In the last article (Medicus newsletter #11), we considered doctors’ intellectual responses to receiving a complaint, and the potential for maladaptive learning. We suggested that receiving appropriate collegial support was essential for learning, and in newsletter #10 we discussed the emotional impact of complaints and the value of members getting trained psychological assistance.
Apart from the benefits of looking after the doctor and facilitating learning and good changes in behaviour, at Medicus we are aware that one outcome of the complaints process is the emergence of defensive medicine.
From a societal perspective, there is nothing good about defensive medicine. Thinking about these ideas may help our members reflect on both their practice and their roles in their practices and hospitals.
There are two types of defensive medicine, positive and negative.
Positive defensive medicine has nothing positive to be said for it. Unlike a good defensive strategy in sport, it is the motivation behind the changes in practice that is at fault.
The idea behind so-called positive defensive medicine is to ‘do stuff’ that is over and above normal or good medical practice, for the purpose of reducing the chances of a complaint happening, or being able to better defend a complaint, should one happen. It has nothing to do with good patient care. It exposes patients to the risks and costs of unnecessary investigations or therapies, and the healthcare system to the costs of unnecessary referrals and overuse of resources.
A genuine concern is that left unexamined, defensive strategies become normalised. An example might be an emergency department consultant missing an intracranial tumour in a patient presenting with migraine. Having endured the complaints process, that doctor resolves to always request an MR head scan in similar cases, because (they believe) if they had done so that time, the complaint would not have happened. Over time, trainees in that department come to believe that this is the approach that they also should take, and the consultant’s maladaptive learning becomes normalised.
Negative defensive medicine is about withdrawal, and I have interviewed many doctors who have given up an area of practice (rural and obstetric practice spring to mind) after receiving a complaint, in the fallacious belief that not practising in those fields will somehow stop further complaints from happening. The logic is wrong but understandable.
All of this brings us back to the importance of receiving emotional and intellectual support if you receive a complaint. Our hope is that high-quality collegial review of the events around a complaint will identify areas for learning and change without positive defensive medicine emerging. Our society cannot afford that cost. Similarly, high-quality psychological support may reduce the emergence of negative defensive medicine, reducing the shame response that makes us want to withdraw or flee, and preserving doctors as a vital resource.
Wayne Cunningham
General Practitioner
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