Factors influencing defensive medicine-based decision-making in primary care: A scoping review

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.

Allergic and hypersensitivity conditions in non-specialist care: Flow diagrams to support clinical practice

Most patients presenting with allergies are first seen by primary care health professionals. The perceived knowledge gaps and educational needs were recently assessed in response to which the LOGOGRAM Task Force was established with the remit of constructing pragmatic flow diagrams for common allergic conditions in line with an earlier EAACI proposal to develop simplified pathways for the diagnosis and management of allergic diseases in primary care. To address the lack of accessible and pragmatic guidance, we designed flow diagrams for five major clinical allergy conditions: asthma, anaphylaxis, food allergy, drug allergy, and urticaria. Existing established allergy guidelines were collected and iteratively distilled to produce five pragmatic and accessible tools to aid diagnosis and management of these common allergic problems. Ultimately, they should now be validated prospectively in primary care settings.

Inductive foraging: patients taking the lead in diagnosis, a mixed-methods study

BACKGROUND

Patient involvement in treatment decisions is widely accepted. Making a diagnosis, however, is still seen as a technical task mainly driven by physicians. Patients in this respect are perceived as passive providers of data. But, recent patient-centred concepts highlight the value of an active patient involvement in diagnosis.

OBJECTIVE

We aim to reach a deeper understanding of how patients themselves contribute to the diagnostic process.

METHODS

This is an observational study of patient consultations with their General Practitioner (GP) in 12 German practices. We performed a mixed-method qualitative and quantitative analysis of 134 primary care consultations.

RESULTS

At the beginning of most consultations lies a phase where patients were invited to freely unfold their reason for encounter: This was named "inductive foraging" (IF). While patients actively present their complaints, GPs mainly listen and follow the presentation. This episode was found with every GP participating in this study. Ninety-one percent of consultations with diagnostic episodes were opened by IF. IF had a major contribution to the number of cues (diagnostic information) yielded in the diagnostic process. We illustrate a variety of tactics GPs make use of to invite, support, and terminate their patients in IF.

CONCLUSION

IF was found to be a highly relevant strategy in the diagnostic process. Patient involvement through IF offered a major contribution of diagnostic cues. We hypothesize that a patient-centred approach improves diagnosis.

Ethics of uncertainty

Uncertainty is inherent in clinical medicine. However, just because absolute certainty is unachievable does not mean that rational and optimal decisions cannot be made. It is argued that we need to distinguish legitimate from illegitimate scientific uncertainties that are generated by manufacturing doubts aiming to create mis- and disinformation. The attempt to create doubts implies that actions under uncertainties are impossible. Such a belief ultimately harms public, which requires reasoned actions within a context of genuine scientific and medical uncertainties. The latter indicates that rational decisions, even in the absence of guaranteed absolute certainty, are not only possible but, on average, beneficial both for society and individuals.

What is the significance of guidelines in the primary care setting? : Results of an exploratory online survey of general practitioners in Germany

Medical guidelines aim to ensure that care processes take place in an evidence-based and structured manner. They are especially relevant in outpatient primary care due to the wide range of symptoms and clinical pictures. In German-speaking countries, there is a lack of current findings documenting general practitioners’ opinions and experiences regarding guidelines, their expectations and their views on what improvements could be made to increase the use of this type of evidence-based instrument in the primary care setting. Between April and August 2020, a total of 3098 general practitioners were surveyed in the states of Baden–Württemberg, Hesse and Rhineland–Palatinate via an online questionnaire. Alongside the descriptive evaluation, t‑testing was used to determine significant differences between two independent sampling groups. A factor analysis was also used to cluster the expectations of those surveyed regarding the fulfilment of requirements relating to guidelines. A total of 52% of those surveyed have a positive view of guidelines. Overall, guidelines are associated with an increased evidence-based approach (69%), standardisation of diagnosis and treatment (62%) and a reduction in overprovision or underprovision of care (57%). In all, 62% of the physicians who implemented guidelines observed positive effects on the quality of care provided, and 67% reported that the implementation of guidelines improved the quality of their diagnostic or therapeutic skills. However, implementation is often seen as being complicated (43%) and restricting the physician’s ability to act independently (63%). Survey participants suggested that guidelines could be optimised by giving greater consideration to nondrug alternatives (46%), focusing on issues related to quality of life (42%) and offering a comparative assessment of various treatment options (39%). In order to further promote the attractiveness of guidelines for primary care the design of guidelines should be oriented more towards their application; they should be well-presented to make them easier to implement. The scope of action available to the physician should be stressed. The guidelines should provide recommendations on opportunities for the delegation of tasks within practice teams.

The 6C model for accurately capturing the patient's medical history

Diagnostic errors are an internationally recognized patient safety concern, and leading causes are faulty data gathering and faulty information processing. Obtaining a full and accurate history from the patient is the foundation for timely and accurate diagnosis. A key concept underlying ideal history acquisition is "history clarification," meaning that the history is clarified to be depicted as clearly as a video, with the chronology being accurately reproduced. A novel approach is presented to improve history-taking, involving six dimensions: Courtesy, Control, Compassion, Curiosity, Clear mind, and Concentration, the '6 C's'. We report a case that illustrates how the 6C approach can improve diagnosis, especially in relation to artificial intelligence tools that assist with differential diagnosis.

Educational Intervention Reduced Family Medicine Residents' Intention to Request Diagnostic Tests: Results of a Controlled Trial

OBJECTIVE

Dealing with uncertainty is a core competence for physicians. To evaluate the impact of an educational intervention on family medicine residents' (FMRs') intention to request diagnostic tests and their attitudes toward uncertainty.

METHODS

Nonrandomized controlled trial. Intervention group (IG) FMRs participated in interactive "dealing with uncertainty" seminars comprising statistical lessons and diagnostic reasoning. Control group (CG) FMRs participated in seminars without in-depth diagnostic lessons. FMRs completed the Dealing with Uncertainty Questionnaire (DUQ), comprising the Diagnostic Action and Diagnostic Reasoning scales. The Physicians' Reaction to Uncertainty (PRU) questionnaire, comprising 4 scales (Anxiety Due to Uncertainty, Concern about Bad Outcomes, Reluctance to Disclose Uncertainty to Patients, and Reluctance to Disclose Mistakes to Physicians) was also completed. Follow-up was performed 3 months later. Differences were calculated with repeated-measures analysis of variance.

RESULTS

In total, 107 FMRs of the IG and 102 FMRs of the CG participated at baseline and follow-up. The mean (SD) Diagnostic Action scale score decreased from 24.0 (4.8) to 22.9 (5.1) in the IG and increased in the CG from 23.7 (5.4) to 24.1 (5.4), showing significant group difference (P = 0.006). The Diagnostic Reasoning scale increased significantly (P = 0.025) without a significant group difference (P = 0.616), from 19.2 (2.6) to 19.7 (2.4) in the IG and from 18.1 (3.3) to 18.8 (3.2) in the CG. The PRU scale Anxiety Due to Uncertainty decreased significantly (P = 0.029) without a significant group difference (P = 0.116), from 20.5 (4.8) to 18.5 (5.5) in the IG and from 19.9 (5.5) to 19.0 (6.0) in the CG.

CONCLUSION

The structured seminar reduced self-rated diagnostic test requisition. The change in Anxiety Due to Uncertainty and Diagnostic Reasoning might be due to an unspecific accompanying effect of the extra-occupational seminars for residents.

Toward a model of shared meaningful diagnosis

OBJECTIVES

The purpose was to explain the process of diabetes-related diagnosis that prompts patient action (behavior change or treatment adherence). A secondary purpose was to identify barriers/gaps that prevent those outcomes.

METHODS

Using a grounded theory approach, we explored diagnosis from the patient's perspective and through the lens of the electronic health record (EHR). A thematic analysis was conducted on interview and EHR data from 28 patients, using the constant comparative method.

RESULTS

The emerging model of shared meaningful diagnosis included four stages: stimulus to screen, medical decision making, medical information transfer, and patient sensemaking. Barriers to a meaningful diagnosis emerged in clinical documentation, clinician communication, and patient sensemaking.

CONCLUSIONS

This study expands current understanding of "diagnosis," suggesting additional stages between diagnostic labeling and disease management. The additional stages of medical information transfer and patient sensemaking are critical steps to a shared meaningful diagnosis that could enable teamwork among the patient and healthcare team.

PRACTICE IMPLICATIONS

To sustain meaningful diagnosis for the patient, clinicians should document what language they used to explain the diagnosis to the patient so that subsequent clinicians can use similar language. Clinicians who work as a team should unify their approach to discussing prediabetes.

GPs' suspicion of child abuse: how does it arise and what is the follow-up?

Background: Child abuse is widespread, occurs in all cultures and communities, remains undiscovered in 90% of cases and has serious long-term effects. Physicians generally underidentify and underreport child abuse. To understand this low reporting rate and how the suspicion of child abuse arises, we examined GPs' experiences.Research questions: How does the suspicion of child abuse arise in GPs' diagnostic reasoning? How do they act upon their suspicion and which barriers do they encounter in their management?Methods: Twenty-six GPs participated in four focus groups. We used purposive sampling to include GPs with different levels of experience. We performed a thematic content analysis.Results: Suspicion of child abuse arose from common triggers and a gut feeling that 'something is wrong here'. GPs acted upon their suspicion by gathering more data, through history taking and physical examination. They often found it difficult to decide whether a child was abused, because parents, despite good intentions, may simply lack parenting skills and have different values. Clear signs of sexual abuse and physical violence were institutionally reported by GPs, whereas in less clear-cut cases they followed them up and built a supporting network of professionals around the family.Conclusions: A low child abuse reporting rate by GPs to CACRC does not mean a low detection rate. In trying to improve a child's situation, GPs make use of patients' trust in their doctor by involving other professionals. Awareness of the role of gut feelings in developing a suspicion may increase early detection and preventive actions.Key pointsPhysicians generally underidentify and underreport child abuse.Suspicion of child abuse arose from common triggers and a gut feeling that 'something is wrong here'.GPs acted upon their suspicion by gathering more data, through history taking and physical examination.GPs found it difficult to decide whether a child was abused, because parents, despite good intentions, may lack parenting skills.

[How do young general practitioners experience the transition to general practice? A qualitative study]

BACKGROUND

Although the role of general practice has been strengthened in recent years, undergraduate teaching at medical schools and the clinical phase of specialist training remain dominated by specialized care of seriously ill people in hospitals. It is to be assumed that young doctors' views on medical care are strongly shaped by this clinical focus.

OBJECTIVE

To investigate how young general practitioners (GPs) perceive transition from medical school and hospital work to general practice.

METHODS

In a qualitative study, a total of 13 physicians in specialist training for general practice as well as general practitioners who had completed their specialist examination up to two years ago participated in problem-oriented interviews. The interviews were analyzed using content analysis.

RESULTS

The significant differences between hospital-based and primary care practice initially came as quite a shock to the study participants. Key differences and challenges compared to working in a hospital included: 1) the totally different type of patients or complaints they faced; 2) learning that in many situations one can and should bide one's time ("wait-and-see" approach); 3) ruling out avoidable dangerous developments in patients reliably and coping with the corresponding residual risk; 4) the discovery that sometimes it makes sense not to make a diagnosis; 5) that the doctor-patient relationship should be more cooperative in general practice; and 6) that GPs are often under pressure to act although there is no clear need for taking action or no clear treatment option from a medical and scientific point of view.

CONCLUSIONS

Our findings confirm that young doctors' initial views on medical care are strongly shaped by the clinical focus of medical schools and hospital work. Working in general practice is perceived as being very different from working in a hospital.

Relationships Between Medical Doctors' Personality Traits and Their Professional Risk Perception

Medical decision-making is often related to risk and uncertainty, but existing research does not offer a comprehensive approach to this matter. We discuss the necessity to study cognitive representations of risks (CRRs), which we define as the subject’s images of risky situations, possible outcomes, and alternative decisions. The psychometric approach towards risk assessment often involves the evaluation of different risks, but we aim to create such a list from medical professionals’ expert knowledge. Via qualitative analysis, CRRs were obtained from interviews with practicing doctors from Russia (N = 24). The list includes 21 risks from real-life medical practice, with seven aspects for numerical evaluation each. Then, practicing doctors (N = 64) evaluated CRRs along with filling risk-related personality traits questionnaires: Personal Decision-Making Factors Questionnaire, Melbourne Decision Making Questionnaire, Ten Item Personality Measure, and Budner’s Intolerance of Ambiguity Scale. A correlational analysis showed interconnections between most CRRs aspects, with predictability and negative outcome probability seemingly being the central aspects of the risk assessment. CRRs aspects were also found to be gender- and experience-specific, with female doctors and younger specialists being more sensitive to professional risks. Personality traits in relation to CRRs aspects, medical experience and gender are also discussed.

The value of the GP's clinical judgement in predicting dementia: a multicentre prospective cohort study among patients in general practice

BACKGROUND

Clinical judgement is intrinsic to diagnostic strategies in general practice; however, empirical evidence for its validity is sparse.

AIM

To ascertain whether a GP's global clinical judgement of future cognitive status has an added value for predicting a patient's likelihood of experiencing dementia.

DESIGN AND SETTING

Multicentre prospective cohort study among patients in German general practice that took place from January 2003 to October 2016.

METHOD

Patients without baseline dementia were assessed with neuropsychological interviews over 12 years; 138 GPs rated the future cognitive decline of their participating patients. Associations of baseline predictors with follow-up incident dementia were analysed with mixed-effects logistic and Cox regression.

RESULTS

A total of 3201 patients were analysed over the study period (mean age = 79.6 years, 65.3% females, 6.7% incident dementia in 3 years, 22.1% incident dementia in 12 years). Descriptive analyses and comparison with other cohorts identified the participants as having frequent and long-lasting doctor-patient relationships and being well known to their GPs. The GP baseline rating of future cognitive decline had significant value for 3-year dementia prediction, independent of cognitive test scores and patient's memory complaints (GP ratings of very mild (odds ratio [OR] 1.97, 95% confidence intervals [95% CI] = 1.28 to 3.04); mild (OR 3.00, 95% CI = 1.90 to 4.76); and moderate/severe decline (OR 5.66, 95% CI = 3.29 to 9.73)). GPs' baseline judgements were significantly associated with patients' 12-year dementia-free survival rates (Mantel-Cox log rank test P<0.001).

CONCLUSION

In this sample of patients in familiar doctor-patient relationships, the GP's clinical judgement holds additional value for predicting dementia, complementing test performance and patients' self-reports. Existing and emerging primary care-based dementia risk models should consider the GP's judgement as one predictor. Results underline the importance of the GP-patient relationship.

Diagnostic strategies in general practice and the emergency department: a comparative qualitative analysis

OBJECTIVE

We sought to explore differences and commonalities between diagnostic strategies used by clinicians in general practice and the emergency department.

DESIGN

Qualitative study.

SETTINGS

We videotaped 282 consultations of 12 general practitioners (GPs) in Germany, irrespective of presenting complaint or final diagnosis. Reflective interviews were performed after each consultation. In addition, 171 consultations of 16 emergency physicians (EPs) based at two tertiary care hospitals in the Midwest of the USA were observed, and their conversations recorded. Recordings of consultations and GP interviews were transcribed verbatim and analysed using a coding system that was based on published literature and systematically checked for reliability.

RESULTS

EPs more often considered acute and severe conditions, even if pretest probabilities were low. In contrast, GPs more often involved their patients in the decision-making process and provided assurance concerning their complaints. To focus their workup, EPs used a more directive style of interviewing including a high proportion of routine questions and rarely used open questions or active listening.

CONCLUSIONS

Strategies used by physicians in both settings seem to be well adapted to their respective environments. Whereas the physician-led diagnostic process in the emergency department is well suited to rule out life-threating disease, diagnosis and appropriate treatment of everyday problems may require a more patient-centred style.

How to Uncover Sources of Unwarranted Practice Variation: A Case Study in Emergency Medicine

Forty years of statistical database analyses have demonstrated the existence of unwarranted practice variation in care delivery, that is, variations independent of medical need, evidence, or patient preference. Alas, little is known about the underlying mechanisms and thus finding interventions to reduce unwarranted variations remains difficult, hampering quality, equity, and efficiency of care. Whereas statistical analyses describe deviations from ideal patterns, ethnographically inspired analyses aim at understanding when, how, and why variations occur in practice. Based on case studies derived from shadowing emergency physicians, I demonstrate that analyzing practice variation in practice helps to (a) advance the understanding of mechanisms and (b) evaluate/expand the existing repertoire of interventions. Results revealed unmet expectations and new sources of known variations as well as interventions complementing systemic changes with those that empower individuals to better cope with the existing system. These findings highlight the benefits of mixed-methods for understanding and tackling practice variation.

Solving the Diagnostic Challenge: A Patient-Centered Approach

Arriving at an agreed-on and valid explanation for a clinical problem is important to patients as well as to clinicians. Current theories of how clinicians arrive at diagnoses, such as the threshold approach and the hypothetico-deductive model, do not accurately describe the diagnostic process in general practice. The problem space in general practice is so large and the prior probability of each disease being present is so small that it is not realistic to limit the diagnostic process to testing specific diagnoses on the clinician's list of possibilities. Here, new evidence is discussed about how patients and clinicians collaborate in specific ways, in particular, via a process that can be termed inductive foraging, which may lead to information that triggers a diagnostic routine. Navigating the diagnostic challenge and using patient-centered consulting are not separate tasks but rather synergistic.

Beyond accuracy: hidden motives in diagnostic testing

BACKGROUND

Diagnostic decision-making is usually disease-focussed and intended to examine the patient's medical condition accurately. But diagnostic interventions may serve further purposes that are not yet fully understood.

OBJECTIVE

To explore GPs' diagnostic behaviour not related to confirming or refuting a specific disease.

METHODS

We recorded 295 primary care consultations in 12 practices. One hundred thirty-four consultations comprised at least one diagnostic episode. GPs were asked to reflect on their own diagnostic thinking in interviews for every single case. Qualitative and quantitative analyses were applied with focus on the GPs' cognitive processes during diagnostic decision-making.

RESULTS

Primary care physicians clearly stated that they requested some tests for other reasons than diagnosing disease. A feeling of uncertainty stimulated diagnostic procedures aiming to regulate the anticipation of regret. We identified patients' reassurance, patients' requests and strategic issues as further motives for diagnostic actions.

CONCLUSION

Besides focussing on disease in the diagnostic process, emotional and strategic goals are hidden motives that play a critical role in clinical decision-making. They might even represent an initial factor in a cascade of interventions leading to overdiagnosis. How GPs might control these influences provides an important aspect for further research, practice and teaching.

Individual utilisation thresholds and exploring how GPs' knowledge of their patients affects diagnosis: a qualitative study in primary care

BACKGROUND

One of the tenets of general practice is that continuity of care has a beneficial effect on patient care. However, little is known about how continuity can have an impact on the diagnostic reasoning of GPs.

AIM

To explore GPs' diagnostic strategies by examining GPs' reflections on their patients' individual thresholds for seeking medical attention, how they arrive at their estimations, and which conclusions they draw.

DESIGN AND SETTING

Qualitative study with 12 GPs in urban and rural practices in Germany.

METHOD

After each patient consultation GPs were asked to reflect on their diagnostic reasoning for that particular case. Qualitative and quantitative analyses of consultations and interview content were undertaken.

RESULTS

A total of 295 primary care consultations were recorded, 134 of which contained at least one diagnostic episode. When elaborating on known patients, GPs frequently commented on how 'early' or 'late' in an illness progression a patient tended to consult. The probability of serious disease was accordingly regarded as high or low. This influenced GPs' behaviour regarding further investigations or referrals, as well as reassurance and watchful waiting. GPs' explanations for a patient's utilisation threshold comprised medical history, the patient's characteristics, family background, the media, and external circumstances.

CONCLUSION

The concept of an individual threshold for the utilisation of primary care would explain how GPs use their knowledge of individual patients and their previous help-seeking behaviour for their diagnostic decision making. Whether the assumption behind this concept is valid, and whether its use improves diagnostic accuracy, remains to be investigated.