Dr Rob Hendry - Medical Protection Society

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8 SPECIAL FEATURE UNITED KINGDOM CASEBOOK | VOLUME 19 | ISSUE 1 | JANUARY 2011 www.mps.org.uk On the defensive Many doctors have an inflated perception of the risk of being sued, so practise with a dagger at their back. Sara Williams asks: are they missing the point? A US student went to her local emergency department suffering from stomach pains. A computed tomography scan revealed an ovarian cyst; she then presented her father with an $8,500 bill. Her father, a medical director, argued that a history, a pelvic examination and an ultrasound would have been adequate. 1 The hospital defended the CAT scan claiming that an ultrasound may have missed something more serious, such as appendicitis or a kidney stone. Although her father agreed, he argued that the hospital should have started with the ultrasound and undertaken the CAT scan only if necessary. He then contacted the national media, accusing the hospital of performing defensive medicine. Do you order every test on every patient? Do you avoid certain procedures for fear of being sued over a clinical stumble? Do you refer every patient with a cough? If you answered “yes” to all of these, you are practising defensive medicine. As global medicine has become more litigious, such performance patterns are becoming more widespread. This “retrospectoscope” phenomenon not only draws attention away from good clinical diagnosis, in favour of tick-box medicine, but it could put patients at risk through risky procedures by medicalising the well patient. 2 WHY DO DOCTORS PRACTISE DEFENSIVELY? Media scrutiny A Casebook survey (see page 9 for more information) revealed that 70% of MPS members identified media criticism of health professionals as a contributing factor to them practising defensively. In countries such as Singapore and Hong Kong, the press are very aggressive and critical of doctors. As most of the work is private practice, such criticism could affect their reputation and thus their income. Non-monetary cost of litigation The personal impact of litigation, such as the value of lost time, emotional energy and reputational damage, is often perceived to be more costly than the cost of taking precautions. 3 Hero complex If a doctor ordered a significant number of tests, where the prevalence of disease was low, they would occasionally pick up on early-stage malignancies and other pathologies, earning them a reputation as a great doctor or a “hero” to patients. Societal expectations Speaking last year at a patient safety conference, internationally-renowned FOTOCROMO/iStockphoto.com
WHAT IS IT? Defensive medicine is commonly defined as the ordering of tests, treatments, etc, to help protect the doctor rather than to further the patient’s diagnosis. Although this is not “unnecessary care”, defensive medicine offers more economic and psychological benefit to the doctor than to the patient. 4 <strong>Dr</strong> David Studdert identified two types of defensive medicine: Assurance behaviour (positive defensive medicine) Many doctors describe litigation as a dagger at their back. However, it is good evidencebased practice, not defensive practice, that will deflect the blade psychologist Professor James Reason said that the worm at the heart of the medical system was that it was predicated on the belief in “trained perfectability”, where doctors are expected to get it right, and if they don’t we “name, shame, blame and retrain” them. Lawyer phobia According to leading psychiatrist <strong>Dr</strong> Tellefsen, who argues that more doctors practise defensively because they fear being sued, an anticipatory attitude could lead to avoidance and overcompensation. 6 “Just in case” A male Emergency Department (ED) registrar, who wishes to remain anonymous, says that many junior doctors request “pointless” blood tests “just in case”, which creates more problems, such as investigating a test that is not needed. This suggests that poor clinical knowledge or lack of experience drives defensive medicine. Colleagues’ expectations According to the same registrar, in ED lots of tests are done because they are expected by other specialties, but are not necessary, eg, ordering a chest x-ray for someone who has angina, or testing the blood of a child with a broken arm, in case the surgeon asked for the results, even though this is not evidence-based. HOW PREVALENT IS IT? What is defensive medicine to one person may be high quality care to another. 7 An international Casebook survey (see Box A overleaf) asked more than 3,000 MPS members from seven countries whether they practised defensively to avoid complaints and claims. The key findings were: ■ 73% said they practised defensively to avoid complaints and claims ■ 77% said they practised more defensively now than in the past ■ 78% noticed their colleagues practising defensively, eg, ordering more tests than were medically necessary. The survey attempted to find out how this translated into clinical practice, and identify what practices doctors – providing services of no medical value with the aim of reducing adverse outcomes, or persuading the legal system that the standard of care was met, eg, ordering tests, referring patients, increased follow up, prescribing unnecessary drugs. Avoidance behaviour (negative defensive medicine) – reflects doctors’ attempts to distance themselves from sources of legal risk, eg, forgoing invasive procedures, removing high-risk patients from lists. 5 were adopting to avoid complaints and claims. These statistics show: ■ 41% had chosen to stop dealing with certain conditions/ performing specific procedures to avoid complaints and claims ■ 37% changed prescribing habits ■ 61% conducted more investigations. However, not all examples of defensive medicine can be considered negative. The following statistics demonstrate “positive” defensive medicine: ■ 54% referred more patients for a second opinion ■ 76% were more careful to ensure follow-up arrangements were in place ■ 83% kept more detailed records. The results suggested that female doctors were more cautious than their male colleagues, as women referred more patients for a second opinion, kept more detailed records and were more careful to follow up than their male counterparts. The results also indicated that male doctors practise more negative defensive medicine, compared to female doctors. They conducted more investigations and had a lower threshold for removing patients from lists, and more of them chose to stop dealing with certain procedures than their female colleagues. Other surveys and reports suggest that defensive medicine is a prevailing aspect of healthcare. According to Kessler it might add as much as 5% to 9% to overall health costs in some countries. 8 A widely-used example of defensive practice is the dramatic increase in caesarean sections, which have more than doubled in the UK over the last 20 years. A UK study explored the view of 151 clinical directors about why this was the case. One of the top three reasons given was the fear of litigation. Three in five respondents thought the local rate was too high. 9 Last year, an American study looked at the issue of overtesting in late-stage cancer for the first time; it raised questions about overtreatment in healthcare. It identified a “culture of screening on autopilot”, where cancer patients with advanced cancers were being screened for other cancers that couldn’t possibly kill them. 10 Another factor linked to this is the increased risk CT scans pose 9 SPECIAL FEATURE UNITED KINGDOM CASEBOOK | VOLUME 19 | ISSUE 1 | JANUARY 2011 www.mps.org.uk
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Page 3 and 4: ON THE COVER 8 On the defensive Whe
Page 5 and 6: EVENT FOCUS: SOUTH AFRICA Doctors o
Page 7: Images courtesy of The National Arc
Page 11 and 12: Be open about error Dr Aidan O’Do
Page 13 and 14: There is concern that “too much
Page 15 and 16: Introducing… Membership Governanc
Page 17 and 18: Missed opportunities Daniel Miss R
Page 19 and 20: To operate or not to operate? Mr B,
Page 21 and 22: Repeat offender kastock/iStockphoto
Page 23 and 24: A pain in the buttock stefanolunard
Page 25 and 26: see the benefits of careful return
Page 27 and 28: MPS Risk Solutions Knowledge… Exp

Dr Rob Hendry - Medical Protection Society

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