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PubMed1998

[Recent disciplinary committee rulings foster defensive medicine].

Recent medicolegal rulings corrected practitioners for not applying all possible interventions in the care of acute rare conditions. The performance was judged negligent, not on the clinical information available at the time, but in the light of the later course of disease. This paper argues that quality assurance requires a system of critical self and peer assessment, superimposed on medicolegal judgement. In all instances performance should be set against (external) criteria, including guidelines. Guidelines, in particular for general practice, define optimal care, to entitle patients to what is relevant while at the same time protecting them from ill-advised interventions. The point is made that the medicolegal ruling must be based on the same criteria that govern self and peer group assessment, and not on whatever it might be possible to do (maximal criteria), to prevent quality assurance from leading to defensive practice.

Acute Disease↗
PubMedDate not supplied

Defensive medicine and obstetrics.

OBJECTIVE: To test the hypothesis that physicians with greater malpractice claims exposure, either through personal experience or in their practice environment, will use more prenatal resources and have a higher cesarean delivery rate than physicians with lesser claims exposure. DESIGN: Retrospective cohort study using county malpractice defendant rate data from the Washington State Physicians Insurance and Exchange Association and prenatal care, delivery method, and self-reported obstetric suit experience data from the Content of Obstetrical Care Study database. SETTING: Washington State obstetric practices. PARTICIPANTS: Stratified random samples of obstetrician-gynecologists and family physicians. MAIN OUTCOME MEASURES: The rates of obstetric ultrasound use, referral and consultation, prenatal care resource use, and cesarean delivery. RESULTS: After controlling for patient, physician, and sociodemographic characteristics, we found no difference in prenatal resource use or cesarean delivery rate for low-risk patients between physicians with more and less exposure to malpractice claims. CONCLUSIONS: This study does not support an association between the malpractice experience or exposure of individual physicians and an increase in the use of prenatal resources or ceserean deliveries for the care of low-risk obstetric patients.

Cesarean Section↗
PubMed1985

Defensive medicine in diabetic nephropathy.

Conventional insulin treatment fails to prevent the development of disabling and fatal complications in most patients with Type I diabetes. Improved metabolic control is achievable today with fractional insulin doses, or wearable pumps permitting continuous subcutaneous insulin infusion. None of the euglycemia regimens in hand for 1984 are easy or successful uniformly. Careful insulin administration by pumps or in fractional daily doses demands that the patient make expensive and time-consuming multiple finger stick blood glucose measurements each day. But, considering the high stakes involved in the gamble to permit suboptimal glucose regulation, it seems no longer rational to regard hyperglycemia as any more inevitable in the diabetic, than was "laudable pus" in the post-operative patient of yesteryear. Nearly constant euglycemia can be attained in many informed Type I diabetics. There are few complications in a tight control regimen, and patients feel better when their blood glucose level approaches the normal range most of the time. Should the long-term control versus complications trials now beginning show that the effort to maintain euglycemia was futile, little will have been lost. But, by stark contrast, if the euglycemia regimen is efficacious, how shall we console this generation of diabetics who, under "poor" glucose regulation, were the last to progress to uremia and blindness when trials now in progress are completed?

Animals↗