Defensive practices among non-medical health professionals: An overview of the scientific literature

Rinaldi, Carmela; D'Alleva, Antonella; Leigheb, Fabrizio; Vanhaecht, Kris; Knesse, Sanita; Stanislao, Francesco Di; Panella, Massimiliano

doi:10.1016/j.jhqr.2018.12.005

Cited by 9 publications

(6 citation statements)

References 43 publications

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“…Despite these ethical problems, hedging-type behaviour is widely reported by physicians and other health professionals across many countries with varying healthcare and legal systems [ 9 , 10 ]. However, empirical research on defensive practice is dominated by quantitative surveys.…”

Section: Introductionmentioning

confidence: 99%

A qualitative interview study of Australian physicians on defensive practice and low value care: “it’s easier to talk about our fear of lawyers than to talk about our fear of looking bad in front of each other”

2022

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Background Defensive practice occurs when physicians provide services, such as tests, treatments and referrals, mainly to reduce their perceived legal or reputational risks, rather than to advance patient care. This behaviour is counter to physicians’ ethical responsibilities, yet is widely reported in surveys of doctors in various countries. There is a lack of qualitative research on the drivers of defensive practice, which is needed to inform strategies to prevent this ethically problematic behaviour. Methods A qualitative interview study investigated the views and experiences of physicians in Australia on defensive practice and its contribution to low value care. Interviewees were recruited based on interest in medico-legal issues or experience in a health service involved in ‘Choosing Wisely’ initiatives. Semi-structured interviews averaged 60 min in length. Data were coded using the Theoretical Domains Framework, which encapsulates theories of behaviour and behaviour change. Results All participants (n = 17) perceived defensive practice as a problem and a contributor to low value care. Behavioural drivers of defensive practice spanned seven domains in the TDF: knowledge, focused on inadequate knowledge of the law and the risks of low value care; skills, emphasising patient communication and clinical decision-making skills; professional role and identity, particularly clinicians’ perception of patient expectations and concern for their professional reputation; beliefs about consequences, especially perceptions of the beneficial and harmful consequences of defensive practice; environmental context and resources, including processes for handling patient complaints; social influences, focused on group norms that encourage or discourage defensive behaviour; and emotions, especially fear of missing a diagnosis. Overall, defensive practice is motivated by physicians’ desire to avoid criticism or scrutiny from a range of sources, and censure from their professional peers can be a more potent driver than perceived legal consequences. Conclusions The findings call for strengthening knowledge and skills, for example, to improve clinicians’ understanding of the law and their awareness of the risks of low value care and using effective communication strategies with patients. Importantly, supportive cultures of practice and organisational environments are needed to create conditions in which clinicians feel confident in avoiding defensive practice and other forms of low value care.

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Section: Introductionmentioning

confidence: 99%

A qualitative interview study of Australian physicians on defensive practice and low value care: “it’s easier to talk about our fear of lawyers than to talk about our fear of looking bad in front of each other”

2022

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“…Previous studies showed that 32.0–53.0% of midwives claimed to have changed their practices in a preventive manner [ 45 , 47 ]. A recent systematic review demonstrated that many DM behaviors were practiced, 41.5% of midwives and nurses reported improving documentation, 7.6% consent gathering for all procedures, and 23.0% said they handle high-risk care cases less [ 48 ]. A study conducted among medical students showed that 94.0% practice DM behaviors [ 49 ].…”

Section: Discussionmentioning

confidence: 99%

The occurrence, types, reasons, and mitigation strategies of defensive medicine among physicians: a scoping review

Kakemam

Arab‐Zozani

Raeissi

et al. 2022

BMC Health Serv Res

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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

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“…Studies have described such practices in Australia, the United States, Israel, Japan, Italy, Belgium, and the United Kingdom, with many studies showing 50 to 95 percent of respondents reporting that they use defensive practices 15 . While most studies of defensive practices have reported their use among doctors, they are also reportedly employed by other health professionals, including nurses, midwives, mental health staff, and aged care workers 16 …”

Section: Managerialism and Unintended Consequencesmentioning

confidence: 99%

Raising the Dead? Limits of CPR and Harms of Defensive Practices

Skowronski¹,

Kerridge²,

Light³

et al. 2022

Hastings Center Report

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We describe the case of an eighty‐four‐year‐old man with disseminated lung cancer who had been receiving palliative care in the hospital and was found by nursing staff unresponsive, with clinically obvious signs of death, including rigor mortis. Because there was no documentation to the contrary, the nurses commenced cardiopulmonary resuscitation and called a code blue, resulting in resuscitative efforts that continued for around twenty minutes. In discussion with the hospital ethicist, senior nurses justified these actions, mainly citing disciplinary and medicolegal concerns. We argue that moral harms arise from CPR performed on a corpse and that legal concerns about failing to perform it are unfounded. We contend that such efforts are an unintended consequence of managerialist policies mandating do‐not‐resuscitate orders and advance care plans and of defensive practices that can value the interests of institutions and practitioners over those of patients. Health management teaching should include managerialism and its pitfalls, while clinician training should prioritize ethical reasoning and legal knowledge over defensive practice.

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Defensive practices among non-medical health professionals: An overview of the scientific literature

Cited by 9 publications

References 43 publications

A qualitative interview study of Australian physicians on defensive practice and low value care: “it’s easier to talk about our fear of lawyers than to talk about our fear of looking bad in front of each other”

A qualitative interview study of Australian physicians on defensive practice and low value care: “it’s easier to talk about our fear of lawyers than to talk about our fear of looking bad in front of each other”

The occurrence, types, reasons, and mitigation strategies of defensive medicine among physicians: a scoping review

Raising the Dead? Limits of CPR and Harms of Defensive Practices

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