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Wen M, Li L, Zhang Y, Shao J, Chen Z, Wang J, Zhang L, Sun J. Advancements in defensive medicine research: Based on current literature. Health Policy 2024; 147:105125. [PMID: 39018785 DOI: 10.1016/j.healthpol.2024.105125] [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: 01/05/2024] [Revised: 07/05/2024] [Accepted: 07/10/2024] [Indexed: 07/19/2024]
Abstract
To investigate and comprehend the evolving research hotspots, cutting-edge trends, and frontiers associated with defensive medicine. The original data was collected from the Web of Science core collection and then subjected to a preliminary retrieval process. Following screening, a total of 654 relevant documents met the criteria and underwent subsequent statistical analysis. Software CiteSpace was employed for conducting a customized visual analysis on the number of articles, keywords, research institutions, and authors associated with defensive medicine. The defensive medicine research network was primarily established in Western countries, particularly the United States, and its findings and conceptual framework have significantly influenced defensive medicine research in other regions. Currently, quantitative methods dominated most studies while qualitative surveys remained limited. Defensive medicine research mainly focused on high-risk medical specialties such as surgery and obstetrics. Research on defensive medicine pertained to the core characteristics of its conceptual framework. An in-depth investigation into the factors that give rise to defensive medicine is required, along with the generation of more generalizable research findings to provide valuable insights for improving and intervening in defensive medicine.
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Affiliation(s)
- Minhui Wen
- School of Health Care Management, Anhui Medical University, Hefei, China
| | - Limin Li
- School of Health Care Management, Anhui Medical University, Hefei, China
| | - Yuqing Zhang
- School of Health Care Management, Anhui Medical University, Hefei, China
| | - Jiayi Shao
- School of Health Care Management, Anhui Medical University, Hefei, China
| | - Zhen Chen
- The First Affiliated Hospital of Anhui Medical University, Hefei, Anhui, China
| | - Jinian Wang
- The First Affiliated Hospital of Anhui Medical University, Hefei, Anhui, China
| | - Liping Zhang
- School of Marxism, Anhui Medical University, Hefei, China
| | - Jiangjie Sun
- School of Health Care Management, Anhui Medical University, Hefei, China; School of Management, Hefei University of Technology, Hefei, Anhui, China.
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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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Kakudo K, Jung CK, Liu Z, Hirokawa M, Bychkov A, Vuong HG, Keelawat S, Srinivasan R, Hang JF, Lai CR. The Asian Thyroid Working Group, from 2017 to 2023. J Pathol Transl Med 2023; 57:289-304. [PMID: 37981725 PMCID: PMC10660359 DOI: 10.4132/jptm.2023.10.04] [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: 09/19/2023] [Accepted: 10/04/2023] [Indexed: 11/21/2023] Open
Abstract
The Asian Thyroid Working Group was founded in 2017 at the 12th Asia Oceania Thyroid Association (AOTA) Congress in Busan, Korea. This group activity aims to characterize Asian thyroid nodule practice and establish strict diagnostic criteria for thyroid carcinomas, a reporting system for thyroid fine needle aspiration cytology without the aid of gene panel tests, and new clinical guidelines appropriate to conservative Asian thyroid nodule practice based on scientific evidence obtained from Asian patient cohorts. Asian thyroid nodule practice is usually designed for patient-centered clinical practice, which is based on the Hippocratic Oath, "First do not harm patients," and an oriental filial piety "Do not harm one's own body because it is a precious gift from parents," which is remote from defensive medical practice in the West where physicians, including pathologists, suffer from severe malpractice climate. Furthermore, Asian practice emphasizes the importance of resource management in navigating the overdiagnosis of low-risk thyroid carcinomas. This article summarizes the Asian Thyroid Working Group activities in the past 7 years, from 2017 to 2023, highlighting the diversity of thyroid nodule practice between Asia and the West and the background reasons why Asian clinicians and pathologists modified Western systems significantly.
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Affiliation(s)
- Kennichi Kakudo
- Department of Pathology, Cancer Genome Center and Thyroid Disease Center, Izumi City General Hospital, Izumi, Osaka, Japan
| | - Chan Kwon Jung
- Department of Hospital Pathology, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Zhiyan Liu
- Department of Pathology, Shanghai Sixth People’s Hospital, Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | | | - Andrey Bychkov
- Department of Pathology, Kameda Medical Center, Kamogawa, Chiba, Japan
| | - Huy Gia Vuong
- Department of Pathology, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
| | - Somboon Keelawat
- Special Task Force for Activating Research (STAR), Department of Pathology, Chulalongkorn University, Bangkok, Thailand
| | - Radhika Srinivasan
- Department of Cytology and Gynecological Pathology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Jen-Fan Hang
- Department of Pathology and Laboratory Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Chiung-Ru Lai
- Department of Pathology and Laboratory Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
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Forrest C, Madden D, O'Sullivan MJ, O'Reilly S. Learning From Medical Litigation. JCO Oncol Pract 2023; 19:160-163. [PMID: 36652657 DOI: 10.1200/op.22.00763] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Affiliation(s)
- Clara Forrest
- Academic Track Intern Programme, Intern Network Executive, School of Medicine, University College, Cork, Ireland
| | | | | | - Seamus O'Reilly
- Department of Medical Oncology, Cork University Hospital, Cork, Ireland.,Cancer Research@UCC, University College Cork, Cork, Ireland
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Prieto VG, Vollmer RT, Shea CR. Use of modifying phrases in surgical pathology reports: is there a different understanding between pathologists and treating physicians? Virchows Arch 2022; 481:759-766. [PMID: 36098817 DOI: 10.1007/s00428-022-03407-3] [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: 06/21/2022] [Revised: 08/16/2022] [Accepted: 08/30/2022] [Indexed: 10/14/2022]
Abstract
When not all the histopathologic and clinical features necessary for a pathology diagnosis are present in a particular specimen, pathologists may use modifying phrases to convey various degrees of certainty, e.g., "consistent with…" and "suggestive of…." However, it is unclear whether pathologists use such phrases consistently or whether treating physicians fully understand their intended meaning. A questionnaire concerning six common modifying phrases ("consistent with, suggestive of, suspicious for, highly consistent with, highly suggestive of, some features of") was sent to all physicians from a single institution who either issued or routinely received surgical pathology reports. Physicians were asked to rank their understanding of each phrase on a printed scale between 1 ("no evidence of") and 10 ("diagnostic of"). One hundred sixty physicians (74.3%) responded. Despite wide variation, there was a hierarchy (from more to less diagnostic): highly consistent > highly suspicious > consistent > suspicious > suggestive > some features (p < 1 × 10-7). There were no significant differences between pathologists and treating physicians (p = 0.72) or attendings and residents (p = 0.9). Pathologists and treating physicians share an overall common understanding of their hierarchical relationship, albeit with wide ranges. Based upon our results, we propose to use only three qualifying phrases to convey the degree of certainty for a particular diagnosis: "suggestive of" (> 25 ≤ 50% certainty), "suspicious for" (> 50 ≤ 75%), and "consistent with" (> 75%). The phrase "no evidence of" should probably be used only when there is ≤ 5% confidence in a diagnosis, and conversely, "diagnostic of" should probably be used only when there is ≥ 95% confidence in a diagnosis.
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Affiliation(s)
- V G Prieto
- Department of Pathology, University of Texas-MD Anderson Cancer Center, Box 85, Houston, TX, 77030, USA. .,Department of Dermatology, University of Texas-MD Anderson Cancer Center, Houston, TX, 77030, USA.
| | - R T Vollmer
- Department of Pathology, Veterans Administration Hospital, Duke University Medical Center, Durham, 27710, NC, UK
| | - C R Shea
- Departments of Pathology and Medicine, University of Chicago, Chicago, IL, 60611, USA
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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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Kerr KF, Eguchi MM, Piepkorn MW, Radick AC, Reisch LM, Shucard HL, Knezevich SR, Barnhill RL, Elder DE, Elmore JG. Dermatopathologist Perceptions of Overdiagnosis of Melanocytic Skin Lesions and Association With Diagnostic Behaviors. JAMA Dermatol 2022; 158:675-679. [PMID: 35442415 PMCID: PMC9021983 DOI: 10.1001/jamadermatol.2022.0489] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2021] [Accepted: 02/04/2022] [Indexed: 12/13/2022]
Abstract
Importance Despite evidence of overdiagnosis of in situ and invasive melanoma, neither the perceptions of practicing dermatopathologists about overdiagnosis nor possible associations between perceptions of overdiagnosis and diagnostic practices have been studied. Objective To examine practicing US dermatopathologists' perceptions of melanoma overdiagnosis as a public health issue, and to associate diagnostic behaviors of dermatopathologists with perceptions of melanoma overdiagnosis. Design, Setting, and Participants This survey study included 115 board-certified and/or fellowship-trained dermatopathologists and their diagnostic interpretations on a set of 18 skin biopsy cases (5 slide sets comprising 90 melanocytic skin lesions). Participants interpreted cases remotely using their own microscopes. Survey invitations occurred during 2018 to 2019, with data collection completed 2021. Data analysis was performed from June to September 2021. Main Outcomes and Measures Agreement vs disagreement that overdiagnosis is a public health issue for atypical nevi, melanoma in situ, and invasive melanoma. Associations between perceptions regarding overdiagnosis and interpretive behavior on study cases. Results Of 115 dermatopathologists, 68% (95% CI, 59%-76%) agreed that overdiagnosis is a public health issue for atypical nevi; 47% (95% CI, 38%-56%) for melanoma in situ; and 35% (95% CI, 26%-43%) for invasive melanoma. Dermatopathologists with more years in practice were significantly less likely to perceive that atypical nevi are overdiagnosed, eg, 46% of dermatopathologists with 20 or more years of experience agreed that atypical nevi are overdiagnosed compared with 93% of dermatopathologists with 1 to 4 years of experience. Compared with other dermatopathologists, those who agreed that all 3 conditions are overdiagnosed were slightly more likely to diagnose study cases as mild to moderately dysplastic nevi (odds ratio, 1.26; 95% CI, 0.97-1.64; P = .08), but the difference was not statistically significant. Dermatopathologists who agreed that invasive melanoma is overdiagnosed did not significantly differ in diagnosing invasive melanoma for study cases compared with those who disagreed (odds ratio, 1.10; 95% CI, 0.86-1.41; P = .44). Conclusions and Relevance In this survey study, about two-thirds of dermatopathologists thought that atypical nevi are overdiagnosed, half thought that melanoma in situ is overdiagnosed, and one-third thought that invasive melanoma is overdiagnosed. No statistically significant associations were found between perceptions about overdiagnosis and interpretive behavior when diagnosing skin biopsy cases.
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Affiliation(s)
| | - Megan M. Eguchi
- Department of Medicine, University of California, Los Angeles, David Geffen School of Medicine
| | - Michael W. Piepkorn
- Division of Dermatology, Department of Medicine, University of Washington School of Medicine, Seattle
- Dermatopathology Northwest, Bellevue, Washington
| | | | - Lisa M. Reisch
- Department of Biostatistics, University of Washington, Seattle
| | | | | | - Raymond L. Barnhill
- Department of Translational Research, Institut Curie, Paris, France
- Paris Sciences and Lettres Research University, Paris, France
- University of Paris UFR of Medicine, Paris, France
| | - David E. Elder
- Department of Pathology and Laboratory Medicine, Hospital of the University of Pennsylvania, Philadelphia
| | - Joann G. Elmore
- Department of Medicine, University of California, Los Angeles, David Geffen School of Medicine
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Bradfield OM, Bismark M, Scott A, Spittal M. Medical negligence claims and the health and life satisfaction of Australian doctors: a prospective cohort analysis of the MABEL survey. BMJ Open 2022; 12:e059447. [PMID: 35589347 PMCID: PMC9121477 DOI: 10.1136/bmjopen-2021-059447] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVE To assess the association between medical negligence claims and doctors' self-rated health and life satisfaction. DESIGN Prospective cohort study. PARTICIPANTS Registered doctors practising in Australia who participated in waves 4 to 11 of the Medicine in Australia: Balancing Employment and Life (MABEL) longitudinal survey between 2011 and 2018. PRIMARY AND SECONDARY OUTCOME MEASURES Self-rated health and self-rated life satisfaction. RESULTS Of the 15 105 doctors in the study, 885 reported being named in a medical negligence claim. Fixed-effects linear regression analysis showed that both self-rated health and self-rated life satisfaction declined for all doctors over the course of the MABEL survey, with no association between wave and being sued. However, being sued was not associated with any additional declines in self-rated health (coef.=-0.02, 95% CI -0.06 to 0.02, p=0.39) or self-rated life satisfaction (coef.=-0.01, 95% CI -0.08 to 0.07, p=0.91) after controlling for a range of job factors. Instead, we found that working conditions and job satisfaction were the strongest predictors of self-rated health and self-rated life satisfaction in sued doctors. In analyses restricted to doctors who were sued, we observed no changes in self-rated health (p=0.99) or self-rated life satisfaction (p=0.59) in the years immediately following a claim. CONCLUSIONS In contrast to prior overseas cross-sectional survey studies, we show that medical negligence claims do not adversely affect the well-being of doctors in Australia when adjusting for time trends and previously established covariates. This may be because: (1) prior studies failed to adequately address issues of causation and confounding; or (2) legal processes governing medical negligence claims in Australia cause less distress compared with those in other jurisdictions. Our findings suggest that the interaction between medical negligence claims and poor doctors' health is more complex than revealed through previous studies.
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Affiliation(s)
- Owen M Bradfield
- Law and Public Health Unit, Centre for Health Policy, Melbourne School of Population and Global Health, The University of Melbourne, Melbourne, Victoria, Australia
| | - Marie Bismark
- Law and Public Health Unit, Centre for Health Policy, Melbourne School of Population and Global Health, The University of Melbourne, Melbourne, Victoria, Australia
| | - Anthony Scott
- Melbourne Institute of Applied Economic and Social Research, The University of Melbourne, Melbourne, Victoria, Australia
| | - Matthew Spittal
- Centre for Mental Health, Melbourne School of Population and Global Health, The University of Melbourne, Melbourne, Victoria, Australia
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Mehta S, Lu X, Wu W, Weaver D, Hajishirzi H, Elmore JG, Shapiro LG. End-to-End Diagnosis of Breast Biopsy Images with Transformers. Med Image Anal 2022; 79:102466. [PMID: 35525135 PMCID: PMC10162595 DOI: 10.1016/j.media.2022.102466] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2021] [Revised: 02/25/2022] [Accepted: 04/18/2022] [Indexed: 01/18/2023]
Abstract
Diagnostic disagreements among pathologists occur throughout the spectrum of benign to malignant lesions. A computer-aided diagnostic system capable of reducing uncertainties would have important clinical impact. To develop a computer-aided diagnosis method for classifying breast biopsy images into a range of diagnostic categories (benign, atypia, ductal carcinoma in situ, and invasive breast cancer), we introduce a transformer-based hollistic attention network called HATNet. Unlike state-of-the-art histopathological image classification systems that use a two pronged approach, i.e., they first learn local representations using a multi-instance learning framework and then combine these local representations to produce image-level decisions, HATNet streamlines the histopathological image classification pipeline and shows how to learn representations from gigapixel size images end-to-end. HATNet extends the bag-of-words approach and uses self-attention to encode global information, allowing it to learn representations from clinically relevant tissue structures without any explicit supervision. It outperforms the previous best network Y-Net, which uses supervision in the form of tissue-level segmentation masks, by 8%. Importantly, our analysis reveals that HATNet learns representations from clinically relevant structures, and it matches the classification accuracy of 87 U.S. pathologists for this challenging test set.
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Affiliation(s)
| | - Ximing Lu
- University of Washington, Seattle, USA
| | - Wenjun Wu
- University of Washington, Seattle, USA
| | - Donald Weaver
- Department of Pathology, The University of Vermont College of Medicine, USA
| | | | - Joann G Elmore
- David Geffen School of Medicine, University of California, Los Angeles, USA
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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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Abstract
AIM Defensive medicine refers to practices with low marginal benefit to patients that doctors may undertake to protect themselves from legal liability. We aimed to develop a scale to measure the practice of defensive medicine. METHOD We identified aspects of defensive medicine previously reported in the literature and conducted and analyzed semi-structured interviews with 21 physicians in Sakarya to augment and clarify these aspects between May 15, 2018, and June 15, 2018. Informed by these results, we developed, pilot tested, refined, and fielded a 10-item survey to 1724 doctors in Turkey between April 1, 2019, and July 16, 2019. We examined the psychometric properties of the scale using exploratory (EFA) and confirmatory factor analyses (CFA). RESULTS The 10-item scale provided measures of 2 factors: positive defensive medicine (assurance) and negative defensive medicine (avoidance), with Cronbach's alpha >0.8 for the scale and both subscales in both the EFA and CFA subsamples and excellent goodness-of-fit measures. CONCLUSIONS We developed a highly reliable scale to measure positive and negative defensive medicine practice that may be suitable for future research on physician decision making.
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Affiliation(s)
- Özgün Ünal
- Department of Healthcare Management, Business Faculty, Sakarya University, Sakarya, Turkey
| | - Mahmut Akbolat
- Department of Healthcare Management, Business Faculty, Sakarya University, Sakarya, Turkey
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13
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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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14
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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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15
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Boyke AE, Bader ER, Naidu I, Lam S, Alvi MA, Funari A, Agarwal V. Medical malpractice and meningiomas: an analysis of 47 cases. Neurosurg Focus 2020; 49:E22. [DOI: 10.3171/2020.8.focus20598] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Accepted: 08/19/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVEAmong medical practices, surgical fields, including neurosurgery, are at a high risk for medical malpractice litigation. With meningiomas contributing to 10% of the total neurosurgery litigation cases, the aim of this study was to identify demographic characteristics, reasons for litigation, and surgical complications commonly reported in these cases. This analysis serves to increase neurosurgeons’ awareness of factors associated with medical malpractice litigation.METHODSThe online legal database Westlaw was utilized to query public litigation cases related to the medical management of meningiomas between December 1985 and May 2020. Variables extracted included the following: plaintiff and defendant demographics, litigation category, plaintiff medical complaints, and trial outcomes. The authors compared these characteristics between cases with decisions in favor of the defendant and those with decisions in favor of the plaintiff.RESULTSA total of 47 cases met the inclusion criteria. Failure to diagnose (68.1%) was the most common type of malpractice claim, and surgical complications (19.1%), motor weakness (33%), and financial loss (33%) were cited as the most common postoperative complaints. Individual specialties that most often required defense due to malpractice claims were radiology (21.7%) and neurosurgery (19.6%). The jury verdict was in favor of the defense in 51.1% of cases and in favor of the plaintiff in 27.7% of cases. A settlement was reached in 19.1% of cases. The mean payout for a verdict in favor of the plaintiff was $3,409,650.22, while the mean payout for settlements was $867,555.56. The greatest average payout for specialties was in neurosurgery at $3,414,400, followed by radiology at $3,192,960. Cases with a verdict in favor of the plaintiff were more likely to involve an internal medicine physician as a defendant (p = 0.007).CONCLUSIONSOver one-half of the cases resulted in a defendant’s verdict with failure to diagnose cited as the most common reason for litigation. Radiology and neurosurgery were the most common specialties for legal cases and also had some of the largest average payouts based on specialty. Motor weakness and financial loss were the most common plaintiff postoperative complaints. These findings may inform surgeons on active measures to take, such as increasing focus on diagnostic accuracy and reducing specific postoperative complaints, such as motor weakness, through risk management and prophylactic measures, to reduce unfavorable legal outcomes.
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Affiliation(s)
- Andre E. Boyke
- 1Department of Neurological Surgery, Montefiore Medical Center, New York
| | - Edward R. Bader
- 2Department of Neurological Surgery, Albert Einstein College of Medicine, New York, New York; and
| | - Ishan Naidu
- 1Department of Neurological Surgery, Montefiore Medical Center, New York
| | - Sharon Lam
- 1Department of Neurological Surgery, Montefiore Medical Center, New York
| | - Mohammed Ali Alvi
- 3Department of Neurological Surgery, Mayo Clinic, Rochester, Minnesota
| | - Abigail Funari
- 1Department of Neurological Surgery, Montefiore Medical Center, New York
| | - Vijay Agarwal
- 1Department of Neurological Surgery, Montefiore Medical Center, New York
- 2Department of Neurological Surgery, Albert Einstein College of Medicine, New York, New York; and
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16
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Reisch LM, Flores MJ, Radick AC, Shucard HL, Kerr KF, Piepkorn MW, Barnhill RL, Elder DE, Knezevich SR, Elmore JG. Malpractice and Patient Safety Concerns. Am J Clin Pathol 2020; 154:700-707. [PMID: 32651589 DOI: 10.1093/ajcp/aqaa088] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES "Assurance behaviors," a type of defensive medicine, involve physicians' utilization of additional patient services to avoid adverse legal outcomes. We aim to compare the use of clinical behaviors (such as ordering additional tests, services, and consultations) due to malpractice concerns with the same behaviors due to patient safety concerns. METHODS A national sample of dermatopathologists (n = 160) completed an online survey. RESULTS Participants reported using one or more of five clinical behaviors due to concerns about medical malpractice (95%) and patient safety (99%). Self-reported use of clinical behaviors due to malpractice concerns and patient safety concerns was compared, including ordering additional immunohistochemistry/molecular tests (71% vs 90%, respectively, P < .0001), recommending additional surgical sampling (78% vs 91%, P < .0001), requesting additional slides (81% vs 95%, P < .0001), obtaining second reviews (78% vs 91%, P < .0001), and adding caveats into reports regarding lesion difficulty (85% vs 89%, P > .05). CONCLUSIONS Dermatopathologists use many clinical behaviors both as assurance behaviors and due to patient safety concerns, with a higher proportion reporting patient safety concerns as a motivation for specific behaviors.
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Affiliation(s)
- Lisa M Reisch
- Department of Biostatistics, University of Washington, Seattle
| | | | - Andrea C Radick
- Department of Biostatistics, University of Washington, Seattle
| | | | - Kathleen F Kerr
- Department of Biostatistics, University of Washington, Seattle
| | - Michael W Piepkorn
- Division of Dermatology, Department of Medicine, University of Washington School of Medicine, Seattle
- Dermatopathology Northwest, Bellevue, WA
| | - Raymond L Barnhill
- Departments of Pathology and Translational Research, Institut Curie, Paris Sciences and Lettres Research University, and Faculty of Medicine, University of Paris Descartes, Paris, France
| | - David E Elder
- Department of Pathology and Laboratory Medicine, Hospital of the University of Pennsylvania, Philadelphia
| | | | - Joann G Elmore
- Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles
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17
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Dilger AE, Sykes JM. Unhappy Patients Can Turn into Angry Patients: How to Deal with Both. Facial Plast Surg Clin North Am 2020; 28:461-468. [PMID: 33010864 DOI: 10.1016/j.fsc.2020.06.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Patient satisfaction is the ultimate measure of success in cosmetic facial plastic surgery. A successful outcome depends on patient selection, technical performance, and postoperative care. Patient perception can be influenced by physician-patient interactions. Surgical training focuses on diagnosis-identifying variations in physical condition and treatment. Although these skills are essential to a well-trained and successful facial plastic surgeon, the importance of proper patient selection, management of expectations, and empathetic communication in cosmetic surgery are often overlooked in education and cannot be understated. This article outlines the contributing factors to difficult physician-patient relationships and strategies for mitigating these situations.
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Affiliation(s)
- Amanda E Dilger
- Facial Plastic and Reconstructive Surgery, Beverly Hills, CA, USA; Roseville Facial Plastic Surgery, Roseville, CA, USA
| | - Jonathan M Sykes
- Facial Plastic Surgery, UC Davis Medical Center, Sacramento, CA, USA; Facial Plastic Surgery, Roxbury Institute, Beverly Hills, CA, USA.
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18
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Warrick J, Lengerich E. Thyroid Cancer Overdiagnosis and Malpractice Climate. Arch Pathol Lab Med 2019; 143:414-415. [PMID: 30920862 DOI: 10.5858/arpa.2018-0490-le] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Joshua Warrick
- 1 Department of Pathology, Penn State University, Hershey, Pennsylvania
| | - Eugene Lengerich
- 2 Public Health Sciences, Penn State College of Medicine, Hershey, Pennsylvania
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19
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Compton ML, Hogan M, Reisenbichler ES. Differences in immunohistochemistry utilization by general and breast subspecialty pathologists at a large academic institution. Ann Diagn Pathol 2019; 42:92-95. [PMID: 31445409 DOI: 10.1016/j.anndiagpath.2019.08.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2019] [Revised: 08/15/2019] [Accepted: 08/16/2019] [Indexed: 11/24/2022]
Abstract
OBJECTIVES Immunohistochemistry (IHC) can be a useful adjunct in diagnostic breast pathology, but best practices have not been clearly established. We sought to compare the patterns of p63 utilization between general pathologists (GP) and subspecialized breast pathologists (BP), analyze diagnostic discrepancy rates, and identify types of lesions requiring immunohistochemistry. METHODS The pathology database was searched over 6-year period to identify breast needle core biopsy cases utilizing p63 and subsequent excision results. RESULTS P63 was ordered more frequently by BP (2.3% of cores) compared to GP (1.1% of cores, p = 0.0005). The most frequent utilization of p63 by GP for benign lesions (44.0%) followed by invasive carcinomas (36.0%) while BP most frequently ordered p63 on invasive carcinomas (49.5%) and DCIS (26.6%). CONCLUSIONS While IHC use may be thought to be most helpful to those with less experience or knowledge in breast pathology, these results suggest that utilization is increased with subspecialty training.
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Affiliation(s)
- Margaret L Compton
- Department of Pathology, Microbiology, and Immunology, Vanderbilt University Medical Center, 1161 21st Avenue South, MCN CC3322, Nashville, TN 37232-2561, United States of America.
| | - Melissa Hogan
- Department of Pathology, Microbiology, and Immunology, Vanderbilt University Medical Center, United States of America
| | - Emily S Reisenbichler
- Department of Pathology, Microbiology, and Immunology, Vanderbilt University Medical Center, United States of America; Department of Pathology, Yale-New Haven Health System, United States of America
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20
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Luiten JD, Voogd AC, Tjan-Heijnen VC, Wesseling J, Luiten EJ, Duijm LE. Utility of diagnostic breast excision biopsies during two decades of screening mammography. Breast 2019; 46:157-162. [DOI: 10.1016/j.breast.2019.05.018] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2019] [Revised: 05/28/2019] [Accepted: 05/31/2019] [Indexed: 01/19/2023] Open
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21
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Titus LJ, Reisch LM, Tosteson ANA, Nelson HD, Frederick PD, Carney PA, Barnhill RL, Elder DE, Weinstock MA, Piepkorn MW, Elmore JG. Malpractice Concerns, Defensive Medicine, and the Histopathology Diagnosis of Melanocytic Skin Lesions. Am J Clin Pathol 2019; 150:338-345. [PMID: 30007278 DOI: 10.1093/ajcp/aqy057] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Objectives The impact of malpractice concerns on pathologists' use of defensive medicine and interpretations of melanocytic skin lesions (MSLs) is unknown. Methods A total of 207 pathologists interpreting MSLs responded to a survey about past involvement in malpractice litigation, influence of malpractice concerns on diagnosis, and use of assurance behaviors (defensive medicine) to alleviate malpractice concerns. Assurance behaviors included requesting second opinions, additional slides, additional sampling, and ordering specialized tests. Results Of the pathologists, 27.5% reported that malpractice concerns influenced them toward a more severe MSL diagnosis. Nearly all (95.2%) pathologists reported practicing at least one assurance behavior due to malpractice concerns, and this practice was associated with being influenced toward a more severe MSL diagnosis (odds ratio, 2.72; 95% confidence interval, 1.41-5.26). Conclusions One of four US skin pathologists upgrade MSL diagnosis due to malpractice concerns, and nearly all practice assurance behaviors. Assurance behaviors are associated with rendering a more severe MSL diagnosis.
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Affiliation(s)
- Linda J Titus
- Department of Epidemiology and Pediatrics, Norris Cotton Cancer Center, Hanover, NH
| | - Lisa M Reisch
- Department of Medicine, Norris Cotton Cancer Center, Hanover, NH
| | - Anna N A Tosteson
- Departments of Medicine and Community and Family Medicine, Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Norris Cotton Cancer Center, Hanover, NH
| | - Heidi D Nelson
- Departments of Medical Informatics and Clinical Epidemiology and Medicine, Portland
| | - Paul D Frederick
- Department of Medicine, Norris Cotton Cancer Center, Hanover, NH
| | - Patricia A Carney
- Department of Family Medicine, Oregon Health and Science University, Portland
| | - Raymond L Barnhill
- Department of Pathology, Institut Curie, Paris Sciences and Letters Research University, University of Paris Descartes, Paris, France
| | - David E Elder
- Department of Pathology and Laboratory Medicine, Hospital of the University of Pennsylvania, Philadelphia
| | - Martin A Weinstock
- Center for Dermatoepidemiology, VA Medical Center, Providence Department of Dermatology, Rhode Island Hospital, Providence.,Departments of Dermatology and Epidemiology, Brown University, Providence, RI
| | - Michael W Piepkorn
- Division of Dermatology, Department of Medicine, University of Washington School of Medicine, Seattle.,Dermatopathology Northwest, Bellevue, WA
| | - Joann G Elmore
- Department of Medicine, University of California, Los Angeles, David Geffen School of Medicine, Los Angeles, CA
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22
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Luiten JD, Korte B, Voogd AC, Vreuls W, Luiten EJT, Strobbe LJ, Rutten MJCM, Plaisier ML, Lohle PN, Hooijen MJH, Tjan-Heijnen VCG, Duijm LEM. Trends in frequency and outcome of high-risk breast lesions at core needle biopsy in women recalled at biennial screening mammography, a multiinstitutional study. Int J Cancer 2019; 145:2720-2727. [PMID: 31001821 PMCID: PMC6766874 DOI: 10.1002/ijc.32353] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2019] [Revised: 03/21/2019] [Accepted: 04/11/2019] [Indexed: 11/18/2022]
Abstract
Between January 1, 2011, and December 31, 2016, we studied the incidence, management and outcome of high‐risk breast lesions in a consecutive series of 376,519 screens of women who received biennial screening mammography. During the 6‐year period covered by the study, the proportion of women who underwent core needle biopsy (CNB) after recall remained fairly stable, ranging from 39.2% to 48.1% (mean: 44.2%, 5,212/11,783), whereas the proportion of high‐risk lesions at CNB (i.e., flat epithelial atypia, atypical ductal hyperplasia, lobular carcinoma in situ and papillary lesions) gradually increased from 3.2% (25/775) in 2011 to 9.5% (86/901) in 2016 (p < 0.001). The mean proportion of high‐risk lesions at CNB that were subsequently treated with diagnostic surgical excision was 51.4% (169/329) and varied between 41.0% and 64.3% through the years, but the excision rate for high‐risk lesions per 1,000 screens and per 100 recalls increased from 0.25 (2011) to 0.70 (2016; p < 0.001) and from 0.81 (2011) to 2.50 (2016; p < 0.001), respectively. The proportion of all diagnostic surgical excisions showing in situ or invasive breast cancer was 29.0% (49/169) and varied from 22.2% (8/36) in 2014 to 38.5% (5/13) in 2011. In conclusion, the proportion of high‐risk lesions at CNB tripled in a 6‐year period, with a concomitant increased excision rate for these lesions. As the proportion of surgical excisions showing in situ or invasive breast cancer did not increase, a rising number of screened women underwent invasive surgical excision with benign outcome. What's new? Screening mammography aims to catch breast cancer early to reduce associated morbidity and mortality. Women with suspect findings at mammography frequently are recalled for further testing with core needle biopsy (CNB). In this investigation, the proportion of high‐risk lesions detected at CNB was found to have tripled among women in the Netherlands who underwent mammographic screening between 2011 and 2016. This increase was accompanied by an increase in lesion excision rates. Of excised lesions, little more than 14% proved to be malignant at two‐year follow‐up. The remainder of lesions exhibited benign pathology, suggesting that many women underwent potentially unnecessary surgery.
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Affiliation(s)
- Jacky D Luiten
- Department of Surgery, Elisabeth-Tweesteden Hospital, Tilburg, The Netherlands.,School for Oncology and Developmental Biology, Faculty of Health Medicine and Life Sciences, Research Institute GROW, Maastricht University, Maastricht, The Netherlands
| | - Bram Korte
- Department of Radiology, Catharina Hospital Eindhoven, Eindhoven, The Netherlands
| | - Adri C Voogd
- Department of Epidemiology, Faculty of Health Medicine and Life Sciences, Research Institute GROW, Maastricht University, Maastricht, The Netherlands.,Department of Research, Netherlands Comprehensive Cancer Organization, Utrecht, The Netherlands
| | - Willem Vreuls
- Department of Pathology, Canisius Wilhelmina Hospital, Nijmegen, The Netherlands
| | - Ernest J T Luiten
- Department of Surgical Oncology, Amphia Hospital, Breda, The Netherlands
| | - Luc J Strobbe
- Department of Surgical Oncology, Canisius Wilhelmina Hospital, Nijmegen, The Netherlands
| | | | - Menno L Plaisier
- Department of Radiology, Maxima Medical Centre, Veldhoven, The Netherlands
| | - Paul N Lohle
- Department of Radiology, Elisabeth-Tweesteden Hospital, Tilburg, The Netherlands
| | | | - Vivianne C G Tjan-Heijnen
- School for Oncology and Developmental Biology, Faculty of Health Medicine and Life Sciences, Research Institute GROW, Maastricht University, Maastricht, The Netherlands.,Department of Internal Medicine, Division of Medical Oncology, GROW, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Lucien E M Duijm
- Department of Radiology, Canisius Wilhelmina Hospital, Nijmegen, The Netherlands.,Dutch Expert Centre for Screening, Nijmegen, The Netherlands
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23
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Labarge B, Walter V, Lengerich EJ, Crist H, Karamchandani D, Williams N, Goldenberg D, Bann DV, Warrick JI. Evidence of a positive association between malpractice climate and thyroid cancer incidence in the United States. PLoS One 2018; 13:e0199862. [PMID: 30020955 PMCID: PMC6051569 DOI: 10.1371/journal.pone.0199862] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2018] [Accepted: 06/14/2018] [Indexed: 11/19/2022] Open
Abstract
The incidence of thyroid cancer has risen dramatically in the past few decades. The cause of this is unclear, but several lines of evidence indicate it is largely due to overdiagnosis, the diagnosis of tumors that would have never manifest clinically if untreated. Practices leading to overdiagnosis may relate to defensive medicine. In this study, we evaluated the association between malpractice climate and incidence of thyroid, breast, prostate, colon, and lung cancer in U.S. states from 1999-2012 using publicly available government data. State-level malpractice risk was quantified as malpractice payout rate, the number of malpractice payouts per 100,000 people per state per year. Associations between state-level cancer incidence, malpractice payout rate, and several cancer risk factors were evaluated. Risk factors included several social determinants of health, including factors predicting healthcare access. States with higher malpractice payout rate had higher thyroid cancer incidence, on both univariate analysis (r = 0.51, P = 0.009, Spearman) and multivariate analysis (P<0.001, multilevel model). In contrast, state-level malpractice payout rate was not associated with incidence of any other cancer type. Malpractice climate may be a social determinant for being diagnosed with thyroid cancer. This may be a product of greater defensive medicine in states with higher malpractice risk, which leads to increased diagnostic testing of patients with thyroid nodules and potential overdiagnosis. Alternatively, malpractice risk may be a proxy for another, unmeasured risk factor.
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Affiliation(s)
- Brandon Labarge
- College of Medicine, The Pennsylvania State University, Hershey, PA, United States of America
| | - Vonn Walter
- Department of Public Health Sciences, College of Medicine, The Pennsylvania State University, Hershey, PA, United States of America
- Department of Biochemistry, College of Medicine, The Pennsylvania State University, Hershey, PA, United States of America
| | - Eugene J. Lengerich
- Department of Public Health Sciences, College of Medicine, The Pennsylvania State University, Hershey, PA, United States of America
- Penn State Cancer Institute, Hershey, PA, United States of America
| | - Henry Crist
- Department of Pathology, College of Medicine, The Pennsylvania State University, Hershey, PA, United States of America
| | - Dipti Karamchandani
- Department of Pathology, College of Medicine, The Pennsylvania State University, Hershey, PA, United States of America
| | - Nicole Williams
- Department of Pathology, College of Medicine, The Pennsylvania State University, Hershey, PA, United States of America
| | - David Goldenberg
- Department of Surgery–Division of Otolaryngology, College of Medicine, The Pennsylvania State University, Hershey, PA, United States of America
| | - Darrin V. Bann
- Department of Surgery–Division of Otolaryngology, College of Medicine, The Pennsylvania State University, Hershey, PA, United States of America
| | - Joshua I. Warrick
- Penn State Cancer Institute, Hershey, PA, United States of America
- Department of Pathology, College of Medicine, The Pennsylvania State University, Hershey, PA, United States of America
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24
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Carney PA, Frederick PD, Reisch LM, Titus L, Knezevich SR, Weinstock MA, Piepkorn MW, Barnhill RL, Elder DE, Weaver DL, Elmore JG. Complexities of perceived and actual performance in pathology interpretation: A comparison of cutaneous melanocytic skin and breast interpretations. J Cutan Pathol 2018; 45:478-490. [PMID: 29603324 PMCID: PMC6013368 DOI: 10.1111/cup.13147] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2017] [Revised: 02/26/2018] [Accepted: 03/06/2018] [Indexed: 01/18/2023]
Abstract
BACKGROUND Little is known about how pathologists process differences between actual and perceived interpretations. OBJECTIVE To compare perceived and actual diagnostic agreement before and after educational interventions. METHODS Pathologists interpreted test sets of skin and/or breast specimens that included benign, atypical, in situ and invasive lesions. Interventions involved self-directed learning, one skin and one breast, that showed pathologists how their interpretations compared to a reference diagnoses. Prior to the educational intervention, participants estimated how their interpretations would compare to the reference diagnoses. After the intervention, participants estimated their overall agreement with the reference diagnoses. Perceived and actual agreements were compared. RESULTS For pathologists interpreting skin, mean actual agreement was 52.4% and overall pre- and postinterventional mean perceived agreement was 72.9% vs 54.2%, an overestimated mean difference of 20.5% (95% confidence interval [CI] 17.2% to 24.0%) and 1.8% (95% CI -0.5% to 4.1%), respectively. For pathologists interpreting breast, mean actual agreement was 75.9% and overall pre- and postinterventional mean perceived agreement was 81.4% vs 76.9%, an overestimation of 5.5% (95% CI 3.0% to 8.0%) and 1.0% (95% CI 0.0% to 2.0%), respectively. CONCLUSIONS Pathologists interpreting breast tissue had improved comprehension of their performance after the intervention compared to pathologists interpreting skin lesions.
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Affiliation(s)
- Patricia A. Carney
- Professor of Family Medicine, Oregon Health & Science University, Portland, OR
| | - Paul D. Frederick
- Department of Internal Medicine, University of Washington School of Medicine, Seattle, WA
| | - Lisa M. Reisch
- Department of Internal Medicine, University of Washington School of Medicine, Seattle, WA
| | - Linda Titus
- Departments of Epidemiology and of Pediatrics, Geisel School of Medicine at Dartmouth, and the Norris Cotton Cancer Center, Lebanon, NH
| | | | - Martin A. Weinstock
- Professor of Dermatology, The Warren Alpert Medical School of Brown University, Providence, RI
| | - Michael W. Piepkorn
- Division of Dermatology, Department of Medicine, University of Washington School of Medicine, Seattle, WA; Dermatopathology Northwest, Bellevue, WA
| | - Raymond L. Barnhill
- Department of Pathology, Institut Curie, University of Paris Descartes, Paris, France
| | - David E. Elder
- Department of Pathology, University of Pennsylvania, Philadelphia, PA
| | | | - Joann G. Elmore
- Professor of Internal Medicine, University of Washington, Seattle, WA
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25
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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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Bourne T, De Cock B, Wynants L, Peters M, Van Audenhove C, Timmerman D, Van Calster B, Jalmbrant M. Doctors' perception of support and the processes involved in complaints investigations and how these relate to welfare and defensive practice: a cross-sectional survey of the UK physicians. BMJ Open 2017; 7:e017856. [PMID: 29162574 PMCID: PMC5719304 DOI: 10.1136/bmjopen-2017-017856] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVE How adverse outcomes and complaints are managed may significantly impact on physician well-being and practice. We aimed to investigate how depression, anxiety and defensive medical practice are associated with doctors actual and perceived support, behaviour of colleagues and process issues regarding how complaints investigations are carried out. DESIGN A survey study. Respondents were classified into three groups: no complaint, recent/current complaint (within 6 months) or past complaint. Each group completed specific surveys. SETTING British Medical Association (BMA) members were invited to complete an online survey. PARTICIPANTS 95 636 members of the BMA were asked to participate. 7926 (8.3%) completed the survey, of whom 1780 (22.5%) had no complaint, 3889 (49.1%) had a past complaint and 2257 (28.5%) had a recent/current complaint. We excluded those with no complaints leaving 6144 in the final sample. PRIMARY OUTCOMES MEASURES We measured anxiety and depression using the Generalised Anxiety Disorder Scale 7 and Physical Health Questionnaire 9. Defensive practice was assessed using a new measure for avoidance and hedging. RESULTS Most felt supported by colleagues (61%), only 31% felt supported by management. Not following process (56%), protracted timescales (78%), vexatious complaints (49%), feeling bullied (39%) or victimised for whistleblowing (20%), and using complaints to undermine (31%) were reported. Perceived support by management (relative risk (RR) depression: 0.77, 95% CI 0.71 to 0.83; RR anxiety: 0.80, 95% CI 0.74 to 0.87), speaking to colleagues (RR depression: 0.64, 95% CI 0.48 to 0.84 and RR anxiety: 0.69, 95% CI 0.51 to 0.94, respectively), fair/accurate documentation (RR depression: 0.80, 95% CI 0.75 to 0.86; RR anxiety: 0.81, 95% CI 0.75 to 0.87), and being informed about rights (RR depression 0.96 (0.89 to 1.03) and anxiety 0.94 (0.87 to 1.02), correlated positively with well-being and reduced defensive practice. Doctors worried most about professional humiliation following a complaint investigation (80%). CONCLUSION Poor process, prolonged timescales and vexatious use of complaints systems are associated with decreased psychological welfare and increased defensive practice. In contrast, perceived support from colleagues and management is associated with a reduction in these effects.
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Affiliation(s)
- Tom Bourne
- Department of Obstetrics and Gynaecology, Queen Charlotte’s & Chelsea Hospital, Imperial College London, London, UK
- Department of Obstetrics and Gynaecology, University Hospitals Leuven, Leuven, Belgium
- Department of Development and Regeneration, KU Leuven, Leuven, Belgium
| | - Bavo De Cock
- Department of Development and Regeneration, KU Leuven, Leuven, Belgium
| | - Laure Wynants
- Department of Development and Regeneration, KU Leuven, Leuven, Belgium
| | | | | | - Dirk Timmerman
- Department of Obstetrics and Gynaecology, University Hospitals Leuven, Leuven, Belgium
- Department of Development and Regeneration, KU Leuven, Leuven, Belgium
| | - Ben Van Calster
- Department of Development and Regeneration, KU Leuven, Leuven, Belgium
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Kandinov A, Mutchnick S, Nangia V, Svider PF, Zuliani GF, Shkoukani MA, Carron MA. Analysis of Factors Associated With Rhytidectomy Malpractice Litigation Cases. JAMA FACIAL PLAST SU 2017; 19:255-259. [PMID: 28199538 DOI: 10.1001/jamafacial.2016.1782] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Importance This study investigates the financial burden of medical malpractice litigation associated with rhytidectomies, as well as factors that contribute to litigation and poor defendant outcomes, which can help guide physician practices. Objective To comprehensively evaluate rhytidectomy malpractice litigation. Data Sources and Study Selection Jury verdict and settlement reports related to rhytidectomy malpractice litigations were obtained using the Westlaw Next database. Use of medical malpractice in conjunction with several terms for rhytidectomy, to account for the various procedure names associated with the procedure, yielded 155 court cases. Duplicate and nonrelevant cases were removed, and 89 cases were included in the analysis and reviewed for outcomes, defendant specialty, payments, and other allegations raised in proceedings. Data were collected from November 21, 2015, to December 25, 2015. Data analysis took place from December 25, 2015, to January 20, 2016. Results A total of 89 cases met our inclusion criteria. Most plaintiffs were female (81 of 88 with known sex [92%]), and patient age ranged from 40 to 76 years (median age, 56 years). Fifty-three (60%) were resolved in the defendant's favor, while the remaining 36 cases (40%) were resolved with either a settlement or a plaintiff verdict payment. The mean payment was $1.4 million. A greater proportion of cases involving plastic surgeon defendants were resolved with payment compared with cases involving defendants with ear, nose, and throat specialty (15 [36%] vs 4 [24%]). The most common allegations raised in litigation were intraoperative negligence (61 [69%]), poor cosmesis or disfigurement (57 [64%]), inadequate informed consent (30 [34%]), additional procedures required (14 [16%]), postoperative negligence (12 [14%]), and facial nerve injury (10 [11%]). Six cases (7%) involved alleged negligence surrounding a "lifestyle-lift" procedure, which tightens or oversews the superficial muscular aponeurosis system layer. Conclusions and Relevance In this study, although most cases of rhytidectomy malpractice litigation were resolved in the defendant's favor, cases resulting in payments created substantial financial burden for the defendants. Common factors cited by plaintiffs for pursuing litigation included dissatisfaction with cosmetic outcomes and perceived deficits in informed consent. These factors reinforce the importance of a comprehensive, preoperative informed consent process in which the specific potential risks and outcomes are presented by the surgeon to the patient to limit or avoid postsurgical allegations. Intraoperative negligence and facial nerve injury were significantly more likely to result in poor defendant outcomes. Level of Evidence NA.
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Affiliation(s)
- Aron Kandinov
- Department of Otolaryngology-Head and Neck Surgery, Wayne State University School of Medicine, Detroit, Michigan
| | - Sean Mutchnick
- Department of Otolaryngology-Head and Neck Surgery, Wayne State University School of Medicine, Detroit, Michigan
| | - Vaibhuv Nangia
- Department of Otolaryngology-Head and Neck Surgery, Wayne State University School of Medicine, Detroit, Michigan
| | - Peter F Svider
- Department of Otolaryngology-Head and Neck Surgery, Wayne State University School of Medicine, Detroit, Michigan
| | - Giancarlo F Zuliani
- Department of Otolaryngology-Head and Neck Surgery, Wayne State University School of Medicine, Detroit, Michigan2Division of Facial Plastic and Reconstructive Surgery, Wayne State University School of Medicine, Detroit, Michigan
| | - Mahdi A Shkoukani
- Department of Otolaryngology-Head and Neck Surgery, Wayne State University School of Medicine, Detroit, Michigan2Division of Facial Plastic and Reconstructive Surgery, Wayne State University School of Medicine, Detroit, Michigan
| | - Michael A Carron
- Department of Otolaryngology-Head and Neck Surgery, Wayne State University School of Medicine, Detroit, Michigan2Division of Facial Plastic and Reconstructive Surgery, Wayne State University School of Medicine, Detroit, Michigan
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Kapp MB. Defensive medicine: No wonder policymakers are confused. INTERNATIONAL JOURNAL OF RISK & SAFETY IN MEDICINE 2017; 28:213-219. [DOI: 10.3233/jrs-170733] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
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Elmore JG, Longton GM, Pepe MS, Carney PA, Nelson HD, Allison KH, Geller BM, Onega T, Tosteson ANA, Mercan E, Shapiro LG, Brunyé TT, Morgan TR, Weaver DL. A Randomized Study Comparing Digital Imaging to Traditional Glass Slide Microscopy for Breast Biopsy and Cancer Diagnosis. J Pathol Inform 2017; 8:12. [PMID: 28382226 PMCID: PMC5364740 DOI: 10.4103/2153-3539.201920] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2016] [Accepted: 01/18/2017] [Indexed: 01/19/2023] Open
Abstract
Background: Digital whole slide imaging may be useful for obtaining second opinions and is used in many countries. However, the U.S. Food and Drug Administration requires verification studies. Methods: Pathologists were randomized to interpret one of four sets of breast biopsy cases during two phases, separated by ≥9 months, using glass slides or digital format (sixty cases per set, one slide per case, n = 240 cases). Accuracy was assessed by comparing interpretations to a consensus reference standard. Intraobserver reproducibility was assessed by comparing the agreement of interpretations on the same cases between two phases. Estimated probabilities of confirmation by a reference panel (i.e., predictive values) were obtained by incorporating data on the population prevalence of diagnoses. Results: Sixty-five percent of responding pathologists were eligible, and 252 consented to randomization; 208 completed Phase I (115 glass, 93 digital); and 172 completed Phase II (86 glass, 86 digital). Accuracy was slightly higher using glass compared to digital format and varied by category: invasive carcinoma, 96% versus 93% (P = 0.04); ductal carcinoma in situ (DCIS), 84% versus 79% (P < 0.01); atypia, 48% versus 43% (P = 0.08); and benign without atypia, 87% versus 82% (P < 0.01). There was a small decrease in intraobserver agreement when the format changed compared to when glass slides were used in both phases (P = 0.08). Predictive values for confirmation by a reference panel using glass versus digital were: invasive carcinoma, 98% and 97% (not significant [NS]); DCIS, 70% and 57% (P = 0.007); atypia, 38% and 28% (P = 0.002); and benign without atypia, 97% and 96% (NS). Conclusions: In this large randomized study, digital format interpretations were similar to glass slide interpretations of benign and invasive cancer cases. However, cases in the middle of the spectrum, where more inherent variability exists, may be more problematic in digital format. Future studies evaluating the effect these findings exert on clinical practice and patient outcomes are required.
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Affiliation(s)
- Joann G Elmore
- Department of Medicine, University of Washington School of Medicine, Seattle, WA 98104, USA
| | - Gary M Longton
- Fred Hutchinson Cancer Research Center, Seattle, WA 98109, USA
| | - Margaret S Pepe
- Fred Hutchinson Cancer Research Center, Seattle, WA 98109, USA; Department of Biostatistics, University of Washington School of Public Health, Seattle, WA 98104, USA
| | - Patricia A Carney
- Department of Family Medicine, Oregon Health and Science University, Portland, OR 97239, USA
| | - Heidi D Nelson
- Department of Medical Informatics and Clinical Epidemiology, Oregon Health and Science University, Portland, OR 97239, USA; Providence Cancer Center, Providence Health and Services Oregon, Portland, OR 97213, USA
| | - Kimberly H Allison
- Department of Pathology, Stanford University School of Medicine, Stanford, CA 94305, USA
| | - Berta M Geller
- Department of Family Medicine, University of Vermont, Burlington, VT 05405, USA
| | - Tracy Onega
- Department of Biomedical Data Science, Geisel School of Medicine at Dartmouth, Lebanon, NH 03756, USA
| | - Anna N A Tosteson
- The Dartmouth Institute for Health Policy and Clinical Practice, Norris Cotton Cancer Center, Geisel School of Medicine at Dartmouth, Lebanon, NH 03756, USA
| | - Ezgi Mercan
- Department of Computer Science and Engineering, University of Washington, Seattle, WA 98195, USA
| | - Linda G Shapiro
- Department of Computer Science and Engineering, University of Washington, Seattle, WA 98195, USA
| | - Tad T Brunyé
- Department of Psychology, Tufts University, Medford, MA 02155, USA
| | - Thomas R Morgan
- Department of Medicine, University of Washington School of Medicine, Seattle, WA 98104, USA
| | - Donald L Weaver
- Department of Pathology, UVM Cancer Center, University of Vermont, Burlington, VT 05405, USA
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Rayess HM, Gupta A, Svider PF, Raza SN, Shkoukani M, Zuliani GF, Carron MA. A critical analysis of melanoma malpractice litigation: Should we biopsy everything? Laryngoscope 2016; 127:134-139. [DOI: 10.1002/lary.26167] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2016] [Revised: 05/26/2016] [Accepted: 06/06/2016] [Indexed: 01/08/2023]
Affiliation(s)
- Hani M. Rayess
- Department of Otolaryngology-Head and Neck Surgery; Wayne State University School of Medicine; Detroit Michigan U.S.A
| | - Amar Gupta
- Department of Otolaryngology-Head and Neck Surgery; Wayne State University School of Medicine; Detroit Michigan U.S.A
| | - Peter F. Svider
- Department of Otolaryngology-Head and Neck Surgery; Wayne State University School of Medicine; Detroit Michigan U.S.A
| | - S. Naweed Raza
- Department of Otolaryngology-Head and Neck Surgery; Wayne State University School of Medicine; Detroit Michigan U.S.A
- Barbara Ann Karmanos Cancer Institute; Detroit Michigan U.S.A
| | - Mahdi Shkoukani
- Department of Otolaryngology-Head and Neck Surgery; Wayne State University School of Medicine; Detroit Michigan U.S.A
- Division of Facial Plastic and Reconstructive Surgery; Department of Otolaryngology-Head and Neck Surgery, Wayne State University School of Medicine; Detroit Michigan U.S.A
- Barbara Ann Karmanos Cancer Institute; Detroit Michigan U.S.A
- Section of Otolaryngology; Department of Surgery, John D. Dingell VA Medical Center; Detroit Michigan U.S.A
| | - Giancarlo F. Zuliani
- Department of Otolaryngology-Head and Neck Surgery; Wayne State University School of Medicine; Detroit Michigan U.S.A
- Division of Facial Plastic and Reconstructive Surgery; Department of Otolaryngology-Head and Neck Surgery, Wayne State University School of Medicine; Detroit Michigan U.S.A
- Section of Otolaryngology; Department of Surgery, John D. Dingell VA Medical Center; Detroit Michigan U.S.A
| | - Michael A. Carron
- Department of Otolaryngology-Head and Neck Surgery; Wayne State University School of Medicine; Detroit Michigan U.S.A
- Division of Facial Plastic and Reconstructive Surgery; Department of Otolaryngology-Head and Neck Surgery, Wayne State University School of Medicine; Detroit Michigan U.S.A
- Section of Otolaryngology; Department of Surgery, John D. Dingell VA Medical Center; Detroit Michigan U.S.A
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Frederick PD, Nelson HD, Carney PA, Brunyé TT, Allison KH, Weaver DL, Elmore JG. The Influence of Disease Severity of Preceding Clinical Cases on Pathologists' Medical Decision Making. Med Decis Making 2016; 37:91-100. [PMID: 27037007 DOI: 10.1177/0272989x16638326] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2015] [Accepted: 01/30/2016] [Indexed: 01/29/2023]
Abstract
BACKGROUND Medical decision making may be influenced by contextual factors. We evaluated whether pathologists are influenced by disease severity of recently observed cases. METHODS Pathologists independently interpreted 60 breast biopsy specimens (one slide per case; 240 total cases in the study) in a prospective randomized observational study. Pathologists interpreted the same cases in 2 phases, separated by a washout period of >6 months. Participants were not informed that the cases were identical in each phase, and the sequence was reordered randomly for each pathologist and between phases. A consensus reference diagnosis was established for each case by 3 experienced breast pathologists. Ordered logit models examined the effect the pathologists' diagnoses on the preceding case or the 5 preceding cases had on their diagnosis for the subsequent index case. RESULTS Among 152 pathologists, 49 provided interpretive data in both phases I and II, 66 from only phase I, and 37 from phase II only. In phase I, pathologists were more likely to indicate a more severe diagnosis than the reference diagnosis when the preceding case was diagnosed as ductal carcinoma in situ (DCIS) or invasive cancer (proportional odds ratio [POR], 1.28; 95% confidence interval [CI], 1.15-1.42). Results were similar when considering the preceding 5 cases and for the pathologists in phase II who interpreted the same cases in a different order compared with phase I (POR, 1.17; 95% CI, 1.05-1.31). CONCLUSION Physicians appear to be influenced by the severity of previously interpreted test cases. Understanding types and sources of diagnostic bias may lead to improved assessment of accuracy and better patient care.
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Affiliation(s)
- Paul D Frederick
- Department of Medicine, University of Washington School of Medicine, Seattle, WA, USA (PDF, JGE)
| | - Heidi D Nelson
- Providence Cancer Center, Providence Health and Services Oregon, and Departments of Medical Informatics and Clinical Epidemiology and Medicine, Oregon Health & Science University, Portland, OR, USA (HDN)
| | - Patricia A Carney
- Department of Family Medicine, Oregon Health & Science University, Portland, OR, USA (PAC)
| | - Tad T Brunyé
- Center for Applied Brain & Cognitive Sciences, Tufts University, Medford, MA, USA (TTB)
| | - Kimberly H Allison
- Department of Pathology, Stanford University School of Medicine, Stanford, CA, USA (KHA)
| | - Donald L Weaver
- Department of Pathology, University of Vermont and UVM Cancer Center, Burlington, VT, USA (DLW)
| | - Joann G Elmore
- Department of Medicine, University of Washington School of Medicine, Seattle, WA, USA (PDF, JGE)
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Allen TC, Liang BA. Pathologists and liability: an old medical story needing a new ending. Am J Clin Pathol 2015; 144:828-9. [PMID: 26572987 DOI: 10.1309/ajcp7r6xvxoepfah] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
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