7/28/2019 On the defensive Litigation fear and its impact on surgical trainees clinical practice

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On the defensive Litigation fear and its impact on surgical

trainees clinical practiceFrances Yarlett1, Jonathan RL Wild2, Adam G Hague3, J Edward F Fitzgerald2and Goldie Khera2

1 Cardiff Medical School. 2 The Association of Surgeons in Training. 3 Sheffield Medical School.

o Although the majority of trainees agree that defensive medicine is restrictive to medical care., there is a high prevalence of defensive medicine reported

amongst both surgical trainees, with one third of trainees observing their colleagues practising defensive medicine often.

o The vast majority of trainees report observing their current consultant acting defensively, with a perceived loss of a large number of training opportunities

due to consultant trainers acting to reduce he risk of litigation by performing operations rather than allowing a trainee to operate.

o Half of trainees worry about complaints against them and being sued. With the majority of trainees stating that they would not feel supported by their Trust

in the event of a complaint or claim.

o Males are more likely to alter medical practice due to fear of litigation.

o A higher expectation of being sued appears to influence clinical practice.

o Although positive defensive practices were reported, negative defensive practices, especially the large number of invasive diagnostic test requested, is

cause for concern.

References1. Anderson, R E. Billions for the Defense. Archives of Internal Medic ine. 1999 159 (Nov 8)

2. The Medical Protection Society. Casebook. 2011 19 (1) 8-11

Introduction

The phenomenon of defensive medicine as a by-product of malpractice fear is controversial. Defensive medicine is defined as medical responses undertakento prevent liability rather than for the benefit of the patient1. With an increasingly litigious workplace, the reported rates of defensive practice have risen

accordingly2.

The prevalence of, and attitudes towards, defensive medicine amongst UK surgical trainees has not previously been assessed. We therefore aimed to

assess litigation fear amongst current UK surgical trainees and the impact this has on both clinical practice and training.

A self-administered questionnaire was distributed amongst delegates at the 2012 Association of Surgeons in Training (ASiT) annual meeting. This was then

followed up via email to the ASiT membership mailing list using the SurveyMonkey online survey tool. Responses were recorded on a 7-point Likert scale .

581 completed surveys were analysed. (381 male [66%]; 160 Foundation [28%], 170 Core [29%] and 251 [43%] Higher Surgical Trainees (HSTs), from all

surgical specialities and deaneries.

The authors would like to acknowledge the Medical Protection Society

for their help and support with this study

Fear of Litigation

63% of trainees agree that defensive medicine is restrictive to clinicalpractice.

56% agree they worry about a complaint being made, with 52% agreeing

they worry about being sued.

The median number of times a surgical trainee expects to be sued over a

career is 4. Males expect to be sued more often than females (P=0.036).

Impact on Clinical Practice

Surgical trainees reported that, over the 6 months immediately prior

to the survey, they had requested at least 1662 tests primarily to

avoid complaint or litigation, 58% of these tests were non-invasive

and 33% invasive.

Aims

Methods

Results

Conclusion

0

50

100

150

200

250

300

350

400

450

Never 1-3 times 4-6 times 7-9 times 10+ times

Diagnostic tests ordered primarily to avoid complaint orlitigation over a 6 month period

Non Invasive

Invasive

Surgical Training

59% of trainees report being denied an operative training opportunity

due to their consultant acting defensively. This was more apparent in

males (P=0.010).

This is a perceived loss of 1128 training opportunities amongst all

trainees surveyed over a 6 month period.

91 8779

65 62

40

0

10

20

30

40

50

60

70

80

90

100

Senior ReviewMore DetailedNote Keeping

More DetailedExplanation

Admit thePatient

OutpatientFollow-up

PrescribeUnnecessary

Drugs

Percentage of trainees undertaking the following defensiveactions primarily to avoid complaint or litigation

Male trainees were more likely to alter clinical practice (P=0.048) due

to litigation fear.

Prevalence of Defensive Medicine98% of trainees have observed their consultants and fellow trainees

practising defensively.

2

18

48

32

Reported defensive practiceobserved amongst consultants

Never

Rarely

Sometimes

Often

1

10

52

37

Reported defensive practice

observed amongst fellow trainees

Never

Rarely

Sometimes

Often

Trainees attitudes Towards Defensive Medicine

63% of trainees agree that defensive medicine is restrictive to medical practice.

45% do not think that defensive medicine can improve medical standards.48% agree that defensive medicine is detrimental to the doctor patient

relationship.

29% of trainees stated that they would feel supported by their trust in the event of

a complaint or claim being made about them.