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SHORT COMMUNICATION  
Year : 2021  |  Volume : 46  |  Issue : 4  |  Page : 752-756
 

Defensive medicine practice in different specialties among junior physicians in kasralainy hospitals, Egypt


1 Department of Family Medicine, Faculty of Medicine, Cairo University, Giza, Egypt
2 Department of Forensic Medicine and Clinical Toxicology, Faculty of Medicine, Cairo University, Giza, Egypt

Date of Submission27-Feb-2021
Date of Acceptance04-Sep-2021
Date of Web Publication08-Dec-2021

Correspondence Address:
Dr. Marwa Diaaeldeen Abbass Hasan
Department of Family Medicine, Faculty of Medicine, Cairo University, Giza
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijcm.IJCM_143_21

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   Abstract 


Background: Defensive medicine has great impact on medical practice and population health. It may provide enhanced quality of services with good explanations to patients resulting in increased satisfaction. On the other hand, it might include unnecessary investigations, prescription of unnecessary treatments which may be expensive or dangerous for patients. Aim of Work: This study aims to evaluate awareness and practice of defensive medicine among junior doctors in Cairo University Hospital. Methods: This cross-sectional study includes 261 junior physicians by interviewing them using a structured questionnaire. Results: Defensive medicine practice is highly affected by sociodemographic characteristics of study population. Almost half the female doctors are always giving extra details about the medication use (56%) P < 0.001. Around 90% of both specialties have not been involved in medical litigation. Conclusions: Defensive medicine is highly prevalent among junior physicians. Following clinical standards and fear of legal actions by patients are considered main causes of practice of defensive medicine.


Keywords: Defensive medicine, medical liability, medical litigations


How to cite this article:
Abbass Hasan MD, Shokry DA, Mahmoud RH, Ahmed MM. Defensive medicine practice in different specialties among junior physicians in kasralainy hospitals, Egypt. Indian J Community Med 2021;46:752-6

How to cite this URL:
Abbass Hasan MD, Shokry DA, Mahmoud RH, Ahmed MM. Defensive medicine practice in different specialties among junior physicians in kasralainy hospitals, Egypt. Indian J Community Med [serial online] 2021 [cited 2022 Jan 27];46:752-6. Available from: https://www.ijcm.org.in/text.asp?2021/46/4/752/331965





   Introduction Top


Defensive medicine is defined as the overuse of the resources such as ordering unnecessary investigations, giving treatment, or performing procedures aiming at doctors' self-protection against claims rather than for the patient best interest.[1]

There are two types of defensive medicine: negative defensive medicine includes high-risk patients or procedures avoidance, while positive defensive medicine such as ordering unnecessary procedures and treatments,[2] which are done primarily out of fear of malpractice liability risk.[3] By definition, malpractice is the breach by a member of profession of either a standard of care or a standard of conduct.[4]

Malpractice claims have a great effect on the doctor's financial aspect and reputation. It also has an impact on his professional advancement and career.[5] Egypt, as a developing country, faces the medical malpractice problem but the data are deficient regarding the magnitude of the problems. However, the Egyptian Medical Syndicate sets new regulations in 2013 regarding the good medical practice in professional medical ethics.[6] The defensive medicine practice differs from a country to another affected by the surrounding circumstances.[7]

The defensive medicine practice usually results from the physician's sense of uncertainty, fear of liability, and poor outcomes. This usually directs the physicians to do unnecessary procedures that are not only increase the health-care expenses but also expose the patients to the risk of more hazardous interventions.[8] Some physicians use the expensive screening tools to avoid the feeling of low self-esteem and losing their reputation inside their community.[9] This could be the reflection of increased claims in the Greater Cairo wherein the period from 1973 to 1979, there were only 64 claims recorded that increased to be 2043 cases from 2000 to 2003.[7],[10]

This sharp increase in the number of medical claims can be based upon the increased citizen's awareness by his rights and could be affected by the presence of the specialized lawyers who encourage the patients to raise lawsuits for financial compensations.[11]

Defensive medicine puts a high financial burden over different healthcare systems. In Italy, 10% of spent health-care resources were due to defensive medicine practice.[12] It affects the individuals before birth as it leads to increase the C-sections rate over the normal vaginal deliveries as a known pattern of defensive medicine practice.[1],[13]

Objectives

  1. To evaluate awareness and practice of defensive medicine among junior doctors at KasrAlAiny hospital
  2. To explore reasons of defensive medicine practice.



   Methods Top


This is a cross-sectional study conducted in 261 junior doctors of different specialties in Cairo University Hospitals from February 2019 to October 2019. A sample of 261 junior doctors in different specialties where obtained, among a total of 23 clusters (departments) in the KasrAlAiny hospital, 35% cluster sample (8 clusters including general surgery, gynecology, neurosurgery, cardiothoracic surgery, internal medicine, neurology, cardiology, and chest medicine) was determined using the Open Epi program (Brixton Health/EpiCalc 2000 Website: http://www.brixtonhealth.com)(Gilman, J., and M. Myatt.1998. EpiCalc 2000. Version 1.02. Brixton Books, London, United Kingdom), then EpiCalc 2000 (EpiCalc. exe.) was used to calculate the sample size. Assuming 80% power, 0.05 level of significance, 84% null hypothesis value, and estimated proportion of 90%, the sample size was calculated to be 261.

Ethical approval was obtained from the Research and Ethical Committee of Cairo University.

A five domain-based questionnaire was designed by the researchers after reviewing the literature viz. sociodemography, defensive medicine behaviour, medical litigation experience, defensive medicine practice and perception of good practice.

The participants were interviewed by the researcher after signing an informed written consent. The concept of the defensive medicine was elaborated first, and then, they were asked to fill up the above-designed questionnaire.

Data were statistically described in terms of mean, standard deviation, or frequencies (number of cases) and percentages when appropriate. For comparing categorical data, Chi-square (2) test was performed. Exact test was used when the expected frequency was less than <5. P <0.05 was considered statistically significant. All statistical calculations were done using computer program (Statistical Package for the Social Science, SPSS Inc., Chicago, IL, USA) release 15 for Microsoft Windows (2006).


   Results Top


The age of the majority of participants was between 26 and 30 years (77.0%) and 166 (63.6%) were females. The doctors are almost equally distributed between medical and surgical specialties. Almost all physicians got primary medical qualification and postgraduate qualification only from Egypt. Around 90% of participants do not have insurance against professional errors.

The most common form of positive defensive medicine practice was taking extra details about disease. Around half of participants (55.9%) often take extra details about disease and (36.1%) always do it. The second most common form was following up success of management. Around 57 of participants (57.9%) often follow-up success of management and (33.3%) always follow-up success of management. The least common form was recommendation of unnecessary medication, investigation, and referral. About half of participants do not recommend unnecessary medication, investigation, and referral. The most common form of practicing negative defensive medicine was avoiding high-risk procedures then avoiding high-risk patient where 24.5% of doctors always avoid high-risk procedures and 17.6% avoid high-risk patient.

[Table 1] shows statistically difference between male and female physicians and specialists in different defensive medicine behaviors.
Table 1: Comparison regarding defensive medicine behavior

Click here to view


[Table 2] shows statistically significant difference between the medical and surgical specialties regarding the medical litigations experience. Around 90% of both specialties in different genders have not been involved in medical litigation. Almost half the medical specialty physicians can accept patient previously involved in medical litigation opposite only 38.3% of the surgical specialty that showed statistically significant difference.
Table 2: Comparison regarding medical litigations experience

Click here to view


[Table 3] shows statistically significant difference between medical and surgical specialties regarding the reason for defensive medicine practice where 52.6% of the surgeons consider that the legal concern by the patient is the reason for the defensive medicine practice opposite 28.5% only of the physicians.
Table 3: Comparison regarding defensive medicine practice reasons

Click here to view


Table 4 shows statistically significant difference between the medical and surgical specialties where 4.4% of the surgical physicians considered that defensive medicine is more expensive than medical litigation costs opposite 19.4% in the medical specialty.
Table 4: Comparison regarding good practice perception

Click here to view



   Discussion Top


Many forms of practicing defensive medicine were explored in our study. The most common forms of practicing positive defensive medicine were taking extra details about disease and following up success of management, while the most common form of practicing negative defensive medicine was avoiding high risk procedures followed by avoiding high risk patient.

This was concordant with the study conducted by Hasan et al. in Bahrain who evaluated the practicing of defensive medicine among primary care doctors. They concluded that most common forms of practicing defensive medicine were taking extra detail history (66.4%), ordering more test than called for (60.0%), and avoid risky procedures and interventions (59.1%).[7]

Our results are also in agreement with another study conducted in 2016 in Sudan by Ali et al. They stated that 41% reported practicing positive defensive medicine while 30.8% reported practicing negative one. Arranging unnecessary recommendation including referral, investigation, medication, surgery (cesarean section) was the most common form of defensive medicine.[14]

Another study conducted in Iran concluded that the frequency of defensive medicine was high in the studied population and that most participants showed negative behaviors in their work such as not prescribing risky methods to cure patients, avoiding admitting high-risk patients, prescribing unnecessary clinical procedures, prescribing unnecessary treatment, prescribing unnecessary medicines and patients' unnecessary referral to specialists.[15] This highlights the importance of increasing the physicians' awareness to avoid the unnecessary usage of the available resources to overcome uncertainties encountered in the clinical practice.

The present study shows that there is statistical significance between the practice of different forms of defensive medicine and gender. This is concordant with the study conducted in Bahrain in 2018 which revealed that females practiced defensive medicine significantly higher than male physicians.[7] Another study conducted in Iran in 2014 concluded that negative defensive medicine was more common in female physicians than in their male counterpart (83.6% vs. 76%) and this difference was statistically significant (P = 0.04).[15]

Ortashi et al. in 2013 found no significant relation between litigation and gender.[16] On the other hand, our study shows that 68.4% of male physicians have been involved in medical litigations, while around half of female physicians have been involved in medical litigations. This is may be due to fact that females tend give extra details about the disease and recommend unnecessary (referral, investigation, and medications) more than males in our study.

Many studies suggested that there is significant association between medical litigation and specialty. However, our study did not show any significant different in the medical litigation among different specialties.

Kamel et al. conducted a study in 2015 to evaluate malpractice claims in Dakhalia and Damietta Governorates in Egypt. It was concluded that anesthesia represented the highest percentage of claims followed by general surgery then gynecology and obstetrics, orthopedics, and ophthalmology.[6] On the other hand, Sherief in 2005 found that claims against general surgeons were the most frequent followed by obstetricians and gynecologists in the Greater Cairo. Moreover, the most recurrent positive cases were against obstetricians and gynecologists.[11] This was not the case in the study conducted in Japan in 2005, where the internal medicine was the most frequently affected specialty followed by general surgery then gynecology and obstetrics.[1]

In our study, 46.9% of participants who work at both medical and surgical specialties and their colleagues have been involved in medical litigations.

It is recommended to develop effective programs and interventions to educate medical staff about proper practice of defensive medicine. Further research is needed to investigate the costs of defensive medicine and medical litigations in Egypt.


   Conclusions Top


Defensive medicine practice is common among our study participants. Taking extra details about disease and following up success of management are the common forms of the defensive medicine identified in this study. There is statistical significance difference between the practice of different forms of defensive medicine and gender.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Lykkegaard J, Andersen MK, Nexøe J, Hvidt EA. Defensive medicine in primary health care. Scand J Prim Health Care 2018;36:225-6.  Back to cited text no. 1
    
2.
Catino M. Blame culture and defensive medicine. Cogn Technol Work 2009;11;245.  Back to cited text no. 2
    
3.
Clark JR. Defensive medicine. Air Med J 2015;34;314-6.  Back to cited text no. 3
    
4.
Available from: https://legal-dictionary.thefreedictionary.com/ Malpractice. [Last accessed on 2019 May 05].  Back to cited text no. 4
    
5.
Stamm JA, Korzick KA, Beech K, Wood KE. Medical malpractice: Reform for today's patients and clinicians. Am J Med 2016;129:20-5.  Back to cited text no. 5
    
6.
Kamel FA, El-Bakary AA, Attalla SM, El-Azab SM, Eldeek BS, Ali MA et al. Malpractice claims in Dakhalia and Damietta governorates: A 10 year evaluation study. Forensic Res Criminol Int J 2015;1:00033.  Back to cited text no. 6
    
7.
Hasan B, Abdulrahim H, AlMukhtar M, AlAsfoor R, Mandeel M, Aub M, et al. The practice of defensive medicine by doctors in primary health care in the Kingdom of Bahrain. Saudi J Med 2018:2518-3389. DOI: 10.21276/sjm.2018.3.18.8.  Back to cited text no. 7
    
8.
Yan SC, Hulou MM, Cote DJ, Roytowski D, Rutka JT, Gormley WB, et al. International Defensive Medicine in Neurosurgery: Comparison of Canada, South Africa, and the United States. World Neurosurg 2016;95:53-61.  Back to cited text no. 8
    
9.
Berlin L. Medical errors, malpractice, and defensive medicine: An ill-fated triad. Diagnosis (Berl) 2017;4:133-9.  Back to cited text no. 9
    
10.
Sherief HM, El Segeeny AL, El Masry MK, Abdel Kareem MA. Retrospective Study of Medical Malpractice Cases in Grater Cairo. Msc Thesis, Faculty on Medicine, Ain Shams University, Egypt; 2005. p. 3-152.  Back to cited text no. 10
    
11.
Youssef H, Osman M, Roudi-Fahimi F. Responding to rapid population growth in Egypt. Washington, DC: Policy Brief;PRB (Inform Empower Advance) 2014.  Back to cited text no. 11
    
12.
El-Kolaly HR, El-Din RM, Tawfic NM. Medical malprac- tice-monitoring. Al Azhar Med J 1995;24:539-51.  Back to cited text no. 12
    
13.
Fuglenes D, Oian P, Kristiansen IS. Obstetricians' choice of cesarean delivery in ambiguous cases: Is it influenced by risk attitude or fear of complaints and litigation? Am J Obstet Gynecol 2009;200:48.e1-8.  Back to cited text no. 13
    
14.
Ali AA, Hummeida ME, Elhassan YA, Nabag WO, Ahmed MA, Adam GK. Concept of defensive medicine and litigation among Sudanese doctors working in obstetrics and gynecology. BMC Med Ethics 2016;17:12.  Back to cited text no. 14
    
15.
Moosazadeh M, Movahednia M, Movahednia N, Amiresmaili M, Aghaei I. Determining the frequency of defensive medicine among general practitioners in Southeast Iran. Int J Health Policy Manag 2014;2:119-23.  Back to cited text no. 15
    
16.
Ortashi O, Virdee J, Hassan R, Mutrynowski T, Abu-Zidan F. The practice of defensive medicine among hospital doctors in the United Kingdom. BMC Med Ethics 2013;14:42.  Back to cited text no. 16
    



 
 
    Tables

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



 

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