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ORIGINAL ARTICLE
Year : 2018  |  Volume : 6  |  Issue : 1  |  Page : 30-38

Defensive practice among psychiatrists in middle East Countries: A questionnaire survey


Department of Psychiatry, College of Medicine, Majmaah University, Al Majmaah, Kingdom of Saudi Arabia

Date of Web Publication8-Jan-2018

Correspondence Address:
Abdulrahman A Al-Atram
Department of Psychiatry, College of Medicine, Al Majmaah University, Al Majmaah
Kingdom of Saudi Arabia
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DOI: 10.4103/jhs.JHS_87_17

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  Abstract 

Purpose: Increasing medicolegal litigations, claims and compensation have forced doctors to make some defensive changes in their practice. This study was conducted to examine the prevalence of defensive practice among psychiatrists in Middle Eastern countries along with examining the relationship of defensiveness with seniority and previous medicolegal experiences.
Methods: A questionnaire with thirteen questions was shared among 215 psychiatrists practicing in Middle Eastern countries. The collected data were analysed statistically using SPSS version 21.
Results: Ninety-two valid responses were received and analysed, out of which sixty-two of them were from Saudi Arabia. An overall 30% (n = 28/92) of the psychiatrists have taken a defensive action in their practice in the past one month. Nearly 28% (n = 26/92) of them approved unwanted patient admission, 30% (n = 28/92) kept the patient on a higher observation. Both these defensive actions are less prevalent among the senior psychiatrists. While 24% (n = 22/92) and 30% (n = 28/92) of psychiatrists had written specific remarks such as “not suicidal” and dictated letters more than necessary for managing patient's illness, respectively, and this behaviour was more prevalent among senior psychiatrists.
Conclusion: An overall 30% (n = 28/92) of the psychiatrists have taken a defensive action in their practice over the past one month. Knowledge and experience of previous medicolegal issues were important factors influencing the defensive practice. The propensity of junior psychiatrists to practice defensively may be attributed to decreased confidence. More systematic problem-based training, proper guidelines for practice insurance and more clarity and transparency in the investigation and handling of medicolegal issues may help reduce the defensive practice and improve better patient care.

Keywords: Defensive practice, litigations, medical practice, medicolegal issue, negligence, practice insurance


How to cite this article:
Al-Atram AA. Defensive practice among psychiatrists in middle East Countries: A questionnaire survey. J Health Spec 2018;6:30-8

How to cite this URL:
Al-Atram AA. Defensive practice among psychiatrists in middle East Countries: A questionnaire survey. J Health Spec [serial online] 2018 [cited 2018 Jul 22];6:30-8. Available from: http://www.thejhs.org/text.asp?2018/6/1/30/222467


  Introduction Top


In the early days, the medical profession by large was self-regulated. Treatment was accepted in general by the face value, experience, judgement, and reputation of the doctor himself. As time passed, the knowledge, awareness, expectations about the medical treatment and undesirable outcomes of the treatment increased among the general public, which changed their attitude towards the medical profession. This has posed a challenge to the professional judgement and integrity of the doctor; forcing him to take some defensive measures in his medical practice. Because in the court of law, the data provided by investigations are more acceptable rather than the claims of experience and medical judgements, which resulted in the defensive use of diagnostic tests.[1] There are both good and bad aspects of defensive practice. Some of the good aspects are the enhanced quality of services with good explanations being given to patients resulting in increased patient satisfaction. Some bad aspects might include suggesting unnecessary investigations, prescription of unnecessary treatments, unwarranted higher observation levels of in-patients and prolonged follow-up.[2] According to McQuade, defensive medicine is advocating investigations, treatments in the form of prescribing drugs or procedures for the sake of protecting the doctor himself rather than for the well-being of the patient. Other measures also included the tendency to avoid or reduce the high-risk procedures in practice. The three major factors of medicolegal litigation that bother the physicians are the possibility for litigation, a claim resulting in financial liability and the amount of settlement. Increasing medicolegal litigation increased the defensive practice among doctors in various specialties of medicine. Medicolegal litigation is prevalent in all of the specialties of medicine. The specialists in Neurosurgery, Obsteristics and General Surgery face more claims, but the specialists in relatively less riskier branches such as Pathology and Paediatrics face litigations with much higher payment size. A study done in the US showed that there was 7.4% of malpractice claim, but only 1.6% of them resulted in financial settlement, which means only 22% of the claims were successful. Medicolegal claim is more prevalent in medical specialties like Neurosurgery (19.1%), Cardiothoracic Surgery (18.9%), General Surgery (15.3%) and to a lesser level of 2.6% in Psychiatry.[3] Doctors who have faced a medicolegal claim undergo emotional stress, a feeling of helplessness, anger, guilt, shame, lack of confidence and may quit the profession. In a study conducted among obstetricians in Madinah, Saudi Arabia, 83% of participants suffered depression, 90% of the female participants developed family problems and 15% considered a change of profession.[4] The effect of perceived litigation threat can alter the doctor's behaviour itself. To establish an environment that does not encourage the defensive practice, New Zealand has established a no-fault legislation by which medical practitioners are rarely sued. However, the study conducted among psychiatrists and psychiatric nurses in New Zealand showed that the factors other than financial liability like emotional effects of the patient's suicide, negative attitude towards the mental healthcare workers also lead to the defensive practice.[5] The doctors can get practice insurance only to compensate in case of a claim settlement, whereas he needs to face the indirect effects such as emotional stress, loss of time and loss of reputation in his medical service. To the author's knowledge, there is no published study revealing the prevalence of defensive practice among psychiatrists in the Middle Eastern countries and the result of such a study may help in planning measures to reduce the defensive actions and promote better medical care.


  Methods Top


This study has been conducted in Riyadh province of Saudi Arabia between August 2016 and March 2017. A questionnaire with thirteen questions were made after semi-structured interviews and approved by a panel of psychiatrists and statisticians and the study design and questionnaire was approved by the Institutional Ethical Committee of Majmaah University. The questionnaire included three general questions regarding their number of years of psychiatric practice, designation, the country of practice and no other personal details were collected. Four questions were about defensive practice and remaining six questions were regarding the participant's previous experience with medicolegal issues. The questionnaire was shared among a group of around 215 psychiatrists practicing in the Middle Eastern countries. The collected data were statistically analysed using the SPSS software version 21 (IBM Corp. SPSS for Windows, Version 21.0. Armonk, NY). For group comparison, Pearson's Chi-square test was used and the level of significance P < 0.05 was considered as statistically significant [Questionnaire] [Additional file 1].


  Results Top


A total of 92 valid responses were received, 62 of them being from Saudi Arabia, eight each from Egypt and UAE, six from Oman, four from Jordan and one each from Bahrain, Qatar, Turkey and Kuwait. The analysis of the data showed that 30% (n = 28/92) of the participants had taken a defensive action in their practice over the past one month. [Table 1] shows 28% (n = 26/92) of them admitted patients to the hospital when the patient's condition could be managed in the community or as an outpatient. There is a lesser number of unwanted admission of patients by the psychiatrists with more years of experience when compared to the junior psychiatrists. Than the juniors and has statistically significant Chi-square value about 24.803a and the P = 0.003. It is also evident that 30% (n = 28/92) of psychiatrists kept the patient on a higher observation than warranted by patient's condition. It is less prevalent among the psychiatrists with more years of experience than juniors and has a statistically significant Chi-square value of 35.79a and the 0.000. P = 0.000. While 24% (n = 22/92) and 30% (n = 28/92) of psychiatrists have written specific remarks such as 'not suicidal' and dictated letters more than necessary for managing patient's illness, respectively. This behaviour is more prevalent among senior psychiatrists and has a statistically significant Chi-square value of 34.529, 44.818 and 0.001, 0.000 P values, respectively. In [Table 2], there is a statistically significant difference between position and the prevalence of defensive practice, such as placing the patient on a higher level of observation, writing specific remarks such as 'not suicidal' and dictating letters more than necessary with a Chi-square value 73.130, 46.119, 107.250 and P = 0.000, 0.004 and 0.000, respectively. [Table 3] shows that out of 92 participants, 62 are from Saudi Arabia and constituted the major group (67.4%) of the study sample and had defensive action in the form of unwarranted admission of patients (n = 18/62), showing a statistically significant Chi-square value of 25.660 and a P = 0.004. In [Table 4], the senior group of psychiatrists had more awareness regarding the previous complaints against their colleagues, the previous claims involving colleagues and the previous critical events. While the previous experience of complaint against self is more significant among the junior group. Whereas the previous claim against self and the concern about media are equally prevalent among both the groups. There are statistically significant Chi-square values of 9.045, 8.711 and P = 0.029, 0.033 for the categories of the previous legal claim involving self and previous legal claim involving colleagues, respectively.
Table 1: Relation between number of years of experience and defensive action

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Table 2: Relation between position and defensive action

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Table 3: The relation of country of practice and defensive practice

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Table 4: Number of years of psychiatric experience and previous medico-legal issues

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  Discussion Top


In the present study, out of 92 respondents, 62 were from Saudi Arabia and constituted the majority of the study population. As the numbers of participants were less from other Middle Eastern countries, drawing a conclusion on the prevalence of defensive practice separately for each country becomes insignificant. In the present study, an overall 30% of the participated psychiatrists have taken a defensive action in their practice over the past one month. This result is in contrary to the study conducted among mental health clinicians in New Zealand, which showed a high percentage (85%) of defensive practice.[6] [Table 1] shows that 28% of the participants admitted patients to hospital when the patient's condition could have been managed in the community or as an outpatient, 30% of the participants placed patients on a higher level of observation than warranted by patient's condition, 24% have written in patient records specific remarks such as 'not suicidal' and 28% dictated letters unnecessarily for managing patient illness. These findings correlate with a study conducted in the UK, where 75% of the psychiatrists reported to have practiced defensively within the previous month. Nearly 21% had admitted patients overcautiously, and 29% had placed patients at a higher level of observation.[7] In a study conducted in Sudan among obstetricians and gynecologists for identifying their defensive practices, showed unnecessary referral to be the most common (23.1%), followed by avoidance of high-risk procedures (20.5%) and ordering of unnecessary tests (12%) and unnecessary prescription of drugs (6%) and refusal to treat high-risk patients (5.1%).[8] The present study clearly shows that the prevalence of defensive practices like unwarranted admission and higher level of observation were less among senior psychiatrists while writing lengthy notes and specific comments such as “non-suicidal” were more prevalent among senior psychiatrists than juniors. This is in accordance with the study conducted in Israel where 62.1% of participants practiced defensively and also showed the tendency of the younger psychiatrists to report defensive behaviour and practice defensive medicine than senior psychiatrists, whereas studies in other specialties failed to show such age or experience-related factor for defensive practice.[9],[10] [Table 2] shows the comparison between the designation or position of the psychiatrist and the prevalence of defensive practice. There is a clear indication of less prevalent defensive practice among specialists working as hospital consultants and senior consultants working in private clinics and hospital probably due their rich exposure to such incidents and their confidence in handling these issues in their day-to-day practice. On the other hand, a higher prevalence of defensive practice among positions such as the lecturer, assistant professor, and professor may be attributed to the fear of criticism from fellow colleagues, students and higher authorities. A similar study in the UK showed that it is not the age or experience which matters, but that those in the grades of consultant are more confident in their skills and practiced less defensively.[10] [Table 3] shows that out of 92 participants, 62 are from Saudi Arabia and constituted the major group (67.4%) of the study sample and had defensive action in the form of unwarranted admission of patients (n = 18/62), which showed a statistically significant Chi-square value of 25.660 and a P = 0.004. This study attains more importance as it is the first of its kind to add information on defensive practice among psychiatrists in Middle Eastern countries. [Table 4] shows the relation between the number of years of practice and their awareness about medicolegal issues. The senior group of psychiatrists were more aware about the previous complaints against their colleagues, claims involving their colleagues and previous critical events. The previous experience of complaints against self was found to be more in the junior group, whereas the previous claims against self and the concern about media are equally prevalent among both the groups. A study conducted in Australia showed that within the previous one year, 34% of psychiatrists faced a legal action, 39% of them answered a formal complaint, 67% faced verbal or physical abuse by patients or their relatives and 29% faced patient suicide.[11] Suicide is a major event in patients with borderline personality disorder with the resulting medicolegal litigation a major concern for the psychiatrist.[12] Many studies conducted to evaluate the incidence of suicide in psychiatric practice and its effect on the life of practicing psychiatrists showed that 51% – 68% of participated psychiatric consultants experienced having one of their patients commit suicide and suffered personal trauma in the form of lack of sleep, depression and irritability.[13],[14],[15] In a study conducted in the UK, the participant doctors reported that they felt helpless, emotionally traumatised, and also experienced hatred towards the patients and those managing the complaints.[16] In the field of Obstetrics in the USA, the midwives and obstetricians believed that litigation has caused increased defensiveness in the clinical practice.[17] The defensive practice of ordering unnecessary tests, referral and treatment can add up to increased medical care for the patient.[18],[19] In the study conducted among general practitioners, the positive defensive actions taken include more detailed note-taking, more detailed explanation about procedures to the patients, and increased screening of patients and development of audits within the practice.[20] Increased litigation rates and insurance premiums have led to the increased dissatisfaction and pressure to reform the medical profession inside out.[21] A study from Saudi Arabia showed a steady rise of medicolegal litigation from 440 cases in 1999 to 1356 in 2008 and the highest litigation observed in the field of Obstetrics (255%) followed by General Surgery (13.8%).[22] In another study from Saudi Arabia, medicolegal litigation in Anesthesia practice accounted to 3.8% of total litigations and in 9.1% of cases legal claim was awarded against the anesthetist.[23] Undoubtedly, the increase in medicolegal litigation increased the defensive practice in all specialties of medicine which has resulted in high cost of patient care and has changed the mindset of medical practitioners, which needs to be addressed for better patient care.[24]


  Conclusion Top


This study records that 30% of the participated psychiatrists in the Middle Eastern countries had practiced defensively. The propensity of junior psychiatrists to practice more defensively than seniors may be attributed to their decreased confidence and less experience. A psychiatrist working in higher positions such as hospital consultants and senior consultants in private clinics and hospitals are practicing less defensively. Knowledge and experience of previous medicolegal issues (to colleagues/self) were important factors influencing the defensive practice. More systematic problem-based training, proper guidelines for practice insurance and more clarity and transparency in the investigation and handling of medicolegal issues may help in reducing the defensive practice and improve better patient care.

Limitations

The finding from this study should be generalized with caution in context of Middle Eastern countries, since 67% of the participants are from Saudi Arabia and remaining 33% represent participants from eight countries. The study employed the questionnaire, which does not include many other defensive practices such as unnecessary investigations and medications. Furthermore, this study had a limited sample size. Future studies employing more sample size may add knowledge to this much needed aspect of practice for better patient care.

Acknowledgements

The authors would like to thank Dr. Jacob Kuruvilla for the statistical analysis done for the study and Prof. Dr. S. Karthiga Kannan for proof reading of the manuscript.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
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  [Table 1], [Table 2], [Table 3], [Table 4]



 

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