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Goetz K, Oldenburg D, Strobel CJ, Steinhäuser J. The influence of fears of perceived legal consequences on general practitioners' practice in relation to defensive medicine - a cross-sectional survey in Germany. BMC PRIMARY CARE 2024; 25:23. [PMID: 38216861 PMCID: PMC10785451 DOI: 10.1186/s12875-024-02267-x] [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: 07/03/2023] [Accepted: 01/04/2024] [Indexed: 01/14/2024]
Abstract
BACKGROUND Medical decisions are influenced by a variety of factors also by legal requirements and feelings of uncertainty, which results in the term defensive medicine. The aim of the study was to evaluate the influence of fears of perceived legal consequences on the practice of defensive medicine from the perspective of German general practitioners (GPs). METHODS A cross-sectional study was performed from April to May 2022. GPs were invited via an e-mail newsletter of the Institute for Continuing Education in Family Medicine in the German Association of General Practitioners and via an online platform of the German College of General Practitioners and Family Physicians. The evaluation of legal fears, the general assessment of defensive medicine and reasons for and the frequency of defensive medical measures were surveyed in this study. Beside descriptive analyses, a stepwise linear regression analysis was used to explore potential associations between for the primary outcome variable 'fears of legal consequences' on the practice of defensive medicine. RESULTS 413 general practitioners with an average age of 50 years (51% female) responded. The majority rated their fears of legal consequences as low to average whereas for almost a third (27%, n = 113) the fears were strong to very strong. Regarding legal fears, the physician-patient-relationship played a fairly to very large role for 48% (n = 198) of the respondents. One third estimated the probability of being sued civilly in the next 10 years as rather high to very high. 47% (n = 193) of the participants assumed that the risk of being sued could mostly to very much be reduced by defensive medicine. Legal self-protection was for 38% of the responders (n = 157) quite frequently to very frequently a reason for acting defensively. Consequently, half of the respondents stated that they performed unnecessary laboratory tests at least once per week and 40% indicated that they referred patients for radiological diagnostics without medical indication once per month. CONCLUSIONS As legal fears have an influence on medical practice and legal self-protection being a frequent reason for defensive behaviour, understanding and knowledge of the law should be improved by legal education at university and further training of post-graduate trainees and practicing physicians should be implemented. Additionally, a more in-depth enlightenment of society about the phenomenon of Protective and Defensive Medicine and its consequences could be a possibility to decrease the perceived fears of legal consequences on the physicians' side.
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Affiliation(s)
- Katja Goetz
- Institute of Family Medicine, University Medical Center Schleswig-Holstein, Campus Lübeck, Ratzeburger Allee 160, 23538, Lübeck, Germany.
| | - Dorothee Oldenburg
- Institute of Family Medicine, University Medical Center Schleswig-Holstein, Campus Lübeck, Ratzeburger Allee 160, 23538, Lübeck, Germany
| | - Christina Jana Strobel
- Institute of Family Medicine, University Medical Center Schleswig-Holstein, Campus Lübeck, Ratzeburger Allee 160, 23538, Lübeck, Germany
| | - Jost Steinhäuser
- Institute of Family Medicine, University Medical Center Schleswig-Holstein, Campus Lübeck, Ratzeburger Allee 160, 23538, Lübeck, Germany
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Pischedda G, Marinò L, Corsi K. Defensive medicine through the lens of the managerial perspective: a literature review. BMC Health Serv Res 2023; 23:1104. [PMID: 37848915 PMCID: PMC10580549 DOI: 10.1186/s12913-023-10089-3] [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: 12/19/2022] [Accepted: 09/29/2023] [Indexed: 10/19/2023] Open
Abstract
PURPOSE Several studies have been carried out on defensive medicine, but research from the managerial viewpoint is still scarce. Therefore, the aim of the present study is to conduct a literature review to better understand defensive medicine from a managerial perspective. DESIGN/METHODOLOGY/APPROACH A literature review was conducted of studies focusing on the organisational (meso) level of healthcare providers and managerial practices. A final sample of 28 studies was processed. FINDINGS Defensive medicine has mainly been studied in the USA, and scholars have principally used quantitative surveys. High-risk specialities have been a critical field of investigation, and a large portion of the papers are published in journals that cover medicine, health policy, education and law fields. The analysis showed that operations and the organisation of staffing were the most discussed managerial practices. No study considered planning and budgeting aspects. ORIGINALITY/VALUE The review confirmed that the managerial aspect of defensive medicine has not been fully addressed. Stimulated by this gap, this study analyses the managerial background of the defensive medicine phenomenon and shows which managerial practices have been most analysed. This paper also contributes to developing the literature on defensive medicine from the managerial side. Areas for future research include qualitative studies to investigate the behaviour of managers of healthcare companies to give a different perspective on defensive medicine and organisations' decision-making. RESEARCH LIMITATIONS/IMPLICATIONS Some important publications might have been missed in this work because of the choice of only two databases. A further limit could be imposed by the use of the English language as an inclusion criterion.
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Affiliation(s)
- Gianfranco Pischedda
- Department of Economics and Business, University of Sassari, Via Muroni, 25, 07100, Sassari, Italy.
| | - Ludovico Marinò
- Department of Economics and Business, University of Sassari, Via Muroni, 25, 07100, Sassari, Italy
| | - Katia Corsi
- Department of Economics and Business, University of Sassari, Via Muroni, 25, 07100, Sassari, Italy
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Strobel CJ, Oldenburg D, Steinhäuser J. Factors influencing defensive medicine-based decision-making in primary care: A scoping review. J Eval Clin Pract 2023; 29:529-538. [PMID: 36433885 DOI: 10.1111/jep.13799] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2022] [Revised: 10/26/2022] [Accepted: 11/01/2022] [Indexed: 11/28/2022]
Abstract
RATIONALE, AIMS AND OBJECTIVES Medical decision-making processes in primary care are influenced by defensive medical practice. This involves a high possibility for negative consequences on many levels, for example, patient's health, health care system costs and a crisis of trust in the patient-doctor relationship. Aim of this review was to identify factors of defensive medicine-based decision-making in primary care. METHODS This scoping review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping reviews (PRISMA-ScR) guidelines and included systematic research on MEDLINE, Google Scholar and two German databases for additional grey literature. References provided further literature. Articles in English and German published from 1 January 1982 to 15 June 2022 were assessed. RESULTS From 911 publications screened, 13 publications [6 qualitative studies and 7 quantitative (3 cross-sectional) studies] were included. In these, four main categories of factors influencing defensive medical practice were identified: (social) media, patients adopting a consumer attitude, health care system based working conditions and physician's tolerance for uncertainty. Pressure deriving from these four different sources is exerted on the general practitioner and may result in a defensive medical decision behaviour. CONCLUSIONS Four categories on influencing factors of defensive medicine could be identified. Strategies to tolerate uncertainty should be trained in under- and postgraduate training.
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Affiliation(s)
- Christina J Strobel
- Institute of Family Medicine, University Medical Center Schleswig Holstein, Lübeck, Germany
| | - Dorothee Oldenburg
- Institute of Family Medicine, University Medical Center Schleswig Holstein, Lübeck, Germany
| | - Jost Steinhäuser
- Institute of Family Medicine, University Medical Center Schleswig Holstein, Lübeck, Germany
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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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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: 24] [Impact Index Per Article: 6.0] [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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