medicine is defined and understood in European medical literature: protocol for a systematic review

How prepared are newly qualified allied health professionals for practice in the UK? A systematic review

OBJECTIVES

It is important that allied health professionals (AHPs) are prepared for clinical practice from the very start of their working lives to provide quality care for patients, for their personal well-being and for retention of the workforce. The aim of this study was to understand how well newly qualified AHPs were prepared for practice in the UK.

DESIGN

Systematic review.

DATA SOURCES

Embase, MEDLINE, CINAHL, ERIC and BEI were searched from 2012 to 2024. Grey literature searching and citation chasing were also conducted.

ELIGIBILITY CRITERIA

We included primary studies reporting the preparedness for practice of UK graduates across 15 professions; all study types; participants included graduates who were up to 2 years postgraduation, their supervisors, trainers, practice educators and employers; and all outcome measures.

DATA EXTRACTION AND SYNTHESIS

A standardised data extraction form was used. Studies were quality assessed using the Quality Appraisal for Diverse Studies tool. 10% of articles were independently double-screened, extracted and quality assessed; 90% was completed by one researcher.

RESULTS

14 reports were included (9 qualitative, 3 mixed-method and 2 quantitative). Six papers focused on radiographers, three on a mixture of professions, two on paramedics, and one each on physiotherapists, clinical psychologists and orthotists. An important finding of the review is the paucity and low-medium quality of research on the topic. The narrative synthesis tentatively suggests that graduates are adequately prepared for practice with different professions having different strengths and weaknesses. Common areas of underpreparedness across the professions were responsibility and decision-making, leadership and research. Graduates were generally well prepared in terms of their knowledge base.

CONCLUSION

High-quality in-depth research is urgently needed across AHPs to elucidate the specific roles, their nuances and the areas of underpreparedness. Further work is also needed to understand the transition into early clinical practice, ongoing learning opportunities through work, and the supervision and support structures in place.

PROSPERO REGISTRATION NUMBER

CRD42022382065.

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

Defensive medicine, a term known since the 1960s, may lead to risks in healthcare provision. Reported to be prevalent in North America and Europe, it is thought to be spreading globally. This study aims to evaluate defensive medicine practice among physicians in the United Arab Emirates. A quantitative cross-sectional survey consisting of a twenty-three point questionnaire was conducted after obtaining ethics approval. The response data concerning the practice of defensive medicine were summarized as a percentage of the total. There were 562 respondents. Of these, 307 (54.6%) and 258 (45.9%) were aware of positive and negative defensive medicine practice respectively. Of the respondents, 285 (50.7%) agreed that they feared patients or their attendants and 177 (31.5%) were not willing to accept patients involved in previous legal prosecutions against doctors. Case referral to other colleagues as a form of defensive medicine was reported by 186 (31.1%) respondents. The majority, 339 (60.3%) of the respondents thought that their medical decisions were backed by the hospital's managerial staff. The practice of defensive medicine is common among physicians working in the United Arab Emirates. It is a widespread practicing behavior in respondents who have more than fifteen years of working experience as compared to those with less experience.

On-call abdominal ultrasonography: the rate of negative examinations and incidentalomas in a European tertiary care center

Objectives

To determine the proportions of abdominal US examinations during on-call hours that are negative and that contain an incidentaloma, and to explore temporal changes and determinants.

Methods

This study included 1615 US examinations that were done during on-call hours at a tertiary care center between 2005 and 2017.

Results

The total proportion of negative US examinations was 49.2% (795/1615). The total proportion of US examinations with an incidentaloma was 8.0% (130/1615). There were no significant temporal changes in either one of these proportions. The likelihood of a negative US examination was significantly higher when requested by anesthesiology [odds ratio (OR) 2.609, P = 0.011], or when the indication for US was focused on gallbladder and biliary ducts (OR 1.556, P = 0.007), transplant (OR 2.371, P = 0.005), trauma (OR 3.274, P < 0.001), or urolithiasis/postrenal obstruction (OR 3.366, P < 0.001). In contrast, US examinations were significantly less likely to be negative when requested by urology (OR 0.423, P = 0.014), or when the indication for US was acute oncology (OR 0.207, P = 0.045) or appendicitis (OR 0.260, P < 0.001). The likelihood of an incidentaloma on US was significantly higher in older patients (OR 1.020 per year of age increase, P < 0.001) or when the liver was evaluated with US (OR 3.522, P < 0.001).

Discussion

Nearly 50% of abdominal US examinations during on-call hours are negative, and 8% reveal an incidentaloma. Requesting specialty and indication for US affect the likelihood of a negative examination, and higher patient age and liver evaluations increase the chance of detecting an incidentaloma in this setting. These data may potentially be used to improve clinical reasoning and restrain overutilization of imaging.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00261-022-03525-1.

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.

Patient safety assurance in the age of defensive medicine: a review

The definition of defensive medicine has evolved over time given various permutations and combinations. The underlying meaning, however, has persisted in its relevance towards two classifications, positive and negative defensive medicine. Positive defensive medicine is specific to overutilization, excessive testing, over-diagnosing, and overtreatment. Negative defensive medicine, on the contrary, is specific to avoiding, referring, or transferring high risk patients. Given the above bifurcation, the present research analyzes defensive medicine in the landscape of medical errors. In its specificity to medical errors, we consider the cognitive taxonomies of medical errors contextual to execution and evaluation slips and mistakes. We, thereafter, illustrate how the above taxonomy interclasps with five classifications of medical errors. These classifications are those that involve medical errors of operative, drug-related, diagnostic, procedure-related, and other types. This analytical review illustrates the nodular frameworks of defensive medicine. As furtherance of our analysis, this review deciphers the above nodular interconnectedness to these error taxonomies in a cascading stepwise sequential manner. This paper was designed to elaborate and to stress repeatedly that practicing defensive medicine entails onerous implications to physicians, administrators, the healthcare system, and to patients. Practicing defensive medicine, thereby, is far from adhering to those optimal healthcare practices that support quality of care metrics/milestones, and patient safety measures. As an independent standalone concept, defensive medicine is observed to align with the taxonomies of medical errors based on this paper’s diagrammatic and analytical inference.

Is the perceived impact of disciplinary procedures on medical doctors' professional practice associated with working in an open culture and feeling supported? A questionnaire among medical doctors in the Netherlands who have been disciplined

INTRODUCTION

Disciplinary procedures can have a negative impact on the professional functioning of medical doctors. In this questionnaire study, doctors' experience with open culture and support during a disciplinary procedure is studied to determine whether open culture and support are associated with perceived changes in the professional practice of doctors.

METHODS

All doctors who received a warning or a reprimand from the Dutch Medical Disciplinary Board between July 2012 and August 2016 were invited to fill in a 60-item questionnaire concerning open culture, perceived support during the disciplinary procedure and the impact of the procedure on professional functioning as reported by doctors themselves. The response rate was 43% (n=294).

RESULTS

A majority of doctors perceive their work environment as a safe environment in which to talk about and report incidents (71.2% agreed). Respondents felt supported by a lawyer or legal representative and colleagues (92.8% and 89.2%, respectively). The disciplinary procedure had effects on professional practice. Legal support and support from a professional confidant and a professional association were associated with fewer perceived changes to professional practice.

CONCLUSION

Our study shows that doctors who had been disciplined perceive their working environment as open. Doctors felt supported by lawyers and/or legal representatives and colleagues. Legal support was associated with less of a perceived impact on doctors' professional practice.