On the defensive Litigation fear and its impact on surgical trainees clinical practice

Frances Yarlett1, Jonathan RL Wild2, Adam G Hague3, J Edward F Fitzgerald2 and Goldie Khera2
1 Cardiff

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

Introduction The phenomenon of defensive medicine as a by-product of malpractice fear is controversial. Defensive medicine is defined as medical responses undertaken to prevent liability rather than for the benefit of the patient1. With an increasingly litigious workplace, the reported rates of defensive practice have risen accordingly2. Aims 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. Methods 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 . Results 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. Fear of Litigation 63% of trainees agree that defensive medicine is restrictive to clinical practice. 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.
Diagnostic tests ordered primarily to avoid complaint or litigation over a 6 month period
450 400 Non Invasive Invasive

Prevalence of Defensive Medicine 98% of trainees have observed their consultants and fellow trainees practising defensively.
Reported defensive practice observed amongst fellow trainees
1 10 37 52 Never Rarely Sometimes Often 32

350 300 250 200 150 100

Reported defensive practice observed amongst consultants

2 18 Never Rarely Sometimes Often

50 0 Never 1-3 times 4-6 times 7-9 times 10+ times

48

Male trainees were more likely to alter clinical practice (P=0.048) due to litigation fear.
Percentage of trainees undertaking the following defensive actions primarily to avoid complaint or litigation
100 90 80 70 60 50 40 30 20 10 0

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. 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. Conclusion

91

87

79 65 62 40

Senior Review More Detailed More Detailed Note Keeping Explanation

Admit the Patient

Outpatient Follow-up

Prescribe Unnecessary Drugs

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. References
1. Anderson, R E. Billions for the Defense. Archives of Internal Medicine. 1999 159 (Nov 8) 2. The Medical Protection Society. Casebook. 2011 19 (1) 8-11

The authors would like to acknowledge the Medical Protection Society for their help and support with this study