Defensive practice among psychiatrists: a questionnaire survey

Abstract

Objective: There has been little research on the prevalence of defensive practice within hospital settings. The aim of this report was to examine the extent of defensiveness among psychiatrists and to examine the relationship between defensiveness and seniority, as well as the effect of previous experiences on the level of defensiveness. Design: A postal questionnaire survey on defensive practice. Setting: Northern Region of England. Subjects: 154 psychiatrists in the region. Results: 96 responses were received from 48 equivalent consultants, 18 specialist registrars, and 23 equivalent senior house officers. Overall, 75% of those who replied had taken defensive actions within the past month. In particular, 21% had admitted patients overcautiously and 29% had placed patients on higher levels of observations. Junior psychiatrists were particularly prone to practise defensively. Important contributing factors included previous experience of complaints (against colleague or self), critical incidents, and legal claims. Conclusion: Almost three quarters of the psychiatrists who responded had practised defensively within the past month. The higher propensity of junior trainees to practise defensively may be attributable to their lack of confidence and experience. Experience of complaints (colleague or self) and critical incidents were important factors for defensive practice. Better and more structured training might reduce the high level of defensive practice and the way complaints and investigations are handled should be improved to maintain a truly "no blame" environment conducive to learning from past experience.A "no blame" and learning culture is essential for the delivery of quality health care, 1 2 but the close examination of practitioners' practice required for a learning culture might result in defensive practice. One definition of defensive practice is the "ordering of treatments, tests and procedures for the purpose of protecting the doctor from criticism rather than diagnosing or treating the patient". 3It has been proposed that there are both positive and negative aspects of defensive practice. 4 Examples of positive aspects might include improvements in the quality of services with more detailed explanations being given to patients and increased patient satisfaction. Examples of negative aspects might include the prescription of unnecessary treatments, increased observation levels of inpatients, and increased rates of follow up.Although defensive practice has been examined in the USA and Canada, 5-8 few such studies had been carried out in the UK until the 1990s. In high risk specialties such as obstetrics, the majority of obstetricians and midwives believe that litigation has caused a rise in defensiveness.9 However, defensive practice is common even among general practitioners, who are commonly regarded as being in a low risk specialty, with 98% claiming to have made some practice changes as a result of the possibility of a patient complaining. 4 A survey of all consultants in the Oxford Regional Heal...

Uncertainty and risk assessment

“…Within this climate, there is an argument that psychiatrists respond to uncertainty by practising defensively (Coid & Cordess, 1992) and adopting a conservative approach, defined as preferring to err on the side of caution, overstating rather than understating risk (Perhac, 1996). This has been supported by empirical evidence (Passmore & Leung, 2002), both in general and forensic psychiatry (Webster et al, 1982) and in the broader risk literature, where it has been suggested that a precautionary risk management style is more likely when encountering uncertainty (Klinke & Renn, 2002). Furthermore, such a conservative approach has been associated with the tendency to overpredict violence, which Buchanan (1999: p. 468) suggests may occur, among other reasons, because 'clinicians would rather detain someone who will not be violent than release someone who will be'.…”

Professionally Responsible Malpractice Reform

“…Defensive medicine, by definition, is intended for our own benefit and only incidentally, if at all, the patient's. 1,[7][8][9][10][11][12][13][14][15][16] Yet physicians who self-report defensive medical practices do so quite unblushingly and with no sense that their behavior could be challenged as lacking in professionalism. 17,18 They appear not to regard practicing defensively as a choice; rather they appear to see it as being forced upon them by circumstances.…”

Análisis de las sentencias judiciales en la práctica de la cardiología resueltas en segunda instancia en España entre 1992 y 2007

“…En Inglaterra un cuestionario enviado a mé dicos psiquiatras identificó que un 75% de los profesionales había realizado medicina defensiva en el mes anterior 12 . Sin embargo, la actitud defensiva no parece ser la solució n a este problema.…”