A qualitative interview study of Australian physicians on defensive practice and low value care: “it’s easier to talk about our fear of lawyers than to talk about our fear of looking bad in front of each other”

Ries, NM; Johnston, B; Jansen, J

A qualitative interview study of Australian physicians on defensive practice and low value care: “it’s easier to talk about our fear of lawyers than to talk about our fear of looking bad in front of each other”

Ries, NM Johnston, B Jansen, J

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Publisher:: Springer Science and Business Media LLC
Publication Type:: Journal Article
Citation:: BMC Medical Ethics, 2022, 23, (1)
Issue Date:: 2022-12

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Field	Value	Language
dc.contributor.author	Ries, NM
dc.contributor.author	Johnston, B
dc.contributor.author	Jansen, J
dc.date.accessioned	2022-03-06T20:27:08Z
dc.date.available	2022-03-06T20:27:08Z
dc.date.issued	2022-12
dc.identifier.citation	BMC Medical Ethics, 2022, 23, (1)
dc.identifier.issn	1472-6939
dc.identifier.uri	http://hdl.handle.net/10453/154995
dc.description.abstract	<jats:title>Abstract</jats:title><jats:sec> <jats:title>Background</jats:title> <jats:p>Defensive practice occurs when physicians provide services, such as tests, treatments and referrals, mainly to reduce their perceived legal or reputational risks, rather than to advance patient care. This behaviour is counter to physicians’ ethical responsibilities, yet is widely reported in surveys of doctors in various countries. There is a lack of qualitative research on the drivers of defensive practice, which is needed to inform strategies to prevent this ethically problematic behaviour.</jats:p> </jats:sec><jats:sec> <jats:title>Methods</jats:title> <jats:p>A qualitative interview study investigated the views and experiences of physicians in Australia on defensive practice and its contribution to low value care. Interviewees were recruited based on interest in medico-legal issues or experience in a health service involved in ‘Choosing Wisely’ initiatives. Semi-structured interviews averaged 60 min in length. Data were coded using the Theoretical Domains Framework, which encapsulates theories of behaviour and behaviour change.</jats:p> </jats:sec><jats:sec> <jats:title>Results</jats:title> <jats:p>All participants (n = 17) perceived defensive practice as a problem and a contributor to low value care. Behavioural drivers of defensive practice spanned seven domains in the TDF: knowledge, focused on inadequate knowledge of the law and the risks of low value care; skills, emphasising patient communication and clinical decision-making skills; professional role and identity, particularly clinicians’ perception of patient expectations and concern for their professional reputation; beliefs about consequences, especially perceptions of the beneficial and harmful consequences of defensive practice; environmental context and resources, including processes for handling patient complaints; social influences, focused on group norms that encourage or discourage defensive behaviour; and emotions, especially fear of missing a diagnosis. Overall, defensive practice is motivated by physicians’ desire to avoid criticism or scrutiny from a range of sources, and censure from their professional peers can be a more potent driver than perceived legal consequences.</jats:p> </jats:sec><jats:sec> <jats:title>Conclusions</jats:title> <jats:p>The findings call for strengthening knowledge and skills, for example, to improve clinicians’ understanding of the law and their awareness of the risks of low value care and using effective communication strategies with patients. Importantly, supportive cultures of practice and organisational environments are needed to create conditions in which clinicians feel confident in avoiding defensive practice and other forms of low value care.</jats:p> </jats:sec>
dc.language	en
dc.publisher	Springer Science and Business Media LLC
dc.relation	Avant Foundation
dc.relation.ispartof	BMC Medical Ethics
dc.relation.isbasedon	10.1186/s12910-022-00755-2
dc.rights	info:eu-repo/semantics/openAccess
dc.subject	2201 Applied Ethics
dc.subject.classification	Applied Ethics
dc.title	A qualitative interview study of Australian physicians on defensive practice and low value care: “it’s easier to talk about our fear of lawyers than to talk about our fear of looking bad in front of each other”
dc.type	Journal Article
utslib.citation.volume	23
utslib.for	2201 Applied Ethics
pubs.organisational-group	/University of Technology Sydney
pubs.organisational-group	/University of Technology Sydney/Faculty of Law
pubs.organisational-group	/University of Technology Sydney/Strength - HJ - Health Justice
utslib.copyright.status	open_access	*
dc.date.updated	2022-03-06T20:27:07Z
pubs.issue	1
pubs.publication-status	Published online
pubs.volume	23
utslib.citation.issue	1

Abstract:

Abstract Background Defensive practice occurs when physicians provide services, such as tests, treatments and referrals, mainly to reduce their perceived legal or reputational risks, rather than to advance patient care. This behaviour is counter to physicians’ ethical responsibilities, yet is widely reported in surveys of doctors in various countries. There is a lack of qualitative research on the drivers of defensive practice, which is needed to inform strategies to prevent this ethically problematic behaviour. Methods A qualitative interview study investigated the views and experiences of physicians in Australia on defensive practice and its contribution to low value care. Interviewees were recruited based on interest in medico-legal issues or experience in a health service involved in ‘Choosing Wisely’ initiatives. Semi-structured interviews averaged 60 min in length. Data were coded using the Theoretical Domains Framework, which encapsulates theories of behaviour and behaviour change. Results All participants (n = 17) perceived defensive practice as a problem and a contributor to low value care. Behavioural drivers of defensive practice spanned seven domains in the TDF: knowledge, focused on inadequate knowledge of the law and the risks of low value care; skills, emphasising patient communication and clinical decision-making skills; professional role and identity, particularly clinicians’ perception of patient expectations and concern for their professional reputation; beliefs about consequences, especially perceptions of the beneficial and harmful consequences of defensive practice; environmental context and resources, including processes for handling patient complaints; social influences, focused on group norms that encourage or discourage defensive behaviour; and emotions, especially fear of missing a diagnosis. Overall, defensive practice is motivated by physicians’ desire to avoid criticism or scrutiny from a range of sources, and censure from their professional peers can be a more potent driver than perceived legal consequences. Conclusions The findings call for strengthening knowledge and skills, for example, to improve clinicians’ understanding of the law and their awareness of the risks of low value care and using effective communication strategies with patients. Importantly, supportive cultures of practice and organisational environments are needed to create conditions in which clinicians feel confident in avoiding defensive practice and other forms of low value care.

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http://hdl.handle.net/10453/154995