Abstract
Introduction
Defensive medicine takes place when healthcare personnel (doctors and nurses) order unnecessary treatments (positive defensive medicine) or avoid high-risk procedures or patients (negative defensive medicine) with the principle—though not exclusive—aim of reducing their expose to damages claims. This phenomenon is directly related to the significant growth in medical malpractice litigation over recent years. Defensive medicine increases the cost of healthcare and may expose patients to unnecessary risks. In fact, the large number of legal initiatives taken by patients have induced many doctors to set in place a defensive “strategy” so as to avoid placing their careers at risk. The threat of medical malpractice litigation constitutes a major obstacle to improving the reliability of healthcare organizations and patient safety.
Method and survey results
This article presents the results of a recent research survey aimed at measuring the frequency of defensive behaviors in a sample of general practitioners and at understanding the reasons for them. 77.9% of the interviewees (responses were received from 30% of the 1,000 general practitioners to whom the questionnaire was sent) declared that they had practiced at least one form of positive defensive medicine during the previous working month. As far as the practice of negative defensive medicine is concerned, 26.2% of the interviewees declared that they had excluded from certain treatments patients subject to risk (i.e. beyond the dictates of a normal level of prudence).
Discussion and conclusion
The phenomenon of defensive medicine is constantly increasing in Italy as in other countries. This increase is caused by the substantial increase in malpractice medical litigation. A punitive approach to error in hospitals encourages the phenomenon of defensive medicine and acts as an obstacle to the detection and reporting of error. This article discusses the factors, such as the blame culture and the increase in medical malpractice litigation, that may lead to defensive behaviors and result in negative effects both in terms of costs and patient safety. A clear need emerges for a different approach—at a cultural, organizational, and legal level—to the problem of medical error, just as in the case of other organizations subject to high risk. The deterrent of punishment does not increase the reliability of such organizations, nor does it improve the level of safety in them.
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Notes
The National Association of Insurance Companies.
Supported by The Italian Society of Surgery.
Hindsight bias has two distinguishing characteristics: 1) the “it was well known” notion, on account of which analysts emphasize what individuals ought to have known and prevented; 2) the lack of awareness of the influence that the knowledge of results exerts on the perception of past events. Thus, the facts appear straightforward and clear as opposed to ambiguous, contradictory and ill-defined, which is how they probably appeared to the actors at the time of the events themselves. Labeling a past action as erroneous is very often a judgment based on a distinct body of information available only after the event has taken place.
Fundamental attribution bias is understood as the tendency that involves attributing blame for negative results to incompetence and inadequacy on the part of the actor in question as opposed to considering them as the product of a specific situation or as the result of situational factors beyond the control of the said actor.
The research was promoted by S.I.C. (Italian Society of Surgery) and conducted by Maurizio Catino and Chiara Locatelli with the “Centro Studi Federico Stella sulla Giustizia Penale e la Politica Criminale” (Milan).
To obtain this figure, a count was first made of the doctors who had replied “Never” to all the questions posed. This number was then subtracted from the total number of interviewees (307). The resulting figure (239) represented those doctors who had adopted at least one form of defensive medicine in the month preceding the interview, i.e. 77.9%.
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Catino, M. Blame culture and defensive medicine. Cogn Tech Work 11, 245–253 (2009). https://doi.org/10.1007/s10111-009-0130-y
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DOI: https://doi.org/10.1007/s10111-009-0130-y