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Mira JJ, Matarredona V, Tella S, Sousa P, Ribeiro Neves V, Strametz R, López-Pineda A. Unveiling the hidden struggle of healthcare students as second victims through a systematic review. BMC MEDICAL EDUCATION 2024; 24:378. [PMID: 38589877 PMCID: PMC11000311 DOI: 10.1186/s12909-024-05336-y] [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: 01/25/2024] [Accepted: 03/21/2024] [Indexed: 04/10/2024]
Abstract
BACKGROUND When healthcare students witness, engage in, or are involved in an adverse event, it often leads to a second victim experience, impacting their mental well-being and influencing their future professional practice. This study aimed to describe the efforts, methods, and outcomes of interventions to help students in healthcare disciplines cope with the emotional experience of being involved in or witnessing a mistake causing harm to a patient during their clerkships or training. METHODS This systematic review followed the PRISMA guidelines and includes the synthesis of eighteen studies, published in diverse languages from 2011 to 2023, identified from the databases MEDLINE, EMBASE, SCOPUS and APS PsycInfo. PICO method was used for constructing a research question and formulating eligibility criteria. The selection process was conducted through Rayyan. Titles and abstracts of were independently screened by two authors. The critical appraisal tools of the Joanna Briggs Institute was used to assess the risk of bias of the included studies. RESULTS A total of 1354 studies were retrieved, 18 met the eligibility criteria. Most studies were conducted in the USA. Various educational interventions along with learning how to prevent mistakes, and resilience training were described. In some cases, this experience contributed to the student personal growth. Psychological support in the aftermath of adverse events was scattered. CONCLUSION Ensuring healthcare students' resilience should be a fundamental part of their training. Interventions to train them to address the second victim phenomenon during their clerkships are scarce, scattered, and do not yield conclusive results on identifying what is most effective and what is not.
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Affiliation(s)
- José Joaquín Mira
- Atenea Research. FISABIO, Alicante, Spain.
- Universidad Miguel Hernández, Elche, Spain.
| | | | - Susanna Tella
- Faculty of Health and Social Care, LAB University of Applied Sciences, Lappeenranta, Finland
| | - Paulo Sousa
- NOVA National School of Public Health, Public Health Research Centre, Comprehensive Health Research Center, CHRC, NOVA University Lisbon, Lisbon, Portugal
| | | | - Reinhard Strametz
- Wiesbaden Institute for Healthcare Economics and Patient Safety (WiHelP), RheinMain UAS, Wiesbaden, Germany
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Bushuven S, Trifunovic-Koenig M, Bunz M, Weinmann-Linne P, Klemm V, Strametz R, Müller BS. Applicability and Validity of Second Victim Assessment Instruments among General Practitioners and Healthcare Assistants (SEVID-IX Study). Healthcare (Basel) 2024; 12:351. [PMID: 38338236 PMCID: PMC10855668 DOI: 10.3390/healthcare12030351] [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: 11/24/2023] [Revised: 01/19/2024] [Accepted: 01/24/2024] [Indexed: 02/12/2024] Open
Abstract
BACKGROUND The second victim phenomenon and moral injury are acknowledged entities of psychological harm for healthcare providers. Both pose risks to patients, healthcare workers, and medical institutions, leading to further adverse events, economic burden, and dysfunctionality. Preceding studies in Germany and Austria showed a prevalence of second victim phenomena exceeding 53 percent among physicians, nurses, emergency physicians, and pediatricians. Using two German instruments for assessing moral injury and second victim phenomena, this study aimed to evaluate their feasibility for general practitioners and healthcare assistants. METHODS We conducted a nationwide anonymous online survey in Germany among general practitioners and healthcare assistants utilizing the SeViD (Second Victims in Deutschland) questionnaire, the German version of the Second Victim Experience and Support Tool Revised Version (G-SVESTR), and the German version of the Moral Injury Symptom and Support Scale for Health Professionals (G-MISS-HP). RESULTS Out of 108 participants, 67 completed the survey. In G-SVESTR, the collegial support items exhibited lower internal consistency than in prior studies, while all other scales showed good-quality properties. Personality traits, especially neuroticism, negatively correlated to age, seem to play a significant role in symptom count and warrant further evaluation. Multiple linear regression indicated that neuroticism, agreeableness, G-SVESTR, and G-MISS-HP were significant predictors of symptom count. Furthermore, moral injury partially mediated the relationship between second victim experience and symptom count. DISCUSSION The results demonstrate the feasible use of the questionnaires, except for collegial support. With respect to selection bias and the cross-sectional design of the study, moral injury may be subsequent to the second victim phenomenon, strongly influencing symptom count in retrospect. This aspect should be thoroughly evaluated in future studies.
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Affiliation(s)
- Stefan Bushuven
- Training Center for Emergency Medicine (NOTIS e.V), 78234 Engen, Germany;
- Department of Anesthesiology and Critical Care, Faculty of Medicine, Medical Center—University of Freiburg, University of Freiburg, 79106 Freiburg, Germany
- Institute for Medical Education, University Hospital, LMU Munich, 80539 Munich, Germany
| | - Milena Trifunovic-Koenig
- Training Center for Emergency Medicine (NOTIS e.V), 78234 Engen, Germany;
- Wiesbaden Institute for Healthcare Economics and Patient Safety (WiHelP), Wiesbaden Business School, RheinMain University of Applied Sciences, 65183 Wiesbaden, Germany; (V.K.); (R.S.)
| | - Maxie Bunz
- Institute of General Practice, University of Cologne, 50937 Cologne, Germany; (M.B.); (P.W.-L.); (B.S.M.)
| | - Patrick Weinmann-Linne
- Institute of General Practice, University of Cologne, 50937 Cologne, Germany; (M.B.); (P.W.-L.); (B.S.M.)
| | - Victoria Klemm
- Wiesbaden Institute for Healthcare Economics and Patient Safety (WiHelP), Wiesbaden Business School, RheinMain University of Applied Sciences, 65183 Wiesbaden, Germany; (V.K.); (R.S.)
| | - Reinhard Strametz
- Wiesbaden Institute for Healthcare Economics and Patient Safety (WiHelP), Wiesbaden Business School, RheinMain University of Applied Sciences, 65183 Wiesbaden, Germany; (V.K.); (R.S.)
| | - Beate Sigrid Müller
- Institute of General Practice, University of Cologne, 50937 Cologne, Germany; (M.B.); (P.W.-L.); (B.S.M.)
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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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Al-Balas Q, Altawalbeh S, Rinaldi C, Ibrahim I. The practice of defensive medicine among Jordanian physicians: A cross sectional study. PLoS One 2023; 18:e0289360. [PMID: 37943831 PMCID: PMC10635536 DOI: 10.1371/journal.pone.0289360] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2023] [Accepted: 07/18/2023] [Indexed: 11/12/2023] Open
Abstract
BACKGROUND Defensive medicine (DM) is a deviation from medical practice that is induced primarily by a threat of liability. While the DM behavior is well studied in the developed countries, little is known in developing countries and never been evaluated in Jordan. OBJECTIVE To evaluate the prevalence of DM practice in Jordan among physicians and to investigate reasons behind its practice and potential strategies to alleviate this practice. METHODS In this Cross-sectional study, self-administered questionnaire was distributed to a sample of physicians in both public and private sectors in Jordan. The collection period was from Jan 2021 to June 2021. The prevalence of DM practice was estimated among the study sample. Frequency scores of different DM behaviors, reasons of DM behaviors, and effectiveness of strategies in changing DM behaviors were summarized as average frequency scores with standard deviations. Multivariable linear regression models were conducted to evaluate potential predictors of total assurance and avoidance behavior scores. RESULTS A total of 175 Jordanian physicians completed the survey. The prevalence of adopting (or witnessing) DM behaviors among the study sample was 68% (n = 119). Diagnostic laboratory exams followed by prescribed medications were the most practiced behaviors in excessive rate during a typical working week. Unfavorable legislation for the physician was reported as the headmost reason for practicing DM, followed by pressure from the public and mass media opinion. Continuous update of knowledge, abilities, and performance and following specific protocols and/or appropriate clinical evidence and appropriate multidisciplinary and multi-professional communication were the most effective strategies that can mitigate DM behaviors. CONCLUSIONS Defensive medicine practice is common among Jordanian physicians with concerns about increasing pattern in the future.
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Affiliation(s)
- Qosay Al-Balas
- Department of Medicinal Chemistry and Pharmacognosy, Faculty of Pharmacy, Jordan University of Science & Technology, Irbid, Jordan
| | - Shoroq Altawalbeh
- Department of Clinical Pharmacy, Faculty of Pharmacy, Jordan University of Science and Technology, Irbid, Jordan
| | - Carmela Rinaldi
- Department of Translational Medicine, University of Piemonte Orientale, Novara, Italy
- Learning and Research Area, AOU Maggiore Della Carità, Novara, Italy
| | - Ibtihal Ibrahim
- Department of Pharmacy, Faculty of Pharmacy, Al-Zaytoonah University of Jordan, Amman, Jordan
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Bushuven S, Trifunovic-Koenig M, Bentele M, Bentele S, Strametz R, Klemm V, Raspe M. Self-Assessment and Learning Motivation in the Second Victim Phenomenon. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:16016. [PMID: 36498086 PMCID: PMC9736892 DOI: 10.3390/ijerph192316016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 10/28/2022] [Revised: 11/26/2022] [Accepted: 11/27/2022] [Indexed: 06/17/2023]
Abstract
INTRODUCTION The experience of a second victim phenomenon after an event plays a significant role in health care providers' well-being. Untreated; it may lead to severe harm to victims and their families; other patients; hospitals; and society due to impairment or even loss of highly specialised employees. In order to manage the phenomenon, lifelong learning is inevitable but depends on learning motivation to attend training. This motivation may be impaired by overconfidence effects (e.g., over-placement and overestimation) that may suggest no demand for education. The aim of this study was to examine the interdependency of learning motivation and overconfidence concerning second victim effects. METHODS We assessed 176 physicians about overconfidence and learning motivation combined with a knowledge test. The nationwide online study took place in early 2022 and addressed about 3000 German physicians of internal medicine. Statistics included analytical and qualitative methods. RESULTS Of 176 participants, 83 completed the assessment. Analysis showed the presence of two overconfidence effects and in-group biases (clinical tribalism). None of the effects correlated directly with learning motivation, but cluster analysis revealed three different learning types: highly motivated, competent, and confident "experts", motivated and overconfident "recruitables", and unmotivated and overconfident "unawares". Qualitative analysis revealed four main themes: "environmental factors", "emotionality", "violence and death", and "missing qualifications" contributing to the phenomenon. DISCUSSION We confirmed the presence of overconfidence in second victim management competencies in about 3% of all persons addressed. Further, we could detect the same three learning motivation patterns compared to preceding studies on learning motivation in other medical competencies like life support and infection control. These findings considering overconfidence effects may be helpful for safety managers, medical teachers, curriculum developers and supervisors to create preventive educational curricula on second victim recognition and management.
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Affiliation(s)
- Stefan Bushuven
- Institute for Infection Control and Infection Prevention, Hegau-Jugendwerk Gailingen, Health Care Association District of Constance, 78262 Gailingen, Germany
- Institute for Medical Education, University Hospital, LMU Munich, 80336 Munich, Germany
- Department of Anesthesiology and Critical Care, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, 79106 Freiburg im Breisgau, Germany
| | - Milena Trifunovic-Koenig
- Institute for Infection Control and Infection Prevention, Hegau-Jugendwerk Gailingen, Health Care Association District of Constance, 78262 Gailingen, Germany
- Training Center for Emergency Medicine (NOTIS e.V.), 78234 Engen, Germany
| | - Michael Bentele
- Training Center for Emergency Medicine (NOTIS e.V.), 78234 Engen, Germany
- Institute for Anesthesiology, Intensive Care, Emergency Medicine and Pain Therapy, Hegau-Bodensee Hospital Singen, 78224 Singen, Germany
| | - Stefanie Bentele
- Training Center for Emergency Medicine (NOTIS e.V.), 78234 Engen, Germany
- Department of Emergency Medicine, University-Hospital Augsburg, University of Augsburg, 86156 Augsburg, Germany
| | - Reinhard Strametz
- Wiesbaden Business School, Rhein Main University of Applied Sciences, 65183 Wiesbaden, Germany
| | - Victoria Klemm
- Wiesbaden Business School, Rhein Main University of Applied Sciences, 65183 Wiesbaden, Germany
| | - Matthias Raspe
- Department of Internal Medicine, Infectious Diseases and Respiratory Medicine, Charité—Universitätsmedizin Berlin, Charitéplatz 1, 10117 Berlin, Germany
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Rinaldi C, Ratti M, Russotto S, Seys D, Vanhaecht K, Panella M. Healthcare Students and Medical Residents as Second Victims: A Cross-Sectional Study. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:ijerph191912218. [PMID: 36231520 PMCID: PMC9564455 DOI: 10.3390/ijerph191912218] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/29/2022] [Revised: 09/20/2022] [Accepted: 09/22/2022] [Indexed: 06/02/2023]
Abstract
BACKGROUND The term second victim (SV) describes healthcare professionals who remain traumatized after being involved in a patient safety incident (PSI). They can experience various emotional, psychological, and physical symptoms. The phenomenon is quite common; it has been estimated that half of hospital workers will be an SV at least once in their career. Because recent literature has reported high prevalence (>30%) among nursing students, we studied the phenomenon among the whole population of healthcare students. METHODS We conducted a cross-sectional study with an online questionnaire among nursing students, medical students, and resident physicians at the teaching hospital of the University of the Piemonte Orientale located in Novara, Italy. The study included 387 individuals: 128 nursing students, 174 medical students, and 85 residents. RESULTS We observed an overall PSI prevalence rate of 25.58% (lowest in medical students, 14.37%; highest in residents, 43.53%). Of these, 62.63% experienced symptoms typical of an SV. The most common temporary symptom was the feeling of working badly (51.52%), whereas the most common lasting symptom was hypervigilance (51.52%). Notably, none of the resident physicians involved in a PSI spoke to the patient or the patient's relatives. CONCLUSION Our findings highlighted the risk incurred by healthcare students of becoming an SV, with a possible significant impact on their future professional and personal lives. Therefore, we suggest that academic institutions should play a more proactive role in providing support to those involved in a PSI.
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Affiliation(s)
- Carmela Rinaldi
- Department of Translational Medicine (DiMeT), Università del Piemonte Orientale, 28100 Novara, Italy
- Learning and Research Area, AOU Maggiore della Carità, 28100 Novara, Italy
| | - Matteo Ratti
- Department of Translational Medicine (DiMeT), Università del Piemonte Orientale, 28100 Novara, Italy
| | - Sophia Russotto
- Department of Translational Medicine (DiMeT), Università del Piemonte Orientale, 28100 Novara, Italy
| | - Deborah Seys
- KU Leuven Institute for Healthcare Policy, 3000 Leuven, Belgium
| | - Kris Vanhaecht
- KU Leuven Institute for Healthcare Policy, 3000 Leuven, Belgium
| | - Massimiliano Panella
- Department of Translational Medicine (DiMeT), Università del Piemonte Orientale, 28100 Novara, Italy
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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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Baungaard N, Skovvang PL, Assing Hvidt E, Gerbild H, Kirstine Andersen M, Lykkegaard J. How defensive medicine is defined in European medical literature: a systematic review. BMJ Open 2022; 12:e057169. [PMID: 35058268 PMCID: PMC8783809 DOI: 10.1136/bmjopen-2021-057169] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
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.
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Affiliation(s)
- Nathalie Baungaard
- Research Unit of General Practice, Department of Public Health, University of Southern Denmark, Odense, Denmark
| | - Pia Ladeby Skovvang
- Research Unit of General Practice, Department of Public Health, University of Southern Denmark, Odense, Denmark
| | - Elisabeth Assing Hvidt
- Research Unit of General Practice, Department of Public Health, University of Southern Denmark, Odense, Denmark
- Department for the Study of Culture, University of Southern Denmark, Odense, Denmark
| | - Helle Gerbild
- Health Sciences Research Centre, UCL University College, Odense, Denmark
- Faculty of Health Sciences, Oslo Metropolitan University, Oslo, Norway
| | - Merethe Kirstine Andersen
- Research Unit of General Practice, Department of Public Health, University of Southern Denmark, Odense, Denmark
| | - Jesper Lykkegaard
- Research Unit of General Practice, Department of Public Health, University of Southern Denmark, Odense, Denmark
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Andersen MK, Hvidt EA, Pedersen KM, Lykkegaard J, Waldorff FB, Munck AP, Pedersen LB. Defensive medicine in Danish general practice. Types of defensive actions and reasons for practicing defensively. Scand J Prim Health Care 2021; 39:413-418. [PMID: 34463601 PMCID: PMC8725848 DOI: 10.1080/02813432.2021.1970945] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
OBJECTIVE To examine the occurrence of and types of defensive medicine (DM), and the reasons for practicing DM in general practice. DESIGN Prospective survey registration of consecutive consultations regarding defensive medicine defined as: Actions that are not professionally well founded but are carried out due to demands and pressure. The GPs registered the degree of defensiveness, the type(s) of defensive action(s) and the reason(s) for acting defensively. SETTING Danish general practice. SUBJECTS A total of 26 GPs registered a total of 1,758 consultations. MAIN OUTCOME MEASURES Defensive medical actions. RESULTS Defensive actions were performed in 12% (210/1749) of all consultations. A fifth (46/210) of the defensive actions were characterised by the GPs as 'moderately' or 'highly' defensive. Frequent types of defensive actions were: blood tests, point-of-care-tests (POCTs) and referrals. Common reasons for defensive actions were: Influence from patients, 37% (78/210), concerns of overlooking severe disease, 32% (67/210) and influence from patient relatives, 12% (25/210). CONCLUSION Danish GPs registered self-perceived defensive actions in a prospective survey. DM was carried out in one out of eight consultations, most often due to patient influence. The most frequent defensive actions were blood tests, POCTs and referrals.
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Affiliation(s)
- Merethe K. Andersen
- Research Unit of General Practice, Department of Public Health, University of Southern Denmark, Odense, Denmark
- CONTACT Merethe K. Andersen , Research unit of General Practice, Department of Public Health, University of Southern Denmark, J. B. Winsløwsvej 9A, Odense5000, Denmark
| | - Elisabeth Assing Hvidt
- Research Unit of General Practice, Department of Public Health, University of Southern Denmark, Odense, Denmark
- Department for the Study of Culture, University of Southern Denmark, Odense, Denmark
| | - Kjeld M. Pedersen
- Department of Business and Economics, University of Southern Denmark, Odense, Denmark
| | - Jesper Lykkegaard
- Research Unit of General Practice, Department of Public Health, University of Southern Denmark, Odense, Denmark
| | - Frans B. Waldorff
- Research Unit for General Practice and Section of General Practice, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Anders P. Munck
- Research Unit of General Practice, Department of Public Health, University of Southern Denmark, Odense, Denmark
| | - Line B. Pedersen
- Research Unit of General Practice, Department of Public Health, University of Southern Denmark, Odense, Denmark
- DaCHE – Danish Centre for Health Economics, Department of Public Health, University of Southern Denmark, Odense, Denmark
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Chen SL, Zhang H, Gale RP, Tang JY, Pui CH, Chen SJ, Liang Y. Toward the Cure of Acute Lymphoblastic Leukemia in Children in China. JCO Glob Oncol 2021; 7:1176-1186. [PMID: 34292767 PMCID: PMC8457838 DOI: 10.1200/go.21.00049] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
This study explored results of therapy of children with acute lymphoblastic leukemia (ALL) in China, recent progress, and challenges. Included are a survey of therapy outcomes of ALL in Chinese children nationwide, comparison of these data with global ALL therapy outcomes, analyses of obstacles to improving outcomes, and suggestions of how progress can be achieved. Therapy outcomes at many Chinese pediatric cancer centers are approaching those of resource-rich countries. However, nationwide outcomes still need improvement. Obstacles include suboptimal clinical trials participation, children without adequate health care funding, human resource shortages, especially physicians expert in pediatric hematology and oncology, and social-economic disparities. We suggest how these obstacles have been and continue to be remedied including expanded access to protocol-based therapy, improved supportive care, health care reforms, recruitment of trained personnel, and international collaborations. China has made substantial progress treating children with ALL. We envision even better outcomes in the near future.
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Affiliation(s)
- Si-Liang Chen
- Department of Hematologic Oncology, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Sun Yat-sen University Cancer Center, Guangzhou, China
| | - Hui Zhang
- Department of Hematology and Oncology, Guangzhou Women and Children's Medical Center, Guangzhou, Guangdong, China
| | - Robert Peter Gale
- Department of Immunology and Inflammation, Haematology Research Centre, Imperial College London, London, United Kingdom
| | - Jing-Yan Tang
- Key Laboratory of Pediatric Hematology and Oncology Ministry of Health, Department of Hematology and Oncology, Shanghai Children's Medical Center, National Children's Medical Center, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Ching-Hon Pui
- Departments of Oncology, Global Pediatric Medicine, and Pathology, St Jude Children's Research Hospital, Memphis, TN
| | - Sai-Juan Chen
- Shanghai Institute of Hematology, State Key Laboratory of Medical Genomics, National Research Center for Translational Medicine at Shanghai, Ruijin Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yang Liang
- Department of Hematologic Oncology, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Sun Yat-sen University Cancer Center, Guangzhou, China
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Zaed I, Menna G, Auricchio AM, Servadei F, Garbossa D, Olivi A, Della Pepa GM. Medico-legal issues: perception, awareness and behavioral changes among Italian Neurosurgical community. A survey-based analysis. World Neurosurg 2021; 154:e774-e780. [PMID: 34365044 DOI: 10.1016/j.wneu.2021.07.145] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Revised: 07/31/2021] [Accepted: 07/31/2021] [Indexed: 11/17/2022]
Abstract
BACKGROUND AND AIM Despite the rising trend of medicolegal challenges in Italy, there is a significant lack of literature on this topic. To provide better understanding of awareness towards medico-legal aspects, defensive behaviours, consent taking practice and, in general, perceptions of Italian neurosurgeons on this issue, a cross sectional survey was conducted. METHODS A questionnaire covering various aspects of medicolegal issues, in an anonymous online form, was sent to neurosurgeons practicing in Italy via email - through a national mailing list - and social media platforms. Data collection period was 01/11/2020-31/12/2020. RESULTS A total of 64 single responses were included. We assessed: 1) Awareness of Italian neurosurgeons about legal framework: a very low level of knowledge has been reported - 87,5% was unaware even of the terms and conditions outlined by the contract with the Institution, 75,6% of respondents stated they didn't know the main body of law that govern the medical community; 2) Perception towards defensive medicine: 92.2% believed that they were not trained to face possible medico-legal issues but only few tried to acquire more knowledge about medical legal issues, such as learning how to obtain a proper informed consent for a surgical procedure (34.4%). CONCLUSION This study marks the first survey to identify the perceptions among Italian neurosurgeons of medical legal issues and related "defensive medicine" practices: this is of relevance given its exorbitant cost in terms of public expenditure, psychological burden and its relevant impact on health care delivery.
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Affiliation(s)
- Ismail Zaed
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy; Department of Neurosurgery, Humanitas Clinical and Research Center, IRCCS, Rozzano, Milan, Italy
| | - Grazia Menna
- Institute of Neurosurgery, A. Gemelli University Polyclinic, IRCCS and Foundation, Sacred Heart Catholic University, Rome.
| | - Anna Maria Auricchio
- Institute of Neurosurgery, A. Gemelli University Polyclinic, IRCCS and Foundation, Sacred Heart Catholic University, Rome
| | - Franco Servadei
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy; Department of Neurosurgery, Humanitas Clinical and Research Center, IRCCS, Rozzano, Milan, Italy
| | - Diego Garbossa
- Department of Neuroscience "Rita Levi Montalcini," Neurosurgery Unit, University of Turin, Turin, Italy
| | - Alessandro Olivi
- Institute of Neurosurgery, A. Gemelli University Polyclinic, IRCCS and Foundation, Sacred Heart Catholic University, Rome
| | - Giuseppe Maria Della Pepa
- Institute of Neurosurgery, A. Gemelli University Polyclinic, IRCCS and Foundation, Sacred Heart Catholic University, Rome
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Al-Balas QAE, Al-Balas HAE. The ethics of practicing defensive medicine in Jordan: a diagnostic study. BMC Med Ethics 2021; 22:87. [PMID: 34229676 PMCID: PMC8260347 DOI: 10.1186/s12910-021-00658-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Accepted: 06/28/2021] [Indexed: 02/03/2023] Open
Abstract
BACKGROUND Defensive medicine (DM) practice refers to the ordering or prescription of unnecessary treatments or tests while avoiding risky procedures for critically ill patients with the aim to alleviate the physician's legal responsibility and preserve reputation. Although DM practice is recognized, its dimensions are still uncertain. The subject has been highly investigated in developed countries, but unfortunately, many developing countries are unable to investigate it properly. DM has many serious ramifications, exemplified by the increase in treatment costs for patients and health systems, patients' exposure to risks, and negative effects on the psychological health of both health providers and recipients. Ultimately, the most serious consequence is the ethical consequences. METHODS This work is based on a review of the literature related to DM worldwide and a comparison with the available knowledge found in Jordan. It is qualitative with a descriptive nature, aiming to diagnose the current DM practice in Jordan. RESULTS This is the first published article that discusses DM in Jordan by diagnosing its ethical and economic consequences for the health system as well as for patients. Despite the knowledge of the reasons that support its practice, little is being done to solve this issue. The absence of agreeable medical malpractice law, the dearth of unified medical protocols, the overwhelming pressure imposed by patients on medical staff, and the deteriorating patient-physician relationship are some of the causes of DM practice. Surely, the solution to these issues is to focus on fortifying the ethical and humanitarian aspects on the side of both the physician and the patient to ensure positive collaboration. The ethical aim of the physician to treat the patient faithfully and do what is possible to help combined with the appreciation of the physician's efforts and the choice to not take advantage of the physician through litigation could be the most reasonable solution in the near future. CONCLUSION Jordan is suffering from DM due to the limited financial expenditure on the health sector and the impracticality of medical malpractice law. The authors highlight that the cardinal step in solving this dilemma is restoring the ethical dimension of the patient-physician relationship.
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Affiliation(s)
- Qosay A. E. Al-Balas
- grid.37553.370000 0001 0097 5797Department of Medicinal Chemistry and Pharmacognosy, Faculty of Pharmacy, Jordan University of Science and Technology, P.O. Box 3030, Irbid, 22110 Jordan
| | - Hassan A. E. Al-Balas
- grid.37553.370000 0001 0097 5797Department of Radiology, Faculty of Medicine, Jordan University of Science and Technology, P.O. Box 3030, Irbid, 22110 Jordan ,grid.39382.330000 0001 2160 926XBaylor College of Medicine, Houston, TX USA
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Medico-legal implications for the colon perforation during colonoscopy. J Forensic Leg Med 2021; 80:102185. [PMID: 34000660 DOI: 10.1016/j.jflm.2021.102185] [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: 12/24/2020] [Revised: 05/07/2021] [Accepted: 05/09/2021] [Indexed: 11/21/2022]
Abstract
Colon perforation is the most serious complication of colonoscopy, and tends to be considered as malpractice. The aim of this study was to identify the characteristics and causes of medical accidents by analyzing lawsuit cases on colon perforation during colonoscopy. We collected judgment results that were ruled from 2005 to 2015 using the keyword 'colonoscopy' in the 'Korea's Written Judgment Public Reading System' of the Supreme Court, and extracted the cases of colon perforation. Characteristics of medical accidents and the decisions of courts were analyzed from written judgments. Twenty-two lawsuits were analyzed. Most cases were ruled in favor of the plaintiff (n = 20). The allegations against defendants, as filed by the plaintiffs, were performance error (n = 22), improper monitoring after colonoscopy (n = 7), and a lack of informed consent (n = 8). The median compensation was 9335.47 US dollars; this is about 130 times the cost of a single colonoscopy in Korea. The greater the intestinal damage, the greater the amount of compensation (p = 0.016). The time interval from procedure to diagnosis of perforation was most frequently 24 h later (n = 9). It is important to educate patients completely about the symptoms of colon perforation and to guide them to contact medical institutions immediately when symptoms occur. In addition, doctors should explain sufficiently the possibility of perforation before colonoscopy to the patient, and not the caregiver, and get informed consent.
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Sartelli M, Ansaloni L, Bartoletti M, Catena F, Cardi M, Cortese F, Di Marzo F, Pea F, Plebani M, Rossolini GM, Sganga G, Viaggi B, Viale P. The role of procalcitonin in reducing antibiotics across the surgical pathway. World J Emerg Surg 2021; 16:15. [PMID: 33761972 PMCID: PMC7988639 DOI: 10.1186/s13017-021-00357-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Accepted: 02/26/2021] [Indexed: 12/29/2022] Open
Abstract
Procalcitonin (PCT) is widely considered as a highly sensitive biomarker of bacterial infection, offering general and emergency surgeons a key tool in the management of surgical infections. A multidisciplinary task force of experts met in Bologna, Italy, on April 4, 2019, to clarify the key issues in the use of PCT across the surgical pathway. The panelists presented the statements developed for each of the main questions regarding the use of PCT across the surgical pathway. An agreement on the statements was reached by the Delphi method, and this document reports the executive summary of the final recommendations approved by the expert panel.
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Affiliation(s)
| | | | - Michele Bartoletti
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
- Infectious Disease Unit, S. Orsola-Malpighi University Hospital, Bologna, Italy
| | - Fausto Catena
- Department of Emergency Surgery, Parma Maggiore Hospital, Parma, Italy
| | - Maurizio Cardi
- Department of Surgery, “P. Valdoni” Sapienza University, Rome, Italy
| | - Francesco Cortese
- Department of Emergency Surgery, San Filippo Neri Hospital, Roma, Italy
| | | | - Federico Pea
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
- S. Orsola-Malpighi University Hospital, Bologna, Italy
| | - Mario Plebani
- Department of Medicine, Laboratory Medicine, University of Padova, Padova, Italy
| | - Gian Maria Rossolini
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
- Clinical Microbiology and Virology Unit, Florence Careggi University Hospital, Florence, Italy
| | - Gabriele Sganga
- Emergency Surgery and Trauma, Fondazione Policlinico Universitario “A. Gemelli” IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Bruno Viaggi
- Neurointensive Care Unit, Department of Anesthesiology, Careggi University Hospital, Florence, Italy
| | - Pierluigi Viale
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
- Infectious Disease Unit, S. Orsola-Malpighi University Hospital, Bologna, Italy
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Physicians' views and experiences of defensive medicine: An international review of empirical research. Health Policy 2021; 125:634-642. [PMID: 33676778 DOI: 10.1016/j.healthpol.2021.02.005] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2020] [Revised: 02/03/2021] [Accepted: 02/23/2021] [Indexed: 12/22/2022]
Abstract
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.
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Rudey EL, Leal MDC, Rego G. Defensive medicine and cesarean sections in Brazil. Medicine (Baltimore) 2021; 100:e24176. [PMID: 33429803 PMCID: PMC7793425 DOI: 10.1097/md.0000000000024176] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Accepted: 12/10/2020] [Indexed: 01/05/2023] Open
Abstract
Brazil has a high rate of cesarean sections (CS) that cannot be solely justified by women's clinical conditions; thus, other causes, for example, CS on maternal request and physicians' fear of litigation as possible influencing factors, cannot be overlooked.This study aimed to identify through a survey whether Brazilian gynecologists and obstetricians (GOs) perform defensive CS.In this cross-sectional, descriptive study, a questionnaire was administered. The target population comprised of GOs who were members of premier Brazilian professional associations of gynecology and obstetrics. A total of 403 GOs participated in the survey using an obstetrics questionnaire about litigation and defensive medicine (DM). Statistical analyses were performed on pairs of variables to determine the risk factors of performing CS due to concerns of complications during vaginal delivery and to avoid lawsuits.The mean age of the GOs was 47.7 years who were mostly female (58.3%) and having worked professionally in both public and private sectors (71.7%). Of all participants, 80.6% had been sued or knew an obstetrician who had been sued. The obstetricians who had been sued or who knew a colleague that had been sued exhibited a significantly higher likelihood of performing defensive CS than physicians who had not been sued or did not know physicians who had been sued. The perception of a higher risk of lawsuits against obstetricians influenced the practice of DM and led to a more than six-fold increase in CSs in specialists with this perception compared to specialists who did not believe the presence of an increased risk of litigation in obstetrics existed.The majority of Brazilian GOs perform defensive CS. It is important to consider DM as one of the causes of high CS rates in Brazil and include it in the development of public policies to reduce these CS rates.
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Calikoglu EO, Aras A. 'Defensive medicine among different surgical disciplines: A descriptive cross-sectional study. J Forensic Leg Med 2020; 73:101970. [DOI: 10.1016/j.jflm.2020.101970] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2019] [Revised: 04/19/2020] [Accepted: 04/22/2020] [Indexed: 11/28/2022]
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Garattini L, Padula A. Defensive medicine in Europe: a 'full circle'? THE EUROPEAN JOURNAL OF HEALTH ECONOMICS : HEPAC : HEALTH ECONOMICS IN PREVENTION AND CARE 2020; 21:477-482. [PMID: 31919702 DOI: 10.1007/s10198-019-01151-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Affiliation(s)
- Livio Garattini
- CESAV, Centre for Health Economics, Institute for Pharmacological Research Mario Negri IRCCS, 24020, Ranica, Italy.
| | - Anna Padula
- CESAV, Centre for Health Economics, Institute for Pharmacological Research Mario Negri IRCCS, 24020, Ranica, Italy
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Garattini L, Padula A. Defensive medicine in Europe: a 'full circle'? THE EUROPEAN JOURNAL OF HEALTH ECONOMICS : HEPAC : HEALTH ECONOMICS IN PREVENTION AND CARE 2020; 21:165-170. [PMID: 31879861 DOI: 10.1007/s10198-019-01144-0] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/24/2019] [Accepted: 12/03/2019] [Indexed: 05/24/2023]
Affiliation(s)
- Livio Garattini
- CESAV, Centre for Health Economics, Institute for Pharmacological Research Mario Negri IRCCS, 24020, Ranica, Italy.
| | - Anna Padula
- CESAV, Centre for Health Economics, Institute for Pharmacological Research Mario Negri IRCCS, 24020, Ranica, Italy
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Baungaard N, Skovvang P, Assing Hvidt E, Gerbild H, Kirstine Andersen M, Lykkegaard J. How defensive medicine is defined and understood in European medical literature: protocol for a systematic review. BMJ Open 2020; 10:e034300. [PMID: 32114473 PMCID: PMC7050374 DOI: 10.1136/bmjopen-2019-034300] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2019] [Revised: 12/18/2019] [Accepted: 01/27/2020] [Indexed: 12/03/2022] Open
Abstract
INTRODUCTION The term defensive medicine, referring to actions motivated primarily by litigious concerns, originates from the USA and has been used in medical research literature since the late 1960s. Differences in medical legal systems between the US and most European countries with no tort legislation raise the question whether the US definition of defensive medicine holds true in Europe. AIM To present the protocol of a systematic review investigating variations in definitions and understandings of the term 'defensive medicine' in European research articles. METHODS AND ANALYSIS In concordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, a systematic review of all medical research literature that investigate defensive medicine will be performed by two independent reviewers. The databases PubMed, Embase and Cochrane will be systematically searched on the basis of predetermined criteria. Data from all included European studies will systematically be extracted including the studies' definitions and understandings of defensive medicine, especially the motives for doing medical actions that the study regards as 'defensive'. ETHICS AND DISSEMINATION No ethics clearance is required as no primary data will be collected. The results of the systematic review will be published in a peer-reviewed, international journal. PROSPERO REGISTRATION NUMBER This review has been submitted to International Prospective Register of Systematic Reviews (PROSPERO) and is awaiting registration.
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Affiliation(s)
- Nathalie Baungaard
- Department of Public Health, Research Unit of General Practice, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
| | - Pia Skovvang
- Department of Public Health, Research Unit of General Practice, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
| | - Elisabeth Assing Hvidt
- Department of Public Health, Research Unit of General Practice, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
- Department for the Study of Culture, University of Southern Denmark, Odense, Denmark
| | - Helle Gerbild
- Center for Sexology Research, Department of Clinical Medicine, Aalborg Universitet, Aalborg, Denmark
- Health Sciences Research Centre University College, University College Lillebaelt, Campus Odense, Odense, Denmark
| | - Merethe Kirstine Andersen
- Department of Public Health, Research Unit of General Practice, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
| | - Jesper Lykkegaard
- Department of Public Health, Research Unit of General Practice, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
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Kwee RM, Kwee TC. Medical disciplinary jurisprudence in alleged malpractice in radiology: 10-year Dutch experience. Eur Radiol 2020; 30:3507-3515. [PMID: 32064563 PMCID: PMC7248030 DOI: 10.1007/s00330-020-06685-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2019] [Revised: 01/09/2020] [Accepted: 01/28/2020] [Indexed: 11/09/2022]
Abstract
PURPOSE To systematically investigate the frequency and types of allegations related to radiology practice handled by the Dutch Medical Disciplinary Court in the past 10 years. METHODS The Dutch Medical Disciplinary Court database was searched for verdicts concerning radiology practice between 2010 and 2019. The association between the number of verdicts and time (years) was assessed by Spearman's rho. Other data were summarized using descriptive statistics. RESULTS There were 48 verdicts (mean 4.8 per year). There was no significant association between the number of verdicts and time (Spearman's rho < 0.001, p = 0.99). Most allegations were in breast imaging and musculoskeletal radiology (each 18.8%), followed by interventional radiology, head and neck imaging, and abdominal imaging (each 12.5%), neuroradiology and vascular imaging (each 10.4%), and chest imaging (4.2%). There were 46 allegations against radiologists (95.8%) and 2 against residents (4.2%). The most common allegation (37.5%) was error in diagnosis. In 20.8% of verdicts, the allegation was judged (partially) founded; disciplinary measures were warnings (n = 8) and reprimands (n = 2). An appeal was submitted by the patient in 11 cases and by the radiologist in 3 cases. All appeals by patients were rejected, whereas 2 of the 3 appeals by radiologists were granted and previously imposed disciplinary measures were reversed. CONCLUSION Allegations against radiologists at the Dutch Medical Disciplinary Court are relatively few, their number has remained stable over the past 10 years, and a minority were judged to be (partially) founded. We can learn from the cases presented in this article, which may improve patient care. KEY POINTS • The frequency of allegations against radiologists at the Dutch Medical Disciplinary Court is relatively low and has not exhibited any temporal change over the past 10 years. • These allegations reflect patient dissatisfaction, but this infrequently equals malpractice. • Knowledge of the circumstances under which these allegations have arisen may improve patient care.
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Affiliation(s)
- Robert M Kwee
- Department of Radiology, Zuyderland Medical Center, Heerlen/Sittard/Geleen, The Netherlands
| | - Thomas C Kwee
- Department of Radiology, Nuclear Medicine and Molecular Imaging, University Medical Center Groningen, University of Groningen, Hanzeplein 1, P.O. Box 30.001, 9700 RB, Groningen, The Netherlands.
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Gervasi G, Bellomo G, Mayer F, Zaccaria V, Bacigalupo I, Lacorte E, Canevelli M, Corbo M, Di Fiandra T, Vanacore N. Integrated care pathways on dementia in Italy: a survey testing the compliance with a national guidance. Neurol Sci 2019; 41:917-924. [PMID: 31836948 PMCID: PMC7160089 DOI: 10.1007/s10072-019-04184-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2019] [Accepted: 11/29/2019] [Indexed: 11/05/2022]
Abstract
Dementias are chronic, degenerative neurological disorders with a complex management that require the cooperation of different healthcare professionals. The Italian Ministry of Health produced the document “Guidance on Integrated Care pathway for People with Dementia” (GICPD) with the specific objective of providing a standardized framework for the definition, development, and implementation of integrated care pathways (ICP) dedicated to people with dementia. We searched all available Italian territorial ICPs. Two raters assessed the retrieved ICPs with a 2-point scale on a 43-item checklist based on the GICPD. Only 5 out of 21 regions and 5 out of 101 local health authorities had an ICP, with most ICPs having a moderate compliance to the GICPD, in particular for the items referring to the development and implementation of the care pathways. A low to moderate inter-rater agreement was observed, mainly due to a lack of standardized models to describe ICPs for dementias. Results suggest that policy- and decision-makers should pay more attention to the GICPD when producing ICPs. The direct communication with clinicians, and the implementation of more precise and appropriate clinical outcomes, could increase the involvement of clinicians, whose participation is crucial to guarantee that ICPs meet needs of patients and their carers.
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Affiliation(s)
- Giuseppe Gervasi
- National Center for Disease Prevention and Health Promotion, National Institute of Health, Via Giano della Bella no. 34, 00162, Rome, Italy.,Department of Biomedicine and Prevention, Hygiene and Preventive Medicine School, University of Rome Tor Vergata, Rome, Italy
| | - Guido Bellomo
- National Center for Disease Prevention and Health Promotion, National Institute of Health, Via Giano della Bella no. 34, 00162, Rome, Italy
| | - Flavia Mayer
- National Center for Disease Prevention and Health Promotion, National Institute of Health, Via Giano della Bella no. 34, 00162, Rome, Italy
| | - Valerio Zaccaria
- National Center for Disease Prevention and Health Promotion, National Institute of Health, Via Giano della Bella no. 34, 00162, Rome, Italy
| | - Ilaria Bacigalupo
- National Center for Disease Prevention and Health Promotion, National Institute of Health, Via Giano della Bella no. 34, 00162, Rome, Italy
| | - Eleonora Lacorte
- National Center for Disease Prevention and Health Promotion, National Institute of Health, Via Giano della Bella no. 34, 00162, Rome, Italy
| | - Marco Canevelli
- National Center for Disease Prevention and Health Promotion, National Institute of Health, Via Giano della Bella no. 34, 00162, Rome, Italy.,Department of Human Neuroscience "Sapienza", University of Rome, Rome, Italy
| | - Massimo Corbo
- Department of Neurorehabilitation Sciences, Casa Cura Policlinico, Via Dezza 48, 20144, Milan, Italy
| | - Teresa Di Fiandra
- General Directorate for Health Prevention, Ministry of Health, Rome, Italy
| | - Nicola Vanacore
- National Center for Disease Prevention and Health Promotion, National Institute of Health, Via Giano della Bella no. 34, 00162, Rome, Italy.
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Allen TC. Working to Solve the Thyroid Cytopathology Conundrum. Arch Pathol Lab Med 2019; 143:1171-1173. [PMID: 31556707 DOI: 10.5858/arpa.2019-0290-le] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Timothy Craig Allen
- Department of Pathology, University of Mississippi Medical Center, Jackson, Mississippi
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Wang Y, Han H, Qiu L, Liu C, Wang Y, Liu W. Development of a patient safety culture scale for maternal and child health institutions in China: a cross-sectional validation study. BMJ Open 2019; 9:e025607. [PMID: 31501095 PMCID: PMC6738693 DOI: 10.1136/bmjopen-2018-025607] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
OBJECTIVE This study aimed to develop a patient safety culture (PSC) scale for maternal and child healthcare (MCH) institutions in China. METHODS A theoretical framework of PSC for MCH institutions was proposed through in-depth interviews with MCH workers and patients and Delphi expert consultations. The reliability and validity of the PSC scale were tested in a cross-sectional survey of 1256 MCH workers from 14 MCH institutions in Zhejiang province of China. The study sample was randomly split into half for exploratory and confirmatory factor analyses, respectively. Test-retest reliability was assessed through a repeated survey of 63 voluntary participants 2 weeks apart. RESULTS The exploratory factor analysis extracted 10 components: patient engagement in patient safety (six items), managerial response to patient safety risks (four items), perceived management support (five items), staff empowerment (four items), staffing and workloads (four items), reporting of adverse events (three items), defensive medical practice (three items), work commitment (three items), training (two items) and transfer and handoff (three items). A good model fit was found in the confirmatory factor analysis: χ2/df=1.822, standardised root mean residual=0.048, root mean square error of approximation=0.038, comparative fit index=0.921, Tucker-Lewis index=0.907. The PSC scale had a Cronbach's α coefficient of 0.89 (0.59-0.90 for dimensional scales) and a test-retest reliability of 0.81 (0.63-0.87 for dimensional reliability), respectively. The intracluster correlation coefficients confirmed a hierarchical nature of the data: individual health workers nested within MCH institutions. CONCLUSION The PSC scale for MCH institutions has acceptable reliability and validity. Further studies are needed to establish benchmarking in a national representative sample through a multilevel modelling approach.
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Affiliation(s)
- Yuanyuan Wang
- Department of Obstetrics and Gynecology and Reproductive Medicine Center, Peking University Third Hospital, Beijing, China
| | - Hui Han
- School of Public Health, Peking University, Beijing, China
| | - Liqian Qiu
- Women's Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Chaojie Liu
- School of Psychology and Public Health, La Trobe University, Bundoora, Victoria, Australia
| | - Yan Wang
- School of Public Health, Peking University, Beijing, China
| | - Weiwei Liu
- Second Outpatient Department, Peking University Third Hospital, Beijing, China
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Renkema E, Ahaus K, Broekhuis M, Tims M. Triggers of defensive medical behaviours: a cross-sectional study among physicians in the Netherlands. BMJ Open 2019; 9:e025108. [PMID: 31243028 PMCID: PMC6597621 DOI: 10.1136/bmjopen-2018-025108] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
OBJECTIVES This study investigated whether the attitudes of physicians towards justified and unjustified litigation, and their perception of patient pressure in demanding care, influence their use of defensive medical behaviours. DESIGN Cross-sectional survey using exploratory factor analysis was conducted to determine litigation attitude and perceived patient pressure factors. Regression analyses were used to regress these factors on to the ordering of extra tests or procedures (defensive assurance behaviour) or the avoidance of high-risk patients or procedures (defensive avoidance behaviour). SETTING Data were collected from eight Dutch hospitals. PARTICIPANTS Respondents were 160 physicians and 54 residents (response rate 25%) of the hospital departments of (1) anaesthesiology, (2) colon, stomach and liver diseases, (3) gynaecology, (4) internal medicine, (5) neurology and (6) surgery. PRIMARY OUTCOME MEASURES Respondents' application of defensive assurance and avoidance behaviours. RESULTS 'Disapproval of justified litigation' and 'Concerns about unjustified litigation' were positively related to both assurance (β=0.21, p<0.01, and β=0.28, p<0.001, respectively) and avoidance (β=0.16, p<0.05, and β=0.18, p<0.05, respectively) behaviours. 'Self-blame for justified litigation' was not significantly related to both defensive behaviours. Perceived patient pressures to refer (β=0.18, p<0.05) and to prescribe medicine (β=0.23, p<0.01) had direct positive relationships with assurance behaviour, whereas perceived patient pressure to prescribe medicine was also positively related to avoidance behaviour (β=0.14, p<0.05). No difference was found between physicians and residents in their defensive medical behaviour. CONCLUSIONS Physicians adopted more defensive medical behaviours if they had stronger thoughts and emotions towards (un)justified litigation. Further, physicians should be aware that perceived patient pressure for care can lead to them adopting defensive behaviours that negatively affects the quality and safety of patient care.
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Affiliation(s)
- Erik Renkema
- Department of Operations, Faculty of Economics and Business, University of Groningen, Groningen, The Netherlands
| | - Kees Ahaus
- Department of Operations, Faculty of Economics and Business, University of Groningen, Groningen, The Netherlands
- Department of Health Services Management & Organisation, Erasmus School of Health Policy & Management, Erasmus University Rotterdam, Rotterdam, The Netherlands
| | - Manda Broekhuis
- Department of Operations, Faculty of Economics and Business, University of Groningen, Groningen, The Netherlands
| | - Maria Tims
- Department of Management and Organisation, School of Business and Economics, Amsterdam Business Research Institute, VU University Amsterdam, Amsterdam, The Netherlands
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Assing Hvidt E, Bjørnskov Pedersen L, Lykkegaard J, Møller Pedersen K, Andersen MK. A colonized general practice? A critical habermasian analysis of how general practitioners experience defensive medicine in their everyday working life. Health (London) 2019; 25:141-158. [PMID: 31216878 DOI: 10.1177/1363459319857461] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The aim of this article is to show how Jürgen Habermas' communicative action theory serves as a useful tool in analysing and interpreting empirical data on how Danish general practitioners experience defensive medicine in their everyday working life. Through six qualitative focus group interviews with a total of 28 general practitioners (14 men and 14 women), the general practitioners' understandings of and experiences with defensive medicine were unfolded and discussed. Traditionally, defensive medicine is understood as physicians' deviation from sound medical practice due to fears of liability claims or lawsuits. In this study, however, a broader understanding of defensive medicine emerged as unnecessary medical actions that are more substantiated by feelings of demands and pressures than meaningful clinical behaviour. As a first analytical step, the data are contextualized drawing on the medical sociological literature that has theorized recent changes within primary health care such as regulation, audit, standardization and consumerism. Using Habermas' theorization to further interpret the general practitioners' experiences, we argue that central areas of the general practitioners' clinical everyday work life can be seen as having become subject to the habermasian social and political processes of 'strategic action' and 'colonization'. It is furthermore shown that the general practitioners share an impulse to resist these colonizing processes, hereby pointing to a need for challenging the increasingly defensive medical culture that seems to pervade the organization of general practice today.
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28
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Párniczky A, Lantos T, Tóth EM, Szakács Z, Gódi S, Hágendorn R, Illés D, Koncz B, Márta K, Mikó A, Mosztbacher D, Németh BC, Pécsi D, Szabó A, Szücs Á, Varjú P, Szentesi A, Darvasi E, Erőss B, Izbéki F, Gajdán L, Halász A, Vincze Á, Szabó I, Pár G, Bajor J, Sarlós P, Czimmer J, Hamvas J, Takács T, Szepes Z, Czakó L, Varga M, Novák J, Bod B, Szepes A, Sümegi J, Papp M, Góg C, Török I, Huang W, Xia Q, Xue P, Li W, Chen W, Shirinskaya NV, Poluektov VL, Shirinskaya AV, Hegyi PJ, Bátovský M, Rodriguez-Oballe JA, Salas IM, Lopez-Diaz J, Dominguez-Munoz JE, Molero X, Pando E, Ruiz-Rebollo ML, Burgueño-Gómez B, Chang YT, Chang MC, Sud A, Moore D, Sutton R, Gougol A, Papachristou GI, Susak YM, Tiuliukin IO, Gomes AP, Oliveira MJ, Aparício DJ, Tantau M, Kurti F, Kovacheva-Slavova M, Stecher SS, Mayerle J, Poropat G, Das K, Marino MV, Capurso G, Małecka-Panas E, Zatorski H, Gasiorowska A, Fabisiak N, Ceranowicz P, Kuśnierz-Cabala B, Carvalho JR, Fernandes SR, Chang JH, Choi EK, Han J, Bertilsson S, Jumaa H, Sandblom G, Kacar S, Baltatzis M, Varabei AV, Yeshy V, Chooklin S, Kozachenko A, Veligotsky N, Hegyi P. Antibiotic therapy in acute pancreatitis: From global overuse to evidence based recommendations. Pancreatology 2019; 19:488-499. [PMID: 31068256 DOI: 10.1016/j.pan.2019.04.003] [Citation(s) in RCA: 62] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2019] [Accepted: 04/01/2019] [Indexed: 02/08/2023]
Abstract
BACKGROUND Unwarranted administration of antibiotics in acute pancreatitis presents a global challenge. The clinical reasoning behind the misuse is poorly understood. Our aim was to investigate current clinical practices and develop recommendations that guide clinicians in prescribing antibiotic treatment in acute pancreatitis. METHODS Four methods were used. 1) Systematic data collection was performed to summarize current evidence; 2) a retrospective questionnaire was developed to understand the current global clinical practice; 3) five years of prospectively collected data were analysed to identify the clinical parameters used by medical teams in the decision making process, and finally; 4) the UpToDate Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system was applied to provide evidence based recommendations for healthcare professionals. RESULTS The systematic literature search revealed no consensus on the start of AB therapy in patients with no bacterial culture test. Retrospective data collection on 9728 patients from 22 countries indicated a wide range (31-82%) of antibiotic use frequency in AP. Analysis of 56 variables from 962 patients showed that clinicians initiate antibiotic therapy based on increased WBC and/or elevated CRP, lipase and amylase levels. The above mentioned four laboratory parameters showed no association with infection in the early phase of acute pancreatitis. Instead, procalcitonin levels proved to be a better biomarker of early infection. Patients with suspected infection because of fever had no benefit from antibiotic therapy. CONCLUSIONS The authors formulated four consensus statements to urge reduction of unjustified antibiotic treatment in acute pancreatitis and to use procalcitonin rather than WBC or CRP as biomarkers to guide decision-making.
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Affiliation(s)
- Andrea Párniczky
- Institute for Translational Medicine, Szentágothai Research Centre, Medical School, University of Pécs, Pécs, Hungary; Heim Pál National Insititute of Pediatrics, Budapest, Hungary
| | - Tamás Lantos
- Department of Medical Physics and Informatics, Faculty of Medicine, University of Szeged, Szeged, Hungary
| | - Eszter Margit Tóth
- Pándy Kálmán Hospital of Békés County, Gyula, Hungary; First Department of Medicine, Faculty of Medicine, University of Szeged, Szeged, Hungary
| | - Zsolt Szakács
- Institute for Translational Medicine, Szentágothai Research Centre, Medical School, University of Pécs, Pécs, Hungary
| | - Szilárd Gódi
- Division of Gastroenterology, First Department of Medicine, Medical School, University of Pécs, Pécs, Hungary
| | - Roland Hágendorn
- Intesive Care Unit, First Department of Medicine, Medical School, University of Pécs, Pécs, Hungary
| | - Dóra Illés
- First Department of Medicine, Faculty of Medicine, University of Szeged, Szeged, Hungary
| | - Balázs Koncz
- First Department of Medicine, Faculty of Medicine, University of Szeged, Szeged, Hungary
| | - Katalin Márta
- Institute for Translational Medicine, Szentágothai Research Centre, Medical School, University of Pécs, Pécs, Hungary
| | - Alexandra Mikó
- Institute for Translational Medicine, Szentágothai Research Centre, Medical School, University of Pécs, Pécs, Hungary; Division of Translational Medicine, First Department of Medicine, Medical School, University of Pécs, Pécs, Hungary
| | - Dóra Mosztbacher
- Institute for Translational Medicine, Szentágothai Research Centre, Medical School, University of Pécs, Pécs, Hungary; First Department of Pediatrics, Semmelweis University, Budapest, Hungary
| | - Balázs Csaba Németh
- First Department of Medicine, Faculty of Medicine, University of Szeged, Szeged, Hungary; Hungarian Academy of Sciences-University of Szeged, Momentum Gastroenterology Multidisciplinary Research Group, Szeged, Hungary
| | - Dániel Pécsi
- Institute for Translational Medicine, Szentágothai Research Centre, Medical School, University of Pécs, Pécs, Hungary
| | - Anikó Szabó
- Institute for Translational Medicine, Szentágothai Research Centre, Medical School, University of Pécs, Pécs, Hungary
| | - Ákos Szücs
- First Department of Surgery, Faculty of Medicine, Semmelweis University, Budapest, Hungary
| | - Péter Varjú
- Institute for Translational Medicine, Szentágothai Research Centre, Medical School, University of Pécs, Pécs, Hungary
| | - Andrea Szentesi
- Institute for Translational Medicine, Szentágothai Research Centre, Medical School, University of Pécs, Pécs, Hungary; First Department of Medicine, Faculty of Medicine, University of Szeged, Szeged, Hungary
| | - Erika Darvasi
- First Department of Medicine, Faculty of Medicine, University of Szeged, Szeged, Hungary
| | - Bálint Erőss
- Institute for Translational Medicine, Szentágothai Research Centre, Medical School, University of Pécs, Pécs, Hungary
| | - Ferenc Izbéki
- Szent György University Teaching Hospital of Fejér County, Székesfehérvár, Hungary
| | - László Gajdán
- Szent György University Teaching Hospital of Fejér County, Székesfehérvár, Hungary
| | - Adrienn Halász
- Szent György University Teaching Hospital of Fejér County, Székesfehérvár, Hungary
| | - Áron Vincze
- Division of Gastroenterology, First Department of Medicine, Medical School, University of Pécs, Pécs, Hungary
| | - Imre Szabó
- Division of Gastroenterology, First Department of Medicine, Medical School, University of Pécs, Pécs, Hungary
| | - Gabriella Pár
- Division of Gastroenterology, First Department of Medicine, Medical School, University of Pécs, Pécs, Hungary
| | - Judit Bajor
- Division of Gastroenterology, First Department of Medicine, Medical School, University of Pécs, Pécs, Hungary
| | - Patrícia Sarlós
- Division of Gastroenterology, First Department of Medicine, Medical School, University of Pécs, Pécs, Hungary
| | - József Czimmer
- Division of Gastroenterology, First Department of Medicine, Medical School, University of Pécs, Pécs, Hungary
| | | | - Tamás Takács
- First Department of Medicine, Faculty of Medicine, University of Szeged, Szeged, Hungary
| | - Zoltán Szepes
- First Department of Medicine, Faculty of Medicine, University of Szeged, Szeged, Hungary
| | - László Czakó
- First Department of Medicine, Faculty of Medicine, University of Szeged, Szeged, Hungary
| | | | - János Novák
- Pándy Kálmán Hospital of Békés County, Gyula, Hungary
| | | | | | - János Sümegi
- Borsod-Abaúj-Zemplén County Hospital and University Teaching Hospital, Miskolc, Hungary
| | - Mária Papp
- Department of Internal Medicine, Division of Gastroenterology, University of Debrecen, Debrecen, Hungary
| | - Csaba Góg
- Healthcare Center of County Csongrád, Makó, Hungary
| | - Imola Török
- County Emergency Clinical Hospital of Targu Mures Hospital, University of Medicine, Pharmacy, Sciences and Technology of Targu Mures, Targu Mures, Romania
| | - Wei Huang
- Department of Integrated Traditional Chinese and Western Medicine, Sichuan Provincial Pancreatitis Centre and West China-Liverpool Biomedical Research Centre, West China Hospital of Sichuan University, Chengdu, China
| | - Qing Xia
- Department of Integrated Traditional Chinese and Western Medicine, Sichuan Provincial Pancreatitis Centre and West China-Liverpool Biomedical Research Centre, West China Hospital of Sichuan University, Chengdu, China
| | - Ping Xue
- Department of Integrated Traditional Chinese and Western Medicine, Shangjin Hospital, West China Medical School of Sichuan University, Chengdu, China
| | - Weiqin Li
- Surgical Intensive Care Unit (SICU), Department of General Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, China
| | - Weiwei Chen
- Department of Gastroenterology, Subei People's Hospital of Jiangsu Province, Clinical Medical College of Yangzhou University, Yangzhou, China
| | - Natalia V Shirinskaya
- Omsk State Medical Information-Analytical Centre, Omsk State Clinical Emergency Hospital #2, Omsk, Russia
| | | | - Anna V Shirinskaya
- Department of Surgery and Urology, Omsk State Medical University, Omsk, Russia
| | - Péter Jenő Hegyi
- Institute for Translational Medicine, Szentágothai Research Centre, Medical School, University of Pécs, Pécs, Hungary; Departement of Gastroenterology Slovak Medical University in Bratislava, Bratislava, Slovakia
| | - Marian Bátovský
- Departement of Gastroenterology Slovak Medical University in Bratislava, Bratislava, Slovakia
| | - Juan Armando Rodriguez-Oballe
- Department of Gastroenterology, University Hospital Santa María - University Hospital Arnau de Vilanova, Lerida, Spain
| | - Isabel Miguel Salas
- Department of Gastroenterology, University Hospital Santa María - University Hospital Arnau de Vilanova, Lerida, Spain
| | - Javier Lopez-Diaz
- Department of Gastroenterology, University Hospital of Santiago de Compostela, Santiago de Compostela, Spain
| | - J Enrique Dominguez-Munoz
- Department of Gastroenterology, University Hospital of Santiago de Compostela, Santiago de Compostela, Spain
| | - Xavier Molero
- Exocrine Pancreas Research Unit, Hospital Universitari Vall d'Hebron - Institut de Recerca, Autonomous University of Barcelona, CIBEREHD, Barcelona, Spain
| | - Elizabeth Pando
- Department of Hepato-pancreato-biliary and Transplat Surgery, Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | | | - Beatriz Burgueño-Gómez
- Digestive Diseases Department Clinical University Hospital of Valladolid, Valladolid, Spain
| | - Yu-Ting Chang
- Department of Internal Medicine, National Taiwan University Hospital, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Ming-Chu Chang
- Department of Internal Medicine, National Taiwan University Hospital, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Ajay Sud
- Liverpool Pancreatitis Research Group, University of Liverpool and the Royal Liverpool and Broadgreen University Hospital Trust, Liverpool, United Kingdom
| | - Danielle Moore
- Liverpool Pancreatitis Research Group, University of Liverpool and the Royal Liverpool and Broadgreen University Hospital Trust, Liverpool, United Kingdom
| | - Robert Sutton
- Liverpool Pancreatitis Research Group, University of Liverpool and the Royal Liverpool and Broadgreen University Hospital Trust, Liverpool, United Kingdom
| | - Amir Gougol
- Division of Gastroenterology, Hepatology and Nutrition, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Georgios I Papachristou
- Division of Gastroenterology, Hepatology and Nutrition, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | | | | | - António Pedro Gomes
- Department of Surgery, Hospital Prof. Dr. Fernando Fonseca, Amadora, Portugal
| | | | - David João Aparício
- Department of Surgery, Hospital Prof. Dr. Fernando Fonseca, Amadora, Portugal
| | - Marcel Tantau
- Iuliu Hatieganu" University of Medicine and Pharmacy, Department of Internal Medicine, 3rd Medical Clinic and "Prof. Dr. Octavian Fodor" Regional Institute of Gastroenterology and Hepatology, Cluj-Napoca, Romania
| | - Floreta Kurti
- Department of Gastroenterology and Hepatology, University Hospital Center "Mother Theresa", Tirana, Albania
| | - Mila Kovacheva-Slavova
- University Hospital "Tsaritsa Ioanna - ISUL", Departement of Gastroenterology, Sofia, Bulgaria
| | | | - Julia Mayerle
- Department of Medicine II, University Hospital, LMU Munich, Germany
| | - Goran Poropat
- Department of Gastroenterology, Clinical Hospital Center Rijeka, Faculty of Medicine, University of Rijeka, Croatia
| | - Kshaunish Das
- Division of Gastroenterology, School of Digestive and Liver Diseases, IPGME &R, Kolkata, India
| | - Marco Vito Marino
- Azienda Ospedaliera Ospedali Riuniti Villa Sofia-Cervello, Palermo, Italy
| | - Gabriele Capurso
- PancreatoBiliary Endoscopy and EUS Division, Pancreas Translational and Clinical Research Center, IRCCS San Raffaele Scientific Institute, Vita Salute San Raffaele University, Milan, Italy
| | - Ewa Małecka-Panas
- Department of Digestive Tract Diseases, Medical University of Lodz, Poland
| | - Hubert Zatorski
- Department of Digestive Tract Diseases, Medical University of Lodz, Poland
| | | | - Natalia Fabisiak
- Department of Gastroenterology Medical University of Lodz, Poland
| | - Piotr Ceranowicz
- Department of Physiology, Faculty of Medicine, Jagiellonian University Medical College, Krakow, Poland
| | - Beata Kuśnierz-Cabala
- Department of Physiology, Faculty of Medicine, Jagiellonian University Medical College, Krakow, Poland
| | - Joana Rita Carvalho
- Department of Gastroenterology and Hepatology, North Lisbon Hospital Center, Hospital Santa Maria, University of Lisbon, Lisbon, Portugal
| | - Samuel Raimundo Fernandes
- Department of Gastroenterology and Hepatology, North Lisbon Hospital Center, Hospital Santa Maria, University of Lisbon, Lisbon, Portugal
| | - Jae Hyuck Chang
- Bucheon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Eun Kwang Choi
- Department of Internal Medicine, Jeju National University College of Medicine, Jeju, South Korea
| | - Jimin Han
- Department of Internal Medicine, Daegu Catholic University Medical Center, Daegu Catholic University School of Medicine, Daegu, South Korea
| | - Sara Bertilsson
- Department of Clinical Sciences, Lund University, Lund, Sweden; Department of Health Sciences, Lund University, Lund, Sweden
| | - Hanaz Jumaa
- Eskilstuna Hospital, Mälarsjukhuset, Eskilstuna, Sweden
| | - Gabriel Sandblom
- Department of Clinical Science and Education Södersjukhuset, Karolinska Institutet, Department of Surgery, Södersjukhuset, Stockholm, Sweden
| | - Sabite Kacar
- Department of Gastroenterology Türkiye Yüksek İhtisas Hospital, Ankara, Turkey
| | - Minas Baltatzis
- Manchester Royal Infirmary Hospital, Manchester, United Kingdom
| | | | - Vizhynis Yeshy
- Department of Surgery, Belarusian Medical Academy Postgraduate Education, Minsk, Belarus
| | | | - Andriy Kozachenko
- Kharkiv Emergency Hospital, Medical Faculty of V. N. Karazin Kharkiv National University, Kharkiv, Ukraine
| | - Nikolay Veligotsky
- Department Thoraco-abdominal Surgery Kharkov Medical Academy Postgraduate Education, Kharkov, Ukraine
| | - Péter Hegyi
- Institute for Translational Medicine, Szentágothai Research Centre, Medical School, University of Pécs, Pécs, Hungary; First Department of Medicine, Faculty of Medicine, University of Szeged, Szeged, Hungary; Division of Translational Medicine, First Department of Medicine, Medical School, University of Pécs, Pécs, Hungary; Hungarian Academy of Sciences-University of Szeged, Momentum Gastroenterology Multidisciplinary Research Group, Szeged, Hungary.
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Di Paolo M, Gori F, Papi L, Turillazzi E. A review and analysis of new Italian law 219/2017: 'provisions for informed consent and advance directives treatment'. BMC Med Ethics 2019; 20:17. [PMID: 30832644 PMCID: PMC6399822 DOI: 10.1186/s12910-019-0353-2] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2018] [Accepted: 02/21/2019] [Indexed: 01/17/2023] Open
Abstract
Background In December 2017, Law 219/2017, ‘Provisions for informed consent and advance directives’, was approved in Italy. The law is the culmination of a year-long process and the subject of heated debate throughout Italian society. Contentious issues (advance directives, the possibility to refuse medical treatment, the withdrawal of medical treatment, nutrition and hydration) are addressed in the law. Main text What emerges clearly are concepts such as quality of life, autonomy, and the right to accept or refuse any medical treatment – concepts that should be part of an optimal relationship between the patient and healthcare professionals. The law maximizes the value of the patient’s time to decide. Every patient is allowed to make choices for the present (consenting to or refusing current treatment) as well as for the future, conceived as a continuation of the present, and to decide what comes next, based on what he/she already knows. The law identifies three distinct but converging paths towards the affirmation of a care relationship based on reciprocal trust and respect: the possibility to consent to or refuse treatment, the shared care planning, and advance directives. Conclusions The fundamental point to emerge from the new Italian law is that consensus is an essential connotation of the treatment relationship. Consensus is not limited to the acceptance/rejection of medical treatment but is ongoing. It is projected into the future through shared care planning and advance directives which act as tools for self-determination and the manifestation of the beliefs and preferences of persons unable to express their will. These principles are in line with the idea of appropriate care as evaluated from two different perspectives, one of scientific adequacy and the other commensurate with the individual’s resources, fragility, values, and beliefs. Surely, however, the new law is not the end of the matter on issues such as conscientious objection, which is deeply rooted within the Italian cultural and political debate. In this regard, healthcare institutions and policymakers will be called upon to develop and implement organizational policies aimed at the management of foreseeable conscientious objection in this field.
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Affiliation(s)
- Marco Di Paolo
- Section of Legal Medicine, Department of Clinical, Medical, Molecular Pathology and Critical Medicine, University of Pisa, Via Paolo Savi 57, 56126, Pisa, Italy
| | - Federica Gori
- Section of Legal Medicine, Department of Clinical, Medical, Molecular Pathology and Critical Medicine, University of Pisa, Via Paolo Savi 57, 56126, Pisa, Italy
| | - Luigi Papi
- Section of Legal Medicine, Department of Clinical, Medical, Molecular Pathology and Critical Medicine, University of Pisa, Via Paolo Savi 57, 56126, Pisa, Italy
| | - Emanuela Turillazzi
- Section of Legal Medicine, Department of Clinical, Medical, Molecular Pathology and Critical Medicine, University of Pisa, Via Paolo Savi 57, 56126, Pisa, Italy.
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Rinaldi C, D'Alleva A, Leigheb F, Vanhaecht K, Knesse S, Di Stanislao F, Panella M. Defensive practices among non-medical health professionals: An overview of the scientific literature. J Healthc Qual Res 2019; 34:97-108. [PMID: 30928325 DOI: 10.1016/j.jhqr.2018.12.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2018] [Accepted: 12/21/2018] [Indexed: 06/09/2023]
Abstract
INTRODUCTION Defensive medicine (DM) is used when a doctor deviates from good practices to prevent complaints from patients or caregivers. This is a structured phenomenon that may not only affect the physician, but all healthcare personnel. The aim of this review was to determine whether DM is also performed by Non-Medical Health Professionals (NMHP), and the reasons, features, and effects of NMHP-DM. MATERIALS AND METHODS The review was conducted according to PRISMA guidelines, and specific inclusion criteria were used to search for relevant documents published up to 12 April 2018 in the main biomedical databases. RESULTS A total of 91 potentially relevant studies were identified. After the removal of duplicates, 72 studies were screened for eligibility, separately by two of the authors. Finally, 14 qualitative and quantitative studies were considered relevant for the purpose of the present review. These last studies were assessed for their methodological quality. CONCLUSIONS NMHP-DM is quite similar to DM practiced by doctors, and is mainly caused by fear of litigation. Midwives and nursing personnel practiced both active and passive DM, such as over-investigation, over-treatment, and avoidance of high-risk patients. NMHP-DM could increase risks for patient health, costs, risk of burnout for healthcare employees. Further studies are needed to better understand prevalence and features of NMHP-DM in all health professional fields, in order to apply appropriate preventive strategies to contrast DM among health care personnel.
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Affiliation(s)
- C Rinaldi
- Department of Translational Medicine, School of Medicine, University of Eastern Piedmont, Novara, Italy; A.O.U. Maggiore della Carità, Novara, Italy
| | - A D'Alleva
- Department of Biomedical Sciences and Public Health, Section of Hygiene, Preventive Medicine and Public Health, Polytechnic University of Marche, Ancona, Italy.
| | - F Leigheb
- Department of Translational Medicine, School of Medicine, University of Eastern Piedmont, Novara, Italy; A.O.U. Maggiore della Carità, Novara, Italy
| | - K Vanhaecht
- Leuven Institute for Healthcare Policy, University of Leuven, Belgium; Department of Quality Management, University Hospitals Leuven, Belgium
| | - S Knesse
- Department of Translational Medicine, School of Medicine, University of Eastern Piedmont, Novara, Italy
| | - F Di Stanislao
- Department of Biomedical Sciences and Public Health, Section of Hygiene, Preventive Medicine and Public Health, Polytechnic University of Marche, Ancona, Italy
| | - M Panella
- Department of Translational Medicine, School of Medicine, University of Eastern Piedmont, Novara, Italy
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31
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Vento S, Cainelli F, Vallone A. Defensive medicine: It is time to finally slow down an epidemic. World J Clin Cases 2018; 6:406-409. [PMID: 30294604 PMCID: PMC6163143 DOI: 10.12998/wjcc.v6.i11.406] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2018] [Revised: 07/05/2018] [Accepted: 07/16/2018] [Indexed: 02/05/2023] Open
Abstract
Defensive medicine is widespread and practiced the world over, with serious consequences for patients, doctors, and healthcare costs. Even students and residents are exposed to defensive medicine practices and taught to take malpractice liability into consideration when making clinical decisions. Defensive medicine is generally thought to stem from physicians’ perception that they can easily be sued by patients or their relatives who seek compensation for presumed medical errors. However, in our view the growth of defensive medicine should be seen in the context of larger changes in the conception of medicine that have taken place in the last few decades, undermining the patient–physician trust, which has traditionally been the main source of professional satisfaction for physicians. These changes include the following: time directly spent with patients has been overtaken by time devoted to electronic health records and desk work; family doctors have played a progressively less central role; clinical reasoning is being replaced by guidelines and algorithms; the public at large and a number of young physicians tend to believe that medicine is a perfect science rather than an imperfect art, as it continues to be; and modern societies do not tolerate the inevitable morbidity and mortality. To finally reduce the increasing defensive behavior of doctors around the world, the decriminalization of medical errors and the assurance that they can be dealt with in civil courts or by medical organizations in all countries could help but it would not suffice. Physicians and surgeons should be allowed to spend the time they need with their patients and should give clinical reasoning the importance it deserves. The institutions should support the doctors who have experienced adverse patient events, and the media should stop reporting with excessive evidence presumed medical errors and subject physicians to “public trials” before they are eventually judged in court.
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Affiliation(s)
- Sandro Vento
- Department of Medicine, Nazarbayev University, Astana 010000, Kazakhstan
- University Medical Center, Astana 010000, Kazakhstan
| | - Francesca Cainelli
- Department of Medicine, Nazarbayev University, Astana 010000, Kazakhstan
| | - Alfredo Vallone
- Infectious Diseases Unit, G. Jazzolino Hospital, Vibo Valentia 89900, Italy
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32
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Affiliation(s)
- Jesper Lykkegaard
- Research Unit of General Practice, Institute of Public Health, University of Southern Denmark, Odense, Denmark
| | | | - Jørgen Nexøe
- Research Unit of General Practice, Institute of Public Health, University of Southern Denmark, Odense, Denmark
- Editorial Board, Scandinavian Journal of Primary Health Care
| | - Elisabeth Assing Hvidt
- Research Unit of General Practice, Institute of Public Health, University of Southern Denmark, Odense, Denmark
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33
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Ferorelli D, Lucilla C, Vincenti L, Zotti F, Dell'Erba A. Adoption and Implementation of the Surgical Safety Checklist: Improving Safety in an Italian Teaching Hospital. Am J Med Qual 2018; 34:100. [PMID: 29877091 DOI: 10.1177/1062860618780354] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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34
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Shaheen NJ, Fennerty MB, Bergman JJ. Less Is More: A Minimalist Approach to Endoscopy. Gastroenterology 2018; 154:1993-2003. [PMID: 29454789 DOI: 10.1053/j.gastro.2017.12.044] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2017] [Revised: 11/08/2017] [Accepted: 12/04/2017] [Indexed: 12/20/2022]
Abstract
A substantial literature documents inappropriate usage of gastrointestinal endoscopy in a variety of clinical settings. Overusage of endoscopy appears to be common, and 30% or more of procedures performed in some clinical settings have questionable indications. The potential reasons for overuse of endoscopy are multiple, and include cancer phobia, fear of medical malpractice litigation, profit motive, the investigation of "incidentalomas" found on other imaging, and underappreciation of the delayed harms of endoscopy, among other reasons. Clinical guidelines, which should limit overuse of endoscopy, may instead serve to promote it, if authors opt to be "conservative," recommending endoscopy in situations of unclear utility. Several strategies may decrease overuse of endoscopy, including careful attention to risk stratification when choosing patients to screen, adherence to guidelines for surveillance intervals for colonoscopy, the use of quality indicators to identify outliers in endoscopy utilization, and education on appropriate indications and the risks of overuse at the medical student, residency, and fellowship levels.
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Affiliation(s)
- Nicholas J Shaheen
- University of North Carolina at Chapel Hill, Center for Esophageal Diseases and Swallowing, Division of Gastroenterology and Hepatology, Chapel Hill, North Carolina.
| | - M Brian Fennerty
- Division of Gastroenterology and Hepatology, Oregon Health and Sciences University, Portland, Oregon
| | - Jacques J Bergman
- Department of Gastroenterology and Hepatology, Academic Medical Center, Amsterdam, The Netherlands
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35
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Assing Hvidt E, Lykkegaard J, Pedersen LB, Pedersen KM, Munck A, Andersen MK. How is defensive medicine understood and experienced in a primary care setting? A qualitative focus group study among Danish general practitioners. BMJ Open 2017; 7:e019851. [PMID: 29273671 PMCID: PMC5778280 DOI: 10.1136/bmjopen-2017-019851] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
OBJECTIVES Recent years have witnessed a progressive increase in defensive medicine (DM) in several Western welfare countries. In Danish primary and secondary care, documentation on the extent of DM is lacking. Before investigating the extent of DM, we wanted to explore how the phenomenon is understood and experienced in the context of general practice in Denmark. The objective of the study was to describe the phenomenon of DM as understood and experienced by Danish general practitioners (GPs). DESIGN A qualitative methodology was employed and data were generated through six focus group interviews with three to eight GPs per group (n=28) recruited from the Region of Southern Denmark. Data were analysed using a thematic content analysis inspired by a hermeneutic-phenomenological focus on understanding and meaning. RESULTS DM is understood as unnecessary and meaningless medical actions, carried out mainly because of external demands that run counter to the GP's professionalism. Several sources of pressure to act defensively were identified by the GPs: the system's pressure to meet external regulations, demands from consumerist patients and a culture among GPs and peers of infallibility and zero-risk tolerance. CONCLUSIONS GPs understand DM as unnecessary and meaningless actions driven by external demands instead of a focus on the patient's problem. GPs consider defensive actions to be carried out as a result of succumbing to various sources of pressure deriving from the system, the patients, the GPs themselves and peers.
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Affiliation(s)
- Elisabeth Assing Hvidt
- Department of Public Health, Research Unit of General Practice, University of Southern Denmark, Odense, Denmark
| | - Jesper Lykkegaard
- Department of Public Health, Research Unit of General Practice, University of Southern Denmark, Odense, Denmark
| | - Line Bjørnskov Pedersen
- Department of Public Health, Research Unit of General Practice, University of Southern Denmark, Odense, Denmark
- Department of of Business and Economics, COHERE, University of Southern Denmark, Odense, Denmark
| | - Kjeld Møller Pedersen
- Department of of Business and Economics, COHERE, University of Southern Denmark, Odense, Denmark
| | - Anders Munck
- Department of Public Health, Research Unit of General Practice, University of Southern Denmark, Odense, Denmark
| | - Merethe Kousgaard Andersen
- Department of Public Health, Research Unit of General Practice, University of Southern Denmark, Odense, Denmark
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