Acta Clinica Belgica International Journal of Clinical and Laboratory Medicine
ISSN: 1784-3286 (Print) 2295-3337 (Online) Journal homepage: http://www.tandfonline.com/loi/yacb20
Defensive medicine: implications for clinical practice, patients and healthcare policy T. Vandersteegen, W. Marneffe & D. Vandijck To cite this article: T. Vandersteegen, W. Marneffe & D. Vandijck (2015) Defensive medicine: implications for clinical practice, patients and healthcare policy, Acta Clinica Belgica, 70:6, 396-397, DOI: 10.1179/2295333715Y.0000000037 To link to this article: http://dx.doi.org/10.1179/2295333715Y.0000000037
Published online: 03 Jul 2015.
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Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=yacb20 Download by: [Orta Dogu Teknik Universitesi]
Date: 02 April 2016, At: 06:06
Original Paper
Defensive medicine: implications for clinical practice, patients and healthcare policy T. Vandersteegen1, W. Marneffe1, D. Vandijck2,3,4 Faculty of Applied Economics, Hasselt University, Belgium, 2Faculty of Medicine and Life Sciences, Hasselt University, Belgium, 3Department of Public Health, Ghent University, Belgium, 4Department of General Internal Medicine, Ghent University Hospital, Belgium 1
Downloaded by [Orta Dogu Teknik Universitesi] at 06:06 02 April 2016
Keywords: Defensive medicine, Non-disclosure, Quality of care, Healthcare costs, Adverse event
Background
Despite all quality improving initiatives, healthcare is inherently hazardous. In Belgium, patients who experienced a ‘medical error’ (preferably named an incident or adverse event) can claim compensation in court for the harm suffered. From a physicians’ perspective, this ‘threat’ for a potential lawsuit might drive them towards practicing defensive medicine. Accordingly, the government introduced a medical malpractice system reform, the aspects and impact of which many physicians are still uninformed, to overcome the shortcomings of court-based procedures. A survey among a large cohort of Belgian physician specialists revealed that one out of seven respondents, aware of the reform, had subsequently increased their defensive practices.1 In literature, these defensive practices are mainly considered counterproductive outcomes of the medical malpractice system, as they negatively impact healthcare costs, access and quality of care. Nonetheless, currently a lot of controversy exists regarding physicians’ defensive practices. Proactive information is, therefore, highly needed to get physicians, and also (hospital) management,2 better informed.
What is Defensive Medicine?
Defensive medicine is defined as ‘physicians ordering tests, procedures or visits, or avoiding high-risk patients and/or procedures, primarily (but not necessarily solely) to reduce their risk of malpractice liability’.3 In literature, these actions to reduce the liability risk are often referred to as positive and negative defensive medicine. On the one hand, physicians may want to safeguard themselves by increasing the referrals, follow-up visits, diagnostic and invasive testing, drugs prescription, and the use of patient safety tools as they may be afraid of an incorrect or a delayed diagnosis or want to assure themselves of doing Correspondence to: T. Vandersteegen, Martelarenlaan 42, 3500 Hasselt, Belgium. Email: [email protected]
© 2015 Acta Clinica Belgica DOI 10.1179/2295333715Y.0000000037
everything they can, from a medical point of view (i.e. positive defensive medicine).4 On the other hand, physicians may want to avoid interventions or procedures that are perceived as being high-risk by declining certain patients or restrict their practices (i.e. negative defensive medicine). The latter terminology is often confusing, since positive defensive practices may cause negative effects and vice versa. Therefore, the terms ‘assurance’ and ‘avoidance’ behaviour are ideally used to distinguish both types of defensive practices. Above all, the perception of what constitutes a defensive action can evolve over time. For instance, if a certain procedure is increasingly performed purely based on the threat of a potential lawsuit, over time this way of practicing could be considered as the standard of care instead of defensive practicing.5
Assessing the Impact of Defensive Medicine
The lack of studies on defensive medicine in general, and in Belgium in particular can be explained by the fact that it is difficult to accurately assess whether and to what extent physicians behave defensively. The results of existing studies on defensive medicine should therefore be treated with caution. Nonetheless, if it were possible to precisely measure the extent of defensive medicine, the next step would be to determine whether these practices have beneficial or adverse effects, both from a patient and policy perspective. However, merely the identification of the potential adverse and beneficial effects associated with physicians’ defensive practices proves to be complex, let alone the quantification of these effects. First, defensive medicine could initiate unnecessary care and even adverse effects, such as the ordering of extra laboratory tests, medical imaging, (non)invasive procedures and second opinions to confirm a diagnosis (assurance behaviour), and as such increase healthcare resources use. For example, among a cohort of patients suffering severe chronic heart failure, it was found that the
Acta Clinica Belgica 2015 VOL. 70
NO.
6
396
Downloaded by [Orta Dogu Teknik Universitesi] at 06:06 02 April 2016
Vandersteegen et al. Defensive medicine
costs associated to defensive medicine accounted for up to 10% of total healthcare costs.6 Above all, these ‘unnecessary’ acts might be harmful for patients as well, and consequently, impact patient safety. Also, avoiding high-risk procedures and patients (avoidance behaviour) decreases accessibility to care.7 This delay of receiving adequate treatment may also impact costs, since patients could end up in a more expensive treatment option. Additionally, physicians who fear a malpractice claim could stop applying new experimental treatments such as jeopardising innovation in healthcare. On the other hand, defensive practices may also have beneficial effects. As a result of the threat of a potential claim, physicians may be stimulated to better document the care provided in the patient record, provide additional explanation and intensified follow-up to patients.8 The quality of care might even improve rather than worsen if the avoidance of malpractice risk leads to clinical services that would be only performed by a small group of dedicated and (sub)specialised physicians treating those patients with seldom and/or highly complex case-mix.9 Above, more intensive diagnosis and follow-up may lead to improved quality of care, and as such to better patient outcome.10,11 For example, diseases may coincidentally be detected due to unnecessary testing. Hence, the occurrence of medical incidents as well as the number of malpractice lawsuits could decline.
Non-disclosing Behaviour as Defensive Medicine
Traditional defensive medicine is regarded as physicians altering their clinical decision making because of the threat of medical liability and takes place before a potential adverse event. In this context, however, little attention has been given to how physicians behave after the occurrence of an adverse event. Disclosing medical incidents can be challenging for physicians. Although they are often advised to only provide factual information and avoid discussing any attribution of responsibility, practitioners still find it difficult to acknowledge adverse events before colleagues and patients,12 and fear damage to the physician–patient relationship. Not surprisingly, though, physicians also fear retaliatory actions, such as professional sanctions or lawsuits. The existing punitive culture of dealing with medical incidents and the absence of blame-free reporting systems may prevent physicians from telling a patient that something went wrong, even if high quality care was delivered. This is regrettable, since open communication about medical incidents is of great importance for patient safety and healthcare quality. Disclosing adverse events to patients may even reduce the risk of a medical lawsuit for physicians, as patients often merely want to be informed about what happened
during and after the treatment that led to the injury. The unwillingness to report medical incidents by physicians, i.e. non-disclosure, should therefore definitely be regarded as defensive behaviour as well.
Conclusion
Defensive medicine is very case- and speciality-dependent, and can be beneficial as well as counterproductive, whether focussing on quality of care, patient safety or healthcare expenditures. Although physicians’ defensive behaviours and their effects are rather hard to determine and quantify, accurate measurement of these practices is necessary for the benefit of policy makers, healthcare management and professionals. This also includes considering non-disclosure of adverse events by physicians as defensive behaviour. The lack of conclusive evidence on defensive behaviour and the recent medical malpractice reform in Belgium therefore necessitate further research on defensive medicine.
Disclaimer Statements Funding None. Conflicts of interest None. Ethics approval None required.
References 1 Vandersteegen T, Marneffe W, Lierman S, De Gendt T, Cleemput I, Vandijck D, et al. Invloed van het Belgische vergoedingssysteem voor medische ongevallen op het gedrag van artsen. T. Gez. 2014–15; 5:331 –346. 2 Van Dijck H. Hospital doctors behave differently, and only by respecting the fundamentals of professional organizations will managers be able to create common goals with professionals. Acta Clin Belg. 2014;69(4):309–11. 3 OTA Office of Technology Assessment. Defensive medicine and medical malpractice. Washington, DC: US Government Printing Office; 1994. 4 Vandijck D, Bergs J. The WHO surgical safety checklist: an innovative or an irrelevant tool?Acta Chir Belg. 2014; 114(4): 225–27. 5 Studdert DM, Mello MM, Sage WM, DesRoches CM, Peugh J, Zapert K, et al.Defensive medicine among high-risk specialist physicians in a volatile malpractice environment. JAMA. 2005;293(21):2609–17. 6 Kessler DP, McClellan M. Do doctors practice defensive medicine?Q J Econ. 1996;111(2):353–90. 7 Mello MM, Studdert DM, DesRoches CM, Peugh J, Zapert K, Brennan TA, et al.Effects of a malpractice crisis on specialist supply and patient access to care. Ann Surg. 2005;242(5):621. 8 Summerton N. Positive and negative factors in defensive medicine: a questionnaire study of general practitioners. BMJ. 1995;310(6971):27–9. 9 Black N. Medical litigation and the quality of care. Lancet. 1990;335(8680):35–7. 10 Trybou J, Spaepen E, Vermeulen B, Porrez L, Annemans L. Costs associated with readmissions in Belgian acute-care hospitals. Acta Clin Belg. 2013;68(4):263–7. 11 Trybou J, Spaepen E, Vermeulen B, Porrez L, Annemans L. Hospitalacquired infections in Belgian acute-care hospitals: financial burden of disease and potential cost savings. Acta Clin Belg. 2013;68(3):199– 205. 12 Finkelstein D, Wu AW, Holtzman NA, Smith MK. When a physician harms a patient by a medical error: ethical, legal, and risk-management considerations. J Clin Ethics. 1996;8(4):330–5.
Acta Clinica Belgica 2015 VOL. 70
NO.
6
397
ISSN: 1784-3286 (Print) 2295-3337 (Online) Journal homepage: http://www.tandfonline.com/loi/yacb20
Defensive medicine: implications for clinical practice, patients and healthcare policy T. Vandersteegen, W. Marneffe & D. Vandijck To cite this article: T. Vandersteegen, W. Marneffe & D. Vandijck (2015) Defensive medicine: implications for clinical practice, patients and healthcare policy, Acta Clinica Belgica, 70:6, 396-397, DOI: 10.1179/2295333715Y.0000000037 To link to this article: http://dx.doi.org/10.1179/2295333715Y.0000000037
Published online: 03 Jul 2015.
Submit your article to this journal
Article views: 23
View related articles
View Crossmark data
Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=yacb20 Download by: [Orta Dogu Teknik Universitesi]
Date: 02 April 2016, At: 06:06
Original Paper
Defensive medicine: implications for clinical practice, patients and healthcare policy T. Vandersteegen1, W. Marneffe1, D. Vandijck2,3,4 Faculty of Applied Economics, Hasselt University, Belgium, 2Faculty of Medicine and Life Sciences, Hasselt University, Belgium, 3Department of Public Health, Ghent University, Belgium, 4Department of General Internal Medicine, Ghent University Hospital, Belgium 1
Downloaded by [Orta Dogu Teknik Universitesi] at 06:06 02 April 2016
Keywords: Defensive medicine, Non-disclosure, Quality of care, Healthcare costs, Adverse event
Background
Despite all quality improving initiatives, healthcare is inherently hazardous. In Belgium, patients who experienced a ‘medical error’ (preferably named an incident or adverse event) can claim compensation in court for the harm suffered. From a physicians’ perspective, this ‘threat’ for a potential lawsuit might drive them towards practicing defensive medicine. Accordingly, the government introduced a medical malpractice system reform, the aspects and impact of which many physicians are still uninformed, to overcome the shortcomings of court-based procedures. A survey among a large cohort of Belgian physician specialists revealed that one out of seven respondents, aware of the reform, had subsequently increased their defensive practices.1 In literature, these defensive practices are mainly considered counterproductive outcomes of the medical malpractice system, as they negatively impact healthcare costs, access and quality of care. Nonetheless, currently a lot of controversy exists regarding physicians’ defensive practices. Proactive information is, therefore, highly needed to get physicians, and also (hospital) management,2 better informed.
What is Defensive Medicine?
Defensive medicine is defined as ‘physicians ordering tests, procedures or visits, or avoiding high-risk patients and/or procedures, primarily (but not necessarily solely) to reduce their risk of malpractice liability’.3 In literature, these actions to reduce the liability risk are often referred to as positive and negative defensive medicine. On the one hand, physicians may want to safeguard themselves by increasing the referrals, follow-up visits, diagnostic and invasive testing, drugs prescription, and the use of patient safety tools as they may be afraid of an incorrect or a delayed diagnosis or want to assure themselves of doing Correspondence to: T. Vandersteegen, Martelarenlaan 42, 3500 Hasselt, Belgium. Email: [email protected]
© 2015 Acta Clinica Belgica DOI 10.1179/2295333715Y.0000000037
everything they can, from a medical point of view (i.e. positive defensive medicine).4 On the other hand, physicians may want to avoid interventions or procedures that are perceived as being high-risk by declining certain patients or restrict their practices (i.e. negative defensive medicine). The latter terminology is often confusing, since positive defensive practices may cause negative effects and vice versa. Therefore, the terms ‘assurance’ and ‘avoidance’ behaviour are ideally used to distinguish both types of defensive practices. Above all, the perception of what constitutes a defensive action can evolve over time. For instance, if a certain procedure is increasingly performed purely based on the threat of a potential lawsuit, over time this way of practicing could be considered as the standard of care instead of defensive practicing.5
Assessing the Impact of Defensive Medicine
The lack of studies on defensive medicine in general, and in Belgium in particular can be explained by the fact that it is difficult to accurately assess whether and to what extent physicians behave defensively. The results of existing studies on defensive medicine should therefore be treated with caution. Nonetheless, if it were possible to precisely measure the extent of defensive medicine, the next step would be to determine whether these practices have beneficial or adverse effects, both from a patient and policy perspective. However, merely the identification of the potential adverse and beneficial effects associated with physicians’ defensive practices proves to be complex, let alone the quantification of these effects. First, defensive medicine could initiate unnecessary care and even adverse effects, such as the ordering of extra laboratory tests, medical imaging, (non)invasive procedures and second opinions to confirm a diagnosis (assurance behaviour), and as such increase healthcare resources use. For example, among a cohort of patients suffering severe chronic heart failure, it was found that the
Acta Clinica Belgica 2015 VOL. 70
NO.
6
396
Downloaded by [Orta Dogu Teknik Universitesi] at 06:06 02 April 2016
Vandersteegen et al. Defensive medicine
costs associated to defensive medicine accounted for up to 10% of total healthcare costs.6 Above all, these ‘unnecessary’ acts might be harmful for patients as well, and consequently, impact patient safety. Also, avoiding high-risk procedures and patients (avoidance behaviour) decreases accessibility to care.7 This delay of receiving adequate treatment may also impact costs, since patients could end up in a more expensive treatment option. Additionally, physicians who fear a malpractice claim could stop applying new experimental treatments such as jeopardising innovation in healthcare. On the other hand, defensive practices may also have beneficial effects. As a result of the threat of a potential claim, physicians may be stimulated to better document the care provided in the patient record, provide additional explanation and intensified follow-up to patients.8 The quality of care might even improve rather than worsen if the avoidance of malpractice risk leads to clinical services that would be only performed by a small group of dedicated and (sub)specialised physicians treating those patients with seldom and/or highly complex case-mix.9 Above, more intensive diagnosis and follow-up may lead to improved quality of care, and as such to better patient outcome.10,11 For example, diseases may coincidentally be detected due to unnecessary testing. Hence, the occurrence of medical incidents as well as the number of malpractice lawsuits could decline.
Non-disclosing Behaviour as Defensive Medicine
Traditional defensive medicine is regarded as physicians altering their clinical decision making because of the threat of medical liability and takes place before a potential adverse event. In this context, however, little attention has been given to how physicians behave after the occurrence of an adverse event. Disclosing medical incidents can be challenging for physicians. Although they are often advised to only provide factual information and avoid discussing any attribution of responsibility, practitioners still find it difficult to acknowledge adverse events before colleagues and patients,12 and fear damage to the physician–patient relationship. Not surprisingly, though, physicians also fear retaliatory actions, such as professional sanctions or lawsuits. The existing punitive culture of dealing with medical incidents and the absence of blame-free reporting systems may prevent physicians from telling a patient that something went wrong, even if high quality care was delivered. This is regrettable, since open communication about medical incidents is of great importance for patient safety and healthcare quality. Disclosing adverse events to patients may even reduce the risk of a medical lawsuit for physicians, as patients often merely want to be informed about what happened
during and after the treatment that led to the injury. The unwillingness to report medical incidents by physicians, i.e. non-disclosure, should therefore definitely be regarded as defensive behaviour as well.
Conclusion
Defensive medicine is very case- and speciality-dependent, and can be beneficial as well as counterproductive, whether focussing on quality of care, patient safety or healthcare expenditures. Although physicians’ defensive behaviours and their effects are rather hard to determine and quantify, accurate measurement of these practices is necessary for the benefit of policy makers, healthcare management and professionals. This also includes considering non-disclosure of adverse events by physicians as defensive behaviour. The lack of conclusive evidence on defensive behaviour and the recent medical malpractice reform in Belgium therefore necessitate further research on defensive medicine.
Disclaimer Statements Funding None. Conflicts of interest None. Ethics approval None required.
References 1 Vandersteegen T, Marneffe W, Lierman S, De Gendt T, Cleemput I, Vandijck D, et al. Invloed van het Belgische vergoedingssysteem voor medische ongevallen op het gedrag van artsen. T. Gez. 2014–15; 5:331 –346. 2 Van Dijck H. Hospital doctors behave differently, and only by respecting the fundamentals of professional organizations will managers be able to create common goals with professionals. Acta Clin Belg. 2014;69(4):309–11. 3 OTA Office of Technology Assessment. Defensive medicine and medical malpractice. Washington, DC: US Government Printing Office; 1994. 4 Vandijck D, Bergs J. The WHO surgical safety checklist: an innovative or an irrelevant tool?Acta Chir Belg. 2014; 114(4): 225–27. 5 Studdert DM, Mello MM, Sage WM, DesRoches CM, Peugh J, Zapert K, et al.Defensive medicine among high-risk specialist physicians in a volatile malpractice environment. JAMA. 2005;293(21):2609–17. 6 Kessler DP, McClellan M. Do doctors practice defensive medicine?Q J Econ. 1996;111(2):353–90. 7 Mello MM, Studdert DM, DesRoches CM, Peugh J, Zapert K, Brennan TA, et al.Effects of a malpractice crisis on specialist supply and patient access to care. Ann Surg. 2005;242(5):621. 8 Summerton N. Positive and negative factors in defensive medicine: a questionnaire study of general practitioners. BMJ. 1995;310(6971):27–9. 9 Black N. Medical litigation and the quality of care. Lancet. 1990;335(8680):35–7. 10 Trybou J, Spaepen E, Vermeulen B, Porrez L, Annemans L. Costs associated with readmissions in Belgian acute-care hospitals. Acta Clin Belg. 2013;68(4):263–7. 11 Trybou J, Spaepen E, Vermeulen B, Porrez L, Annemans L. Hospitalacquired infections in Belgian acute-care hospitals: financial burden of disease and potential cost savings. Acta Clin Belg. 2013;68(3):199– 205. 12 Finkelstein D, Wu AW, Holtzman NA, Smith MK. When a physician harms a patient by a medical error: ethical, legal, and risk-management considerations. J Clin Ethics. 1996;8(4):330–5.
Acta Clinica Belgica 2015 VOL. 70
NO.
6
397
