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PubMed1997

Defensive dental behaviour: illusion or reality?

Defensive medicine or defensive behaviour of physicians is considered a major problem in contemporary health care. It seems reasonable to assume that defensive behaviour also occurs in dental practice, although so far very little has been published in the dental literature on this subject. The main objective of this study was to investigate whether defensive behaviour occurs in dentistry. As a survey study 38 dentists were interviewed: 30 men and 8 women, mainly general dental practitioners with an average of 20.9 years in practice. The results of this pilot-study indicate that it is very likely that defensive behaviour occurs in dental practice, despite the fact that there is hardly any evidence of fear for malpractice claims and lawsuits among the respondents. The majority of the dentists interviewed stated that they carried out some treatments at their patient's request although they did not believe the treatment to be necessary from a professional point of view. A motive for deliberately refraining from treatment is lack of dental motivation by the patient and poor oral hygiene. According to some respondents patients are sometimes referred unnecessarily to specialists. Also 'difficult' patients run the risk of unwarranted referral to specialists, and, moreover referrals because of insurance reasons are mentioned. The financial situation of the patient and the defensive behaviour of dental practitioners seem to be closely connected.

Defensive Medicine↗
PubMed2006

Defensive changes in medical practice and the complaints process: a qualitative study of New Zealand doctors.

AIM: To characterise doctors' responses to complaints. METHOD: Survey of a systematic sample of New Zealand doctors, and indepth interviews with 12 doctors who recently received complaints. RESULTS: 714 written survey responses and 12 indepth interviews revealed changes consistent with positive and negative defensive medicine as well as changes in the direction of "good practice". Positive defensive medicine changes were increased investigation and referral rates, active identification of potential problem patients, over-documentation and consenting, and altered approaches to time and workload. Negative defensive medicine changes involved withdrawal from the doctor-patient relationship and particular fields of practice. Good practice changes included reflective practice, greater sensitivity to societal and professional expectations, and initiating systemic change. CONCLUSIONS: The complaints process in New Zealand has the potential to improve healthcare delivery at a systemic level and to reinforce appropriate standards of professional behaviour, but it may cause individual doctors to practice defensively. Unless an appropriate educational process is allied to the complaints process, defensive medicine may compromise patient care and constrain potential improvements in healthcare delivery overall.

Attitude of Health Personnel↗
PubMed1994

Defensive behavior of Dutch family physicians. Widening the concept.

Defensive medicine is commonly defined as "deviations, induced by a threat of liability, from what the physician believes is, and what is generally regarded as sound medical practice." Although, generally speaking, there is much concern about its prevalence and its consequences for American health care, some authors argue that much of what is passed off as defensive medicine has little to do with fear of lawsuits, because defensive medicine also occurs in countries where malpractice litigation is rare. Studies done in The Netherlands, where there is very little malpractice litigation, indicate that a desire to prevent problems in the doctor-patient relationship is a major cause of defensive behavior by family physicians. We suggest that a wider conceptualization of defensive medicine may improve our understanding of the American situation.

Adaptation, Psychological↗
PubMed1992

["Essential laboratory tests" in primary care medicine--experiences in Comprehensive Medicine, National Defense Medical College].

The "essential laboratory tests" were applied to 1,026 new patients visiting the outpatient unit of Comprehensive Medicine, National Defense Medical College, to determine the usefulness of these tests in primary care medicine. The "essential laboratory tests" have contributed to the establishment of the initial diagnosis or confirmation of the "tentative initial diagnosis", and to the estimation of the nature or degree of seriousness of the disease. In addition, other diseases not related to the patient's chief complaint could be screened in 32% of the new patients examined with these tests. The "essential laboratory tests" were also found to be useful for the estimation of the presence of malignant tumors in 12 patients with various kinds of malignancies as well as the estimation or evaluation for such conditions as infection or inflammation, anemia, liver or renal dysfunction, and the ambulatory screening of metabolic diseases including hyperlipidemia, liver or urinary tract diseases. In conclusion, simultaneous performance of the "essential laboratory tests" with the history taking and the physical examination will provide important medical information in primary care medicine.

Clinical Laboratory Techniques↗
PubMed2000

Choice of cesarean section and perception of legal pressure.

OBJECTIVE: To evaluate the perception of "Defensive Medicine" by hospital based obstetricians and the influence of this attitude on the choice of cesarean delivery. SUBJECTS AND METHODS: Questionnaire sent by mail to a sample (76) of obstetricians of general district, teaching and university hospitals in a region of southern Italy (Puglia). Doctors were selected as the head, the most senior and the most junior specialist of each department. Independent variables of the study were considered as demographic data of the subjects, years of service, interest in private practice, size of the hospital, background cesarean section rate, personal and site of work exposure to legal claims. Outcome measures were experience and confidence in training for operative vaginal and breech delivery, use of the partogram in labor, opinion about a trial of labor after a previous cesarean section and about cesarean section on request, personal perception of defensive medicine. Univariate and multivariate analysis of data were performed. RESULTS: The response rate was 83%. According to our data, seniority in service meant confidence in and request of more teaching of obstetrics manoeuvres, size of hospitals was positively related to a more rationale approach of the diagnosis of dystocia, heads of units were keener to accept the patient's wish for a cesarean section. Doctors with large private practices were less likely to be sued and the perception of legal pressure was directly related to the rate of cesarean section in each unit. DISCUSSION: Defensive Medicine is a reality that encompasses all categories of doctors in this survey. The only differences were in the rate of perception of legal pressure. We believe that residential programs should be modified in order to improve specialists' understanding of malpractice problems and that the patient-doctor relationship should be ameliorated in public hospitals.

Adult↗
PubMed1999

The impact of malpractice fears on cesarean section rates.

A longstanding issue in the health care industry is whether physicians' malpractice fears lead to defensive medicine. We use national birth certificate data from 1990 through 1992 to conduct a county fixed-effects analysis of the impact of malpractice claims risk on cesarean-section rates and infant health. Malpractice claims risk is measured by obstetricians' malpractice premiums. The study provides evidence that physicians practice defensive medicine in obstetrics but that the impact of increased cesarean sections that results from malpractice fears on total obstetric care costs is small. The study also finds that physicians' defensive response varies with the socioeconomic status of the mother.

Cesarean Section↗
PubMed1999

Quality and cost of healthcare: a cross-national comparison of American and Dutch attitudes.

OBJECTIVE: To compare attitudes of consumers in America and Holland toward the quality and cost of healthcare. STUDY DESIGN: Data were derived from one American (n = 466) and two Dutch (n = 260, n = 1629) surveys. PATIENTS AND METHODS: Questionnaires were completed by respondents. Pairwise comparisons requiring respondents to compare statements with one another were used to assess preferences for quality of care. Respondents were asked to "indicate the extent to which each of the factors listed plays a role in placing demands on the American (Dutch) healthcare system." Factors included the public's tendency to consume, high technology, defensive medicine, decrease in informal care, increase in standard diagnostic procedures, and medicalization. RESULTS: Americans reported comparatively greater concern with empathy, whereas the Dutch were more interested in the continuity of care. Effectiveness, knowledge, information, and patient-physician relationships were ranked higher in both nations than waiting time, autonomy, and efficiency. Respondents in both countries attributed the increase in healthcare cost primarily to the high cost of technology. Compared with their Dutch peers, Americans were less likely to attribute increases in the cost of healthcare to the public tendency to consume and to the decrease in informal care and were more likely to implicate defensive medicine and an increase in diagnostic procedures. CONCLUSIONS: As both nations experience pressures to reduce costs while maintaining and augmenting the quality of healthcare, planners and government officials should tailor their approaches to each nation's problems within the context of their public perspectives. Replication of such studies should help assess the impact of changing societal values on healthcare delivery.

Adult↗
PubMed1990

Avoidable claims in the liability experience of Virginia FPs insured by the reciprocal.

In response to the threat of litigation, physicians practice defensive medicine. A more effective means of reducing malpractice liability and improving the quality of patient care is to practice defensible medicine, i.e., those practice patterns that reduce the potential for claims and increase the likelihood that when claims do arise, they can be successfully defended. Unlike hospital-based specialists, family physicians can directly influence a significant portion of their risk of suit. By focusing management time and attention on the factors in their office practices that are linked to malpractice claims activity, family physicians can reduce the likelihood of being involved in claims.

Adult↗
PubMed1992

Treatment decisions for terminally ill patients: physicians' legal defensiveness and knowledge of medical law.

In this study, we investigated physicians' attitudes, knowledge, and reported practices regarding the effects of perceived legal constraints on the abatement of life-sustaining treatment from patients who are clearly dying. A factor in assessing these issues is the concept of defensive medicine -- that is the perception that doctors are being forced to order every possible laboratory test and second opinion, or to continue providing non-beneficial life-sustaining treatment, solely to protect themselves from future legal claims. This perception appears widespread among practicing physicians. However, we believe that defensive medicine represents only part of a complex constellation of factors that comprise physicians' reluctance to abate treatment. This phenomenon encompasses medical, legal, social, psychological, and spiritual factors interacting in ways that are not fully understood. We remain cognizant of the potential impact of all these factors. For purposes of this article, however, we have chosen to focus on legal and psychological aspects of physicians' reluctance to abate treatment and the corresponding ethical implications.

Attitude↗
PubMed1975

Protection against malpractice litigation.

Malpractice insurance costs are based on loss experience and defenses of expenses. Physicians in the high-risk category are in that position because, as a group, they have a high frequency of claims, a high average cost, or both. True, "defensive medicine" is the best way to minimize the risks. This does not mean ordering unnecessary tests or refusal of essential treatment. Rather, it is the habit of exercising extra care and foresight to avoid medical hazards and to apply prompt remedial measures when they occur. It means being aware of the patient's personality and needs. It means taking time to talk to the patient about proposed procedures and their risks. This kind of "defensive medicine" offers the best hope for reducing the frequency and cost of claims that result in the present critical malpractice problems.

Communication↗