Defensive MedicineAhmed Rashid - 8 Feb, 2018
What does defensive medicine mean to GPs?
This was the research question of a study that caught my eye recently. I’ve often heard colleagues describe decisions as ‘defensive’ but have sometimes wondered whether it’s meant as a compliment or an insult. Are defensive doctors conscientious and thorough? Or are they, in fact, neurotic and wasteful? In a healthcare system struggling financially, and in era of enlightenment about the harms of overtreatment, it certainly doesn’t seem like something that should be encouraged.
The study was from Denmark and was published in the BMJ Open in December 2017. The study sample included experienced GPs, who understood defensive medicine to mean actions performed without medical indication to ‘cover one’s back’ and to secure oneself against patient complaints. Interestingly, however, when the phenomenon was explored in more depth, many of these GPs found that this interpretation underestimated the plethora of daily defensive actions that can take place in general practice.
Most GPs in the study identified ‘the system’ (politicians and health authorities) to be important contributors to their defensive practices and explained that complying with policies against their own clinical judgement was a source of enormous frustration for them. National clinical guidelines were highlighted as an important driver to act defensively, as were government policy initiatives related to quality.
Other factors that the GPs identified as important were patient pressures (including the indirect effect of the media), self pressure (including the desire to minimise fear and uncertainty), and peer pressure (including fear of gossip by hospital colleagues).
The Danish authors conclude that their study “may lead to discussions within the medical establishment about the potential impact of externally imposed policy interventions on GPs’ professional autonomy and sustainability of their work”. These conversations are also desperately needed in the UK and it seems pretty clear that a substantial cultural change will only come about following policy changes at the highest level.
The case of Dr Bawa-Garba has prompted much distress and soul-searching from across the medical profession and made us think about defensive medicine in a new light. I don’t think any GP goes to work wanting to practice ‘defensively’. The reasons why we sometimes do are complex and unfortunately can’t be fixed with a magic wand. So I think the main message from this study is that we shouldn’t be too hard on ourselves. Defensive medicine is just one of a series of challenges that healthcare systems around the world are facing and although we’re grappling with it at the GP coalface, the root causes (and therefore solutions), ultimately lie elsewhere in the system.